**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure physician's orders to obtain daily weights for residents with congestive heart failure (a chronic condition where the heart could not pump blood efficiently causing fluid to collect in lungs and legs) were followed for 3 of 12 sampled residents (Residents 2, 6 and 140). The deficient practice placed the residents at risk for a delay in identification of fluid overload and provision of timely interventions. Findings include: Resident 2 (R2) R2 was admitted on [DATE], with diagnoses including hypertensive heart disease with heart failure, acute respiratory failure with hypoxia and pneumonia (fluid in lungs). On 01/07/2025 in the morning, R2 laid awake in bed receiving two liters of humidified Oxygen by nasal cannula. R2 wore bilateral compression stockings and appeared weak as R2 spoke slowly and softly. R2 indicated having difficulty breathing and indicated being treated for pneumonia in the hospital. A physician's order dated 11/30/2024, documented to obtain daily weights, notify physician of three-pound weight gain or continuous weight gain. R2's edema/fluid status care plan initiated on 11/30/2024, documented an intervention to obtain weights per physician's order. A nutritional assessment dated [DATE], revealed R2 had a diagnosis of congestive heart failure (CHF), was on a fluid restriction of 1,500 milliliter (ml) per day and was to be weighed daily. R2's medical record lacked documented evidence weights were taken on 12/07/2024, 12/14/2024, 12/17/2024, 12/21/2024, 12/28/2024, 12/29/2024, and 01/04/2025 with no documented reason for the missed weights such as patient refusal. Resident 6 (R6) R6 was admitted on [DATE], with diagnoses including hypertensive heart disease with heart failure and chronic diastolic congestive heart failure (CHF). On 01/07/2025 in the morning, R6 laid awake in bed receiving two liters of humidified Oxygen by nasal cannula. R6 indicated not being able to be without Oxygen and would be hooked to an Oxygen source during physical therapy. A physician's order dated 11/18/2024, documented to obtain daily weights, notify physician of three-pound weight gain or continuous weight gain. R6's edema/fluid status care plan initiated 11/18/2024, documented interventions to restrict fluids and obtain weights per physician's order. A nutritional assessment dated [DATE], revealed R6 had a diagnosis of CHF with an intervention of obtaining daily weights. R6's medical record lacked documented evidence weights were taken on 11/30/2024, 12/07/2024, 12/14/2024, 12/17/2024, 12/21/2024, 12/28/2024, 12/29/2024, 12/31/2024, and 01/04/2025 with no documented reason for the missed weights such as patient refusal. Resident 140 (R140) R140 was admitted on [DATE], with diagnoses including hypertensive heart disease with heart failure and chronic kidney disease stage four. On 01/07/2025 in the morning, R140 was seated on a chair receiving two liters of humidified Oxygen by nasal cannula. A signage on the head of the bed read Fluid restriction 1,200 ml per day. The LPN pulled R140's pants up, pressed on bilateral lower legs and indicated R140 had bilateral pitting edema plus 4 (severe fluid retention). The LPN indicated the resident liked to sit because R140 had difficulty breathing when lying down in bed. A physician's order dated 12/23/2024, documented to obtain daily weights, notify physician of three-pound weight gain or continuous weight gain. R140's fluid status care plan initiated 12/24/2024, documented interventions to restrict fluid and obtain weights per physician's order. A nutritional assessment dated [DATE], revealed R140 had a diagnosis of CHF with interventions of fluid restrictions and obtaining daily weights. The medical record lacked documented evidence weights were obtained on 12/28/2024, 12/29/2024, and 01/04/2025. On 01/08/2025 at 2:25 PM, the Licensed Practical Nurse (LPN) explained obtaining weights were the responsibility of the restorative nurse aide (RNA) who worked five days a week and not on weekends. The LPN indicated expecting assigned certified nursing assistants (CNAs) to obtain weights on days when the RNA was off duty. The LPN confirmed the missing weights for R2, R6 and R140 and confirmed there was no documented reason for the missed weights such as patient refusal or being out of the facility to an appointment. The LPN indicated daily weights were important for residents with CHF because it enabled nurses to identify weight variances for timely notification to the physician who may want to change the resident's diuretic