Based on observation, interview and document review, the facility failed to ensure food stored inside the walk-in freezer were labeled with a date and time, a label was changed to reflect the appropriate date and time, a container of expired seasoning was discarded, a condiment squeeze bottle was labeled and a dietary aide did not touch and adjust their glasses several times during tray line for the lunch meal service. The deficient practices could have led to contamination of kitchen surfaces and food borne illness. Findings include: On 7/17/2024 in the morning, a brief kitchen tour revealed the following: -A condiment squeeze bottle containing a yellow substance stored on the counter was not labeled. The cook identified the substance as liquid butter. Walk-in Freezer #1 - Cottage Cheese 5 lb. container expired 7/5/2024 - Raw fish stored in container with label used by date 7/14/2024 - Gallon bag containing a corn meal type substance was not labeled. Walk-in Freezer #2 -Pan wrapped with aluminum foil contained approximately 2-3 slices of cheesecake was not labeled. Seasoning Storage Shelf - Pappy's seasoning used by date Nov. 2023 On 07/17/2024 at 8:11 AM, a cook indicated the process for organizing the seasonings was to clean the shelf and relabel the items every week. On 07/18/2024 in the afternoon during the tray line for the lunch meal service, a dietary aide adjusted their glasses several times. On 07/18/2024 in the afternoon, the Nutritional Services Director explained the process of the labeling of the seasoning. The Nutritional Services Director was made aware of the Pappy's seasoning was expired. The Nutritional Services Director removed the container from the shelf and showed it to the cook. The Nutritional Services Director indicated the seasoning should have been thrown away. The Nutritional Services Director disclosed had observed the dietary aide adjusting their glasses and wiping their forehead during tray line. The Nutritional Services Director indicated the staff would be in serviced. The facility policy entitled food storage dated 2021, documented all foods should be covered, labeled, and dated. All foods will be checked to assure foods will be consumed by their safe use by dates or discarded. The facility policy entitled Hand Washing dated 2021, documented to wash hands after engaging in other activities that contaminate hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a physician order for self-administration was obtained and an assessment was completed before allowing the resident to self-administer the medications. This deficient practice could potentially lead to serious medication errors, adverse drug reactions, or other health complications for the resident. Findings include: Resident 23 (R23) R23 was admitted on [DATE], with diagnoses including pleural effusion, muscle weakness and hypertension. The Brief Interview of Mental Status dated 06/29/2023, documented a score of 14/15, which means R23's cognitive status was intact. On 07/19/2023 at 9:22 AM, R23 was in the bathroom. There were three pills placed in the medication cup by R23's bedside. When R23 went back to the bed, R23 explained the medications were potassium, iron, and Lasix (diuretics). R23 indicated more medications were taken earlier and unassisted; the medications were self-administered per resident's request. R23 indicated a desire to self-administer the medications. R23's medical records lacked documented evidence a physician order and self-administration assessment were in place for all medications except for Mucinex (cough medication). On 07/19/2023 at 9:3AM, Registered Nurse 1 (R1) confirmed the medications were left at the bedside per R23's request. RN1 indicated R23 was alert and oriented. On 07/21/2023 at 12:32 PM, Registered Nurse 2 (RN2) indicated the RN who left the medications at bedside was a new RN, but might have forgotten not to leave the medications at bedside. RN2 indicated self-administration of medication required an order and assessment before allowing the resident to self-administer the medications. On 07/21/2023 at 1:34 PM, the Assistant Director of Nursing (ADON) indicated R23 was alert and oriented, but regardless, there should have been a self-administration assessment and an order to ensure the resident's safety. The ADON indicated the resident should meet the criteria, be able to distinguish between colors, various shapes, correctly tell time, read the medication labels, and be psychologically competent to handle and administer their own drug regimen. The ADON confirmed there was no order or assessment in place for R23's self-administration of all the medications except for Mucinex. A facility policy titled Administration of Medication dated 09/28/2023, documented stay with the resident until all medication had been ingested. A facility policy titled Self-Medication Administration (undated), documented the residents may self-administer medications if it was determined were capable of doing so in a safe and consistent manner. As part of the overall