therapy. On 01/08/2025 at 2:45 PM, the Registered Dietitian (RD) confirmed Residents 2, 6 and 140 had CHF and were on fluid restrictions and daily weight orders. The RD indicated tracking weight fluctuations for these residents were important because they were at risk for fluid imbalances particularly fluid overload. According to the RD, missed weights may mean missed opportunities to identify fluid imbalances and delay necessary interventions. On 01/08/2025 at 3:00 PM, the interim Director of Nursing (DON) indicated it was the facility's standard of practice to restrict fluids and obtain daily weights for residents with CHF. According to the DON, missed weights were also missed opportunities to identify a weight variance and a potential delay in appropriate interventions to address fluid overload issues. The DON explained physicians were known to modify a resident's diuretic therapy when significant weight changes were identified related to fluid gains. The DON explained the facility employed one RNA who was responsible for taking weights. The DON indicated expecting assigned CNAs to obtain weights when the RNA was off duty. The DON confirmed missed weights for Residents 2, 6 and 140 did have a documented reason. The Patient Care policy (undated), documented delivery of medications and treatments were provided as ordered by the attending physician. The Weight policy (undated), documented weights would be obtained on admission, weekly and/or per physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure physician's orders for pain medications were followed for 1 of 12 sampled residents (Resident 6). The deficient practice placed the resident at risk for inadequate pain control. Findings include: Resident 6 (R6) R6 was admitted on [DATE], with diagnoses including osteoarthritis and pain in left hip. On 01/07/2025 in the morning, R6 laid in bed covered in blanket, a left boot device was observed in the room. R6 indicated being in the facility for two months after falling at home and although R6 did not sustain a fracture from the fall, the resident verbalized being diagnosed with osteoarthritis more severe in left leg causing the resident chronic pain. A History and Physical dated 11/18/2024, documented R6 had a mechanical fall at home landing on left hip. R6 has had difficulty walking on left leg since the fall and complained of hip pain. A care plan for pain management initiated 11/18/2024, documented interventions to include monitor and record the resident's pain and administer medications as ordered. A physician's order dated 12/05/2024, documented to give Hydrocodone-Acetaminophen 5 milligrams (mg)/325 mg one tablet by mouth PRN (as needed) every four hours for moderate pain level 4-6 (out of 10) on the pain scale. A physician's order dated 12/05/2024, documented to give Hydrocodone-Acetaminophen 7 mg/325 mg one tablet by mouth PRN every four hours for severe pain level 7-10 on pain scale. The medication administration record (MAR) revealed Hydrocodone-Acetaminophen 5 mg/325 mg was administered when R6's pain level was greater than 4-6 on the pain scale on: -12/05/2024 at 2:32 AM pain level 7/10 -12/05/2024 at 8:31 PM pain level 7/10 -12/06/2024 at 7:07 AM pain level 7/10 -12/16/2024 at 1:23 PM pain level 8/10 -12/22/2024 at 3:57 PM pain level 8/10 -12/28/2024 at 8:41 PM pain level 7/10 On 01/09/2025 at 9:31 AM, the Consultant Pharmacist explained it was not unusual to have two narcotic pain medication orders provided the medication given correlated with the resident's expressed pain intensity on the pain scale. On 01/09/2025 at 10:04 AM, the Clinical Nurse Manager (CNM) and interim Director of Nursing (DON) reviewed R6's medical record and confirmed there were two active orders for Hydrocodone, one for moderate pain (4-6) and the other for severe pain (7-10). The CNM and DON confirmed pain parameters were not followed on 12/05/2024, 12/06/2024, 12/16/2024, 12/22/2024 and 2/28/2024 when the resident expressed being in severe pain of 7 or greater and should have been given the stronger dose of Hydrocodone. The CNM and DON indicated expecting pain parameters to be followed and confirmed the above-mentioned administrations were not in accordance with physician's orders. The Pain Management policy (undated) documented all residents would be assessed for pain utilizing the standard pain scale 0 (zero) to 10. Prescribed medications would follow parameters based upon pain intensity. For example, a pain intensity 1-5 should receive the lowest dose while a pain intensity 6-10 may should receive the highest dose.

**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 resident was free from unnecessary medications, specifically, a PRN (as needed) pain medication order was not given earlier than scheduled for 1 of 12 sampled residents (Resident 6). The deficient practice placed the resident at risk for side effects of opioids to include constipation and dependence. Findings include: The Unnecessary Medications policy (undated) documented each resident's drug regimen would remain free from unnecessary drugs which shall not be given in excessive doses and ordered by the attending physician. R6 was admitted on [DATE], with diagnoses including osteoarthritis and pain in left hip. On 01/07/2025 in the morning, R6 laid in bed covered in blanket, a left boot device was observed in the room. R6 indicated being in the facility for two months after falling at home and although R6 did not sustain a fracture from the fall, the resident verbalized being diagnosed with osteoarthritis more severe in left leg causing the resident constant pain. R6 expressed discomfort from chronic constipation due to pain medications. A History and Physical dated 11/18/2024, documented R6 had a mechanical fall at home landing on left hip. R6 has had difficulty walking on left leg since the fall and complained of hip pain. A care plan for pain management initiated 11/18/2024, documented interventions to include monitor and record the resident's pain and administer medications as ordered. A physician's order dated 12/05/2024, documented to give Hydrocodone-Acetaminophen 7 mg/325 mg one tablet by mouth PRN (as needed) every four hours for severe pain level 7-10 on pain scale. The medication administration record (MAR) revealed Hydrocodone-Acetaminophen 7 mg/325 mg was administered before the allowable time (sooner than every four hours) on: -12/07/24 administered at 3:16 AM -12/07/24 administered at 5:56 AM -12/07/24 administered at 9:36 AM -12/07/24 administered at 6:05 PM -12/07/24 administered at 9:44 PM -12/12/24 administered at 4:44 AM -12/12/24 administered at 8:25 AM -12/18/24 administered at 1:45 PM -12/18/24 administered at 5:30 PM On 01/09/2025 at 9:56 AM, the Clinical Nurse Manager (CNM) and the interim Director of Nursing (DON) explained routine medications were able to be administered one hour before or one hour after the scheduled time however, PRN controlled medications must follow the set frequency per physician's order. The CNM and DON confirmed R6's Hydrocodone-Acetaminophen 7 mg/325 mg must not be given sooner than four hours between each administration. The CNM and DON reviewed R6's medical record and confirmed R6 received the narcotic pain medication too early on 12/07/2024 (three times), 12/12/2024 (one time) and on 12/18/2024 (one time). The CNM and DON verbalized the nurse who administered R6's medications on the above-mentioned dates did not follow physician's orders. The Pain Management policy (undated) revealed routine medications allowed for a one-hour variance before or after the scheduled time while the nurse would be prompted by the electronic health record (EHR) for PRN medications. The Medication Administration policy (undated) documented the licensed nurse would appropriately administer prescribed medications at the right time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure 1) infection event forms were being initiated and/or completed and discussions between nursing staff and prescribers were documented regarding adherence to the McGeer criteria for antibiotic orders (a set of guidelines used to determine if a patient has an infection which may need antibiotics) for 4 of 12 sampled residents (Residents and 87, 146, 149 and 5) and; 2) prescribers were being provided education regarding the facility's antibiotic stewardship program (ASP) on an annual basis and as needed in accordance with the facility's ASP policy. The deficient practice placed residents at risk for antimicrobial resistance and adverse effects of antibiotics. Findings include: The Antibiotic Stewardship Program policy and procedure (undated), documented the ASP was designed to improve the use of antibiotics to improve outcomes for patients with infectious disease, prevent antimicrobial resistance, and prevent adverse events associated with antibiotics such as Clostridium difficile diarrhea. The Infection Preventionist (IP) would evaluate the appropriateness of antibiotic therapy and would communicate recommendations with the prescribers. The prescriber would provide explicit written justification in the medical record for non-recommended antibiotic prescribing. Infection Event forms On 01/09/2025 at 10:08 AM, the Infection Preventionist (IP) and Clinical Nurse Manager (CNM) verbalized the facility utilized the McGeer Criteria as the facility's guideline for antibiotic use. The IP explained nurses initiated and completed infection event tracking forms for each infection event and/or antibiotic use. On 01/09/2025 at 11:01 AM, the Regional Director of Clinical Services (RDCS) confirmed the facility adopted