evaluation, staff would assess each resident's mental and physical abilities to determine whether were capable. The resident requesting to self-administer medications would be assessed as mentioned above. The Self-Administration Assessment form would be maintained in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the fall mats were appropriately placed as ordered for a fall risk resident who had repeated falls, for 1 of 14 sampled residents (Resident 138). This deficient practice could potentially lead to serious injuries or further complications for the fall-risk resident, including fractures, head injuries, or other physical harm. Findings include: Resident 138 (R138) R138 was admitted on [DATE], with diagnoses including Parkinson's disease, repeated falls, and rhabdomyolysis (breakdown of muscle tissue). The Brief Interview of Mental Status dated 07/10/2023, documented a score of 7/10, which means R138's cognitive status was severely impaired. A physician order dated 07/20/2023, documented fall precautions: bed in the lowest position, fall mat to be used while in bed, and frequent checks every 2-4 hours. A Care Plan dated 07/07/2023, documented R138 was at risk for falls related to impaired mobility, and an intervention included a fall mat when the resident was is bed. and to check the resident every 2 to 4 hours. The Observation Detail List Report dated 07/07/2023, documented R138 was disoriented and had a history of one to two falls for the past three months. R138 was at risk for falls due to impaired mobility. R138's gait, balance, and ambulation documented a balance problem while standing or walking and decreased muscular coordination or jerking movements. Changes in gait patterns, required the use of assistive devices and was non-ambulatory. The Physical Therapy Treatment Encounter Note dated 07/20/2023 documented R138's precautions, including fall risk and a history of Parkinson's disease. During the session, R138 required extensive assistance due to a rigid posture and difficulty in sequencing during transfers. The main barrier impacting the session was cognitive impairment due to Parkinson's disease. On 07/19/2023 at 9:36 AM, R38 lay in bed and mumbled words. The fall mat on the left side of R138 was in place, but the other fall mat was placed away from the bed, leaning on the wall in the corner adjacent to the television (TV) stand. R138's family was at the bedside and indicated R138 had Parkinson's disease, was at high risk for falling, fell at home, and was injured, which is why R138 was admitted to the hospital. The spouse indicated the fall mat was placed away upon family's arrival to R138's room. On 07/19/2023 at 4:05 PM, R138 lay in bed with eyes closed. R138 was alone in the room. R138's fall mat was placed away from the bed, leaning on the wall in the corner adjacent to the TV stand. On 07/20/2023 at 8:05 AM, R138 lay in bed, awake, and confused, and involuntary movements were noted. R138 was alone in the room. R138's fall mat was placed away from the bed, and was leaning on the side of the TV stand. On 07/20/2023 at 9:43 AM, R138 lay in bed, confused, restless, and unattended. There was one fall mat in place on R138's left side. A Certified Nursing assistant (CNA) indicated R138 was confused, and a fall mat was required because R138 was a fall risk and tried to get out of bed. The CNA and a Registered Nurse (RN) confirmed the other fall mat was not appropriately placed when R138 was in bed and unattended. Both indicated there should have been bilateral floor mats in place to decrease the impact of a fall in case the resident fell. An RN indicated the fall mat could be removed during bedside care or transfer using the wheelchair, but it should be in place when R138 was in bed and unattended. On 07/20/2023 at 9:55 AM, an RN verified R138 was a fall risk. The care plan falls interventions included the placement of the bilateral fall mats at bedside when R138 was in bed and unattended. On 07/21/2023 at 10:19 AM, the Physical Therapist (PT) indicated R138's goal was to increase functional activity tolerance, promote independence to minimize falls, and enhance safety awareness. Currently, R138 required maximum assistance with mobility and transfers. The PT indicated R138 had undergone evaluations and was receiving both Physical Therapy and Occupational Therapy services. On 07/21/2023 at 10:27 AM, the Occupational Therapist (OT) reported that R138 could not walk without assistance and experienced involuntary movement episodes due to Parkinson's disease. The PT further mentioned that R138 required substantial verbal cueing due to confusion. The OT expressed concern that R138's involuntary movements could increase the risk of falls and could also affect the proper placement of the fall mat, potentially resulting in inadequate cushioning or protection upon impact. A facility policy titled Fall Prevention revised 10/28/2022, documented to ensure optimal resident safety while promoting resident independence and maximizing psychosocial well-being. Safety