the McGeer criteria as the facility's guideline for antibiotic therapies and indicated expecting prescribers to follow the McGeer criteria. The RDCS clarified the facility utilized two different forms for tracking infections, one was titled Admit Infection Tracker which was used for residents who were admitted to the facility with antibiotic orders from the hospital and the other was titled Infection Tracker with McGeer criteria for in-house antibiotic starts. According to the RDCS, the infection tracking forms were expected to be initiated and completed for each antibiotic use. On 01/09/2025 in the morning, the IP indicated there were currently four residents who were receiving antibiotics in the facility, namely, Residents 87, 146, 149 and 5. Resident 87 (R87) R87 was admitted on [DATE], with diagnoses including fracture of upper end of right humerus and subsequent encounter with routine healing. A physician's order dated 01/08/2025, documented to give Amoxicillin-pot clavulanate 875 milligrams (mg) - 125 mg one tablet by mouth twice a day for seven days for ear pain. The medical record lacked documented evidence the Infection Tracker with McGeer criteria document was initiated or completed, discussions with the prescriber regarding non-adherence to the McGeer criteria was documented and an explicit written justification for the antibiotic was provided by the prescribing physician. On 01/09/2025 in the afternoon, the IP reviewed the McGeer criteria and confirmed R87's antibiotic order did not meet the criteria to be classified as a cellulitis, soft tissue, or wound infection because the only symptom present was ear pain. The IP confirmed there was no documented evidence the IP or any nurse questioned the prescriber's order nor did the prescriber record a written justification for the antibiotic order in the R87's medical record. Resident 146 (R146) R146 was admitted on [DATE], with diagnoses including sepsis due to Methicillin susceptible Staphylococcus aureus and infection and inflammatory reaction due to internal left knee prosthesis. A physician's order dated 12/24/2024, documented to give Cefazolin reconstituted solution 2 grams/2,000 mg intravenously every eight hours for left knee septic joint times 116 doses. A physician's order dated 12/24/2024, documented to give Metronidazole 500 mg one tablet by mouth three times a day for left knee septic joint for 42 days. The medical record lacked documented evidence the Admit Infection Tracker was initiated appropriately and completed which would include a re-evaluation of R146's treatment plan such as status, progress or effectiveness of R146's current regimen. On 01/09/2025 at 10:41 AM, the IP indicated R146's infection tracker was initiated but not completed. On 01/09/2025 at 10:48 AM, the RDCS indicated R146's infection tracker was started but lacked basic information made available by hospital records such as infection type, site, signs and symptoms, and any diagnostic tests done at the acute setting. Resident 149 (R149) R149 was admitted on [DATE], with diagnoses including laceration without foreign body of abdominal wall and protein-calorie malnutrition. A physician's order dated 01/06/2025, documented to give Amoxicillin-pot clavulanate 875 mg-125 mg one tablet by mouth twice a day for urinary tract infection (UTI). The medical record lacked documented evidence the Infection Tracker with McGeer criteria document was initiated or completed, discussions with the prescriber regarding non-adherence to the McGeer criteria was documented and an explicit written justification for the antibiotic was provided by the prescribing physician. The McGeer Criteria for Infection Surveillance Checklist revised 11/05/2024, revealed residents without indwelling catheters must fulfill one sign and symptom such as acute dysuria (pain when urinating), fever or leukocytosis, suprapubic pain or gross hematuria if afebrile AND a positive diagnostic urine test showing equal to or greater than 10 colony-forming units per milliliter. On 01/09/2025 at 11:14 AM, the IP confirmed no infection tracker was initiated when R149 was started on antibiotics for a suspected UTI on 01/07/2025. The DON recalled the prescriber ordered antibiotics based on a staff report of foul-smelling, cloudy urine, a urine sample was collected with pending results. On 01/09/25 at 11:19 AM, the RDCS confirmed the R149's infection tracker should have been initiated on 01/07/2024 with information such as infection type, site, signs and symptoms, antibiotic order and indication for use, diagnostic tests, whether the treatment was ordered for prophylactic use or otherwise. 01/09/25 11:33 AM, the RDCS verbalized there should have been documented evidence of a discussion between the nurse and the prescriber regarding R149's signs and symptoms, history of UTI, and recommendations when antibiotic orders for the resident was received. On 01/09/2025 in the afternoon, the IP reviewed the McGeer criteria and stated the physician did not follow the McGeer criteria for R149's antibiotic order since R149 met none of the symptoms for a UTI. The IP confirmed there was no documented discussion between the IP and the prescriber regarding non-adherence to the McGeer criteria and there was no documented justification by the ordering physician regarding the antibiotic prescription. Resident 5 (R5) R5 was admitted on [DATE], with diagnoses including fracture of left tibia with subsequent encounter for closed fracture with routine healing. A physician's order for Doxycycline hyclate 100 mg one capsule by mouth twice a day for seven days for possible wound infection on left lower lateral and medial leg open wound. The medical record lacked documented evidence the Infection Tracker with McGeer criteria document was initiated or completed, discussions with the prescriber regarding non-adherence to the McGeer criteria was documented and a written justification for the antibiotic was provided by the prescribing physician. The McGeer Criteria for Infection Surveillance Checklist revised 11/05/2024, revealed cellulitis, soft tissue or wound infection must present with pus at wound, skin or soft tissue site, or four of the following symptoms to include heat, redness, swelling, tenderness, serous drainage and fever or a positive superficial wound culture. On 01/09/2025 at 3:29 PM, the CNM confirmed an infection tracker was not started and completed, a diagnostic test such as a wound swab was not recommended or ordered. On 01/09/2025 at 3:30 PM, the IP indicated the prescriber ordered R5's antibiotics based on reports of serosanguinous drainage of left leg wound with no other accompanying symptoms or a positive wound culture. The IP confirmed R5's infection status did not meet McGeer criteria for cellulitis, soft tissue or wound infection. The IP stated there was no documented evidence of a nurse-physician discussion regarding adherence to the McGeer criteria and no documented justification by the prescriber for R5's antibiotic order. On 01/09/2025 at 11:47 AM, the IP acknowledged there were gaps with the facility's implementation of the ASP program particularly with 1) completion of infection event tracking forms, 2) documentation of nurse-physician discussions regarding adherence to the McGeer criteria and 3) prescribers providing written justifications for antibiotic orders which went against the McGeer criteria for example prophylactic use. On 01/09/2025 at 3:43 PM, the RDCS indicated the infection tracking forms served the purpose of confirming the presence of an infection and ensuring appropriate antibiotic use. The completion of the form allowed the facility to identify prevalence or trend of an organism, classification of drug being used or a certain physician's trend with antibiotic ordering. Based on all the information, the facility could identify practices of care by staff or providers for timely interventions and education needs, if any. The RDCS indicated the following information was expected to be completed before initiation or upon receipt of new antibiotic order: Phase 1: infection type, site, origin, signs and symptoms, history of infection, device involved, type of diagnostic (results may be pending), and whether treatment was prophylactic or not, and order origin (ex: hospital, clinic, other nursing facility). Phase 2: laboratory results made available. New antibiotic orders. Communication with doctors for clarification on whether orders met criteria. Phase 3: resolution or outcome of treatment. On 01/09/2025 at 3:53 PM, the RDCS indicated expecting the infection tracker was expected to be completed or at least phases one and two, for resident who were admitted with existing antibiotic orders. The RDCS indicated the infection event form should be initiated with basic information present prior to the start of a new antibiotic order. Phase three would be completed if the resident was still in the facility when the infection resolved. 01/09/25 03:54 PM, the RDCS reiterated the infection tracker served as a guide to ensure clinicians were following the McGeer criteria which was the criteria the facility elected to employ for antibiotic therapy. The purpose of following the McGeer criteria was to ensure antibiotics were not being misused or abused thereby preventing antibiotic resistance. The RDCS acknowledged gaps with the facility's implementation of the ASP program and identified a knowledge deficit with nursing staff and prescribers. ASP Education for Prescribers The ASP policy and procedure (Undated) revealed education of practitioners regarding appropriate use of antibiotics would be done by the members of the ASP team as needed but not less than annually. On 01/09/2025 at 11:44 AM, the IP reported there were currently four physician groups who had rounding privileges in the facility. The IP confirmed there was no documentation education was provided to any of the physicians regarding the facility's ASP program and use of the McGeer criteria on an as needed basis or at minimum once a year in accordance with the facility's policy.

**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 provider was notified of the resident's persistent refusal of the blood pressure medication and when medication was held for 1 of 13 sampled residents (Resident #138). The deficient practice had the potential to result in unmanaged hypotension, increased cardiovascular risks, and compromised overall health. Findings include: Resident 138 (R138) R138 was admitted on [DATE], with diagnoses including joint replacement surgery, present of left artificial hip joint, polyneuropathy, and anxiety disorder. A Physician order dated 08/16/2023, documented a Midodrine tablet of 5 mg to be administered by mouth three times (x) a day for hypotension. Hold if systolic blood pressure (SBP) is greater than 110. A Care Plan dated 08/16/2024, documented R138 was at risk for an alteration in cardiac function related to hypotension (low blood pressure). The Administration History from 08/19/2023-08/21/2023, documented the Midodrine ordered to treat hypotension was held when the SBP was within ordered parameters per the Vital Signs Summary and documented R138 had refused the medication multiple times as follows: -08/19/2023 at 8:23 AM, on hold, 08/19/2023 at 8:23 AM blood pressure (BP) was 102/62. -08/20/2023 at 9:55 AM, refused, 08/20/2023 at 7:11 AM, BP was 100/69 -08/20/2023 at 2:14 PM, refused, 08/20/2023 at 3:26 PM, BP was 102/67 -08/20/2023 at 8:43 PM, refused, 08/20/2023 at 10:35 PM, BP was 101/66 -08/21/2023 at 9:00 AM, refused, 08/21/2023 at 6:56 AM, BP was 106/70 -08/21/2023 at 1:36 PM, refused R138's medical records lacked documented evidence the provider was notified when R138 had been refusing the Midodrine and was being held when R138's SBP was within the ordered parameter. On 01/18/2024 at 2:54 PM, the pharmacist indicated the blood pressure medication should have been given without delay if the resident's BP was outside the ordered parameter. On 01/19/2024 at 2:20 PM, a Registered Nurse (RN) explained the BP medication should have been administered promptly, and when the resident refused to take the medication, the provider should have been notified to obtain orders. On 01/19/2023 at 2:25 PM, a Licensed Practical Nurse (LPN) who was assigned to R138 in August 2023, indicated could not remember R138 and had no recollection as to why the Midodrine had been held. The LPN could not access the record of the discharged resident. On 01/19/2024 at 2:35 PM, the Director of Nursing (DON) explained with the resident's persistent refusals for two or more consecutive times, the provider should have been notified to obtain the order to discontinue or change the prescription, and it should have been documented in the progress notes. The DON confirmed the lack of documented evidence the provider was notified regarding R138's refusal to take Midodrine to treat hypotension. On 01/18/2024 at 2:54 PM, the pharmacist indicated the resident's BP medication should have been given without delay if the BP was within the ordered parameter. The pharmacist indicated the licensed nurses were expected to notify the provider promptly to obtain orders. A facility policy titled Administration of Medication (undated), documented the licensed personnel, in accordance with professional standards of practice, would appropriately administer prescribed medications. A facility policy titled Medication Administration (undated), documented the medications were administered in accordance with the provider's written orders. A facility policy titled Change in Resident Condition (undated), documented the attending physician and representative would be notified of the resident's refusal of medication two or more consecutive times. Complaint #NV00069461

**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 medication was delivered as ordered or communicated for 1 of 13 sampled residents (Resident 97). The deficient practice could have potentially led to ineffective treatment, non-healing of medical conditions, and delayed recovery. Findings include: Resident 97 (R97) R97 was admitted on [DATE], with diagnoses including osteoarthritis and spinal stenosis. A physician order dated 01/16/2024, documented a Super B complex capsule to be administered daily by mouth as a supplement. On 01/18/2024 at 7:40 AM, during medication pass, a Registered Nurse (RN) prepared R97's medications except the Super B complex. An RN explained the Super B complex was not available since it was ordered on 01/16/2024, as the pharmacy had not delivered the medication. An RN demonstrated the ordering process through the computer system, which was accessible and linked to the pharmacy. The Medications Administration History from 01/17/2024 to 01/19/2024, documented the Super B Complex was not administered due to unavailability and awaiting delivery from the pharmacy. On 01/18/2024 at 2:47 PM, the pharmacist indicated the Super B complex was ordered on 01/16/2024 at night, the medication was over the counter and out of stock. The pharmacist indicated there was no documented evidence the facility was notified the Super B complex was out of stock and the pharmacy was unable to deliver. On 01/19/2024 at 11:00 AM, the Director of Nursing (DON) indicated the ordering process was accessible without difficulty and the pharmacy delivery was round the clock. The DON indicated if the pharmacy was unable to deliver, there should have been communication, and the physician should have been notified to obtain orders and then documented in the progress notes. A Medication Pass Licensed Nurse Competency Evaluation dated 06/13/2018, documented medications were administered within one hour of the prescribed time. A facility policy titled Medication Administration (undated), documented the medications were administered in accordance with the provider's written orders. A facility policy titled Pharmacy Services (undated) documented the facility provided routine and emergency drugs and biologicals to residents, supplied by contracted services, and administered by facility staff. The pharmacy had to dispense, and the facility had to ensure the necessary drugs and biologicals were provided in a timely manner.

Based on observation, interview, record review, and document review, the facility failed to ensure the discontinued intravenous (IV) fluids and expired suppositories were removed from the active supply and discarded. The deficient practice had the potential for adverse reactions and compromised the effectiveness of treatments. Findings include: On 01/18/2024 at 8:30 AM, an inspection was conducted in the medication room with the Clinical Nurse Manager (CNM). Three bags of discontinued IV fluids belonging to three unsampled residents were stored together in the active supply. The CNM indicated the IV fluids were discontinued following residents discharge as follows: - Two bags of 0.9 sodium chloride (one (1) liter per bag). - 1 bag of 5% Dextrose, 1 liter The medication refrigerator stored expired Acetaminophen 650 milligrams (mg) suppositories with an expiration date of 12/2023 as follows: - 4 unopened boxes (12 suppositories/box) -11 suppositories in an open box. On 01/18/2024 at 8:40 AM, the CNM confirmed the Acetaminophen suppositories were expired and should have been removed from the active supply in the medication refrigerator to prevent misadministration. The CNM indicated that the expired medications should have been taken out of the refrigerator and placed in the designated area for disposal. The CNM explained the licensed nurses were responsible for checking the expiration dates and discarding them appropriately. A facility policy titled Medication Storage (undated), documented medications and biologicals were stored safely and securely.

Based on observation, interview, and document review, the facility failed to ensure expired meal products were disposed, failed to ensure ready to use raw meat was properly stored, and failed to ensure dishwasher machine attained an acceptable sanitizing temperature. The failure had the potential to place all residents at risk to contract food-related illnesses. Findings included: On 01/17/2024 in the morning, an inspection of the kitchen was conducted with a cook. The following issues were observed: Small refrigerator: 2- 1 gallon cartons of soy milk, expired 01/14/2024. 1 - 1/2 gallon carton of buttermilk, expired 01/10/2024. Walk-in refrigerator: Raw thawed ground beef and a thawed chicken packet were stored in same tray. There was leakage from the ground beef noted in the tray. Dry storage: A bag of chocolate chips was open to the air. Dishwasher: A high temperature dishwasher machine wash cycle temperature was 146 degrees Fahrenheit (F), and rinse cycle temperature was 117 degrees F. On 01/17/2024 at 8:30 AM, the cook confirmed the observations and acknowledged expired meal products should have been discarded, the bag of chocolate chips should have been closed to avoid contamination or infestation, and the ready to use ground beef should not have been stored on the same level and in the same tray where the chicken was stored. On 01/17/2024 at 9:00 AM, the Food Service Manager confirmed the dishwasher machine was not reaching the acceptable temperature parameters of 160-170 degrees F for the wash cycle and the 180 degrees F for the final rinse cycle. The Food Service Manager explained the dishwasher machine was recently checked by a contractor for the same issue. The Manager acknowledged staff should have been more aware of the functioning status of the dishwasher. The undated facility policy titled Food Storage documented raw animal foods would be separated from each other. The policy indicated all foods