interventions would be implemented and monitored with appropriate documentation as indicated. The assigned Licensed Nurse would be responsible for ensuring safety checks were completed and documented in notes for verification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure: the indwelling (Foley) catheter order size was followed or clarified for two of 14 sampled residents (Residents 25 and 95), the urinary output was adequately monitored for a resident with a urinary indwelling catheter for one of 14 sampled residents (Resident 95); and the attending physician was notified regarding bladder scanner results above 400 milliliters for a resident with an indwelling catheter for one of 14 sampled residents (Resident 95). These deficient practices could potentially lead to complications, such as urinary tract infections, urinary retention, catheter-associated issues, urethral damage, leakage, and bladder kidney damage, and compromise the residents' overall health and well-being. Findings include: A facility policy titled Indwelling Urinary Catheter Site Care revised 12/19/2022, documented residents with indwelling urinary catheters would receive routine catheter care during daily care and as needed. Resident # 25 (R25) R25 was admitted on [DATE], with diagnoses including urinary retention and knee joint replacement. The Brief Interview of Mental Status dated 07/03/2023, documented a score of 12/15, which means R25's cognitive status was intact. A physician order dated 06/18/2023, documented an indwelling catheter size 16 French, 10 cc balloon for urinary retention. A physician order dated 07/08/2023, documented an indwelling catheter size 14 French, 5 cc balloon for urinary retention. A Care Plan dated 06/18/2023, documented impaired urinary elimination related to urinary retention with a Foley catheter. The Observation Detail List Repot dated 06/18/2023, documented R25 was incontinent with an indwelling (Foley) catheter. The Bowel and Bladder observation dated 06/18/2023, documented R25 was alert and oriented times four and had a 16 French Foley catheter in place. An evaluation of R25's Foley utilization was justified and would be assessed daily. On 07/19/2023 at 12:10 PM, R25 was in the wheelchair, and the Foley catheter was in place, anchored, and draining yellow urine. R25 indicated having urinary retention at night on 7/17/2023, and bladder pain. R25 indicated the staff reinserted the Foley catheter at almost midnight on the same day, and in the morning, the urine output was 1400 milliliters. On 07/20/2023 at 9:24 AM, R25 lay in bed. The Foley was anchored to R25's left thigh and kinked at this time. The Foley bag had 400 milliliters (ml) of yellow urine with no sediments noted. R25 indicated the bladder training had started at 7:30 AM for 3 days before removal. R25 indicated the staff attempted to discontinue before, bladder training was done, but after it was removed, R25 experienced urinary retention after 24 hours, so the Foley had been reinserted. A Certified Nursing Assistant confirmed the Foley currently in place was 14 French. On 07/20/23 at 11:30 AM, the Charge Registered Nurse (CRN) indicated the Foley catheter order should have been verified for the correct order size and match with what was inserted. If there were two orders, the physician should have been notified to clarify the Foley orders to prevent confusion and discontinue the other one. The CRN indicated the assigned nurse was responsible for ensuring the correct Foley size was carried out as ordered. On 07/20/2023 at 11:35 AM, the Director of Nursing (DON) indicated R25's Foley catheter had attempted to be removed and reinserted three times. The DON indicated there were three different orders, and one order was discontinued, but the standing order did not match what R25 had in place. The DON indicated the correct size must be verified to avoid confusion among staff and to prevent resident urethral damage if a bigger size had been used or a smaller size could result in leakage because Foley catheters had different sizes. The DON indicated the order should have been promptly clarified. Resident #95 (R95) R95 was admitted on [DATE], with diagnoses including dementia, urinary retention, anemia, urinary tract infection. A physician's order dated 07/12/2023, documented an order for indwelling catheter size of 16 French (16 French were equivalent to 5.3 millimeters of diameter) and balloon 10 cubic centimeter (CC) for urinary retention. A physician order dated 07/12/2023, documented indwelling catheter may be changed French 16, balloon 10 cc for malfunction. On 07/21/2023, a Registered Nurse (RN) confirmed R95 had an indwelling catheter size 18 French (6.0 millimeter). The RN verbalized physician orders for indwelling catheter replacement should be followed, including the size of the indwelling catheter. The vitals report revealed R95's urine output was not monitored on 07/12/2023 night shift, and on 07/13/2023 in the morning shift. The Medication Administration Record (MAR) documented the indwelling catheter was replaced because it was not in place and the bladder scan documented a urinary retention of 692 ml. The MAR did not document the size of the catheter inserted. A Physician's order dated 07/12/2023, revealed a bladder scan may be performed if there was no urine output within eight hours and/or the resident complained of bladder discomfort. The order indicated straight catheterization may be used if the bladder scan resulted in equal or more that 400 milliliters (ml) and the attending physician notified. On 07/21/2023 at 9:30 AM, the Clinical Manager explained Certified Nursing Assistances (CNAs) emptied drainage bags every shift or more often and would document amount in the medical record. The CNAs should notify the licensed nurses about abnormal findings in the urine such as hematuria (bloody urine), cloudy urine or no output. The Clinical Manager indicated if a resident with indwelling catheter did not have urine output, or had retention confirmed by scan, it was considered a change in condition, the attending physician should be notified, and pertinent documentation should have been recorded in medical record. The Clinical Manager verbalized nurses could use clinical judgment to choose the size of the indwelling catheter. The Clinical Manager acknowledged the attending physician should have been notified about the urinary retention and the change of the indwelling catheter size. 07/21/23 4:41 PM, a CNA explained urine output was measured when emptying the indwelling catheter drainage bag and documented in the medical record. The CNA indicated licensed nurses should be notified if there was no urine output. The Medical record lacked documented evidence of change in condition documentation related to urinary retention detected on 07/13/2023. There was no evidence a new physician order for an indwelling catheter size 18 French was obtained. A Care Plan dated 07/12/2023, documented impaired urinary elimination related to the presence of an indwelling catheter. The care plan lacked documented evidence of approaches to monitor urinary output for indwelling catheter malfunctioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure an empty Oxygen (O2) humidifier bottle was changed as ordered / scheduled and appropriately documented in the Medication Administration Record (MAR) for 1 of 14 sampled residents (Resident 136). This deficient practice had the potential to lead to serious health consequences and compromising the resident's respiratory support and overall well-being. Findings include: R136 (R136) R136 was admitted on [DATE], with diagnoses including long term use of anticoagulants and multiple myeloma A Physician order dated 07/04/2023, documented to change Oxygen tubing and humidifier bottle each week on Friday AM shift. Initial and date tubing and bottle when replaced. A Care Plan dated 07/04/2023, documented R136 was at risk of ineffective breathing pattern related to episode of shortness of breath while lying. The Medication Administration Record dated 07/14/2023, documented the humidifier bottle was changed. The humidifier bottle itself was dated 07/11/2023. On 07/19/2023 at 9:49 AM, R136 was verbally responsive but exhibited confusion. O2 was being administered at 2 liters per minute (LPM) through a nasal cannula connected to the O2 source on the wall. The humidifier bottle contained approximately 125 milliliters (ml) of water, and it was dated 07/11/2023, the O2 tubing was unlabeled. On 07/20/2023 at 12:34 PM, R136 was lying in bed with eyes closed. O2 was flowing at 2LPM through nasal cannula, the humidifier bottle was dated 07/11/2023 and was almost empty. On 07/21/2023 at 08:23 AM, R136 was lying in bed with eyes closed but easily arousable. O2 was flowing at 2LPM, but the humidifier bottle was empty. The water bottle was dated 07/11/2023. The Medication Administration Record dated 07/14/2022, documented the humidifier was changed as scheduled on 07/14/2023. On 07/21/2023 at 12:20 PM, a Registered Nurse (RN) confirmed the O2 humidifier bottle was empty and dated 07/11/2023. The RN explained the humidifier bottle was supposed to be changed, but the empty bottle was already taken out, and unaware of who had changed it. The RN indicated the assigned nurse was responsible for changing the humidifier bottle. On 07/21/2023 at 12:31 PM, a Charge RN (CRN) confirmed the humidifier bottle was empty and dated 07/11/2023. The CRN replaced it with a new humidifier bottle, dating it for the current day. The CRN indicated the night nurses were responsible for ensuring the humidifier bottle was not empty and were changed as scheduled. On 07/21/2023 at 12:45 PM, the Director of Nursing (DON) indicated the O2 humidifier should have been changed weekly on Fridays, irrespective of the remaining water content in the bottle, and the used bottle should be discarded. The DON indicated the staff were expected to document accurately if the O2 humidifier was not changed, it should not be documented as being changed. The DON verbalized the potential risks of not changing the empty O2 humidifier, which could lead to skin dryness in the nose and potentially cause bleeding. A facility policy titled Oxygen Administration dated 10/28/2023, documented appropriate safety precautions were utilized to provide safe administration. Equipment was maintained per the manufacturer's recommendations. Verify the physician orders or facility protocol for Oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and document review, the facility failed to ensure a pain assessment was performed and documented for the administration of pain medication prescribed as needed for 1 of 14 sampled residents (Resident #2). The deficient practice had the potential to lead to adverse physical and psychological resident outcomes affecting the recovery and interfering with the activities of daily living. Finding include: Resident #2 (R2) R2 was admitted on [DATE], with diagnoses including recurrent intermittent falls in the past 2-years, history of bilateral knee surgery, lumbar spinal stenosis, chronic back pains, and history of lumbar spine surgery. On 07/19/2023 in the morning, R2 verbalized having pain often in the knees and low back and occasionally medications were not effective. R2's medical record documented the following orders for pain management: Hydrocodone-acetaminophen 10-325 milligrams (mg) 1 tablet orally every four hours as needed for pain scale four to ten (4-10) ordered on 06/30/2023, discontinued on 07/14/2023, and re-ordered on 07/16/2023. Lidocaine adhesive patch 5 %; topical for right heel pain to be applied to the affected area in the morning and remove at night. The medication was ordered on 07/04/2023. Acetaminophen 325 mg tablet, administer 650 mg orally for pain level one to three, headache, or body temperature greater than 100.4 Fahrenheit every four hours as needed. The medication administration record (MAR) for July 2023, revealed Hydrocodone-acetaminophen was administered 46 times from 07/01/2023 through 07/21/2023. The pain level assessment was documented only four times on 07/09/2023 at 7:32 AM, 07/09/2023 at 3:08 PM, 07/10/2023 at 4:37 AM, and 07/18/2023 at 7:20 AM. On 07/20/2023 at 2:00 PM, a Registered Nurse (RN) explained pain medications ordered as needed should be administered following pain scale parameters. The RN indicated pain level assessment should have been documented in the MAR. On 07/21/2023 at 4:00 PM, the Nurse Clinical Manager (NCM) explained pain medication should be administered following the prescribed parameters to prevent the administration of unnecessary medications. The NCM acknowledged that by assessing the pain intensity nurses could determine which medication was indicated to manage the pain if the resident had two or more pain medications ordered as needed, that follow pain scale parameters for the administration. The care plan dated 06/15/2023, documented approaches for pain management including monitoring the resident for pain using the 1 to 10 pain scale and administer pain medication as ordered. The facility policy titled Pain Management indicated pain would be assessed using a standard pain scale of zero (0) to ten (10). The policy documented pain medication ordered as needed would be administered following the pain assessment including location, onset, duration, and intensity. The policy indicated pain medication administered as needed should be documented in the EMAR (electronic MAR) including the reason for the administration and the location and the intensity of the pain as per the 0-10 pain scale.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure a patient with cognitive impairment did not sign an arbitration agreement for 1 of 14 sampled residents (Resident #95). The deficient practice had the potential to deny the residents and/or surrogates their right to resolve their disputes in a court of law. Findings include: Resident #95 (R95) R95 was admitted on [DATE], with diagnoses including dementia, urinary retention, anemia, urinary tract infection. Arbitration agreement document dated 07/12/2023, revealed R95 signed the document. On 07/20/2023, R95's representative explained the resident was not capable to perform decision-making tasks due to the impaired cognition and the arbitration agreement document should have been discussed and signed by the representative. On 07/20/2023 at 4:00 PM, the Director of Nursing (DON) explained documents were given by admission staff to sign at the date of admission. The DON acknowledged R95 had impaired cognition and the arbitration agreement should have been discussed with the power of attorney (POA). Care plan dated 07/12/2023, revealed R95 was at risk for abuse, neglect, and exploitation related to dementia, episodes of confusion, and impaired physical mobility. The approaches included education to be provided to the resident and family regarding residents' rights. The facility policy titled Arbitration Agreement Translation dated 05/08/2023, documented the facility would ensure the patient and their representatives understood the arbitration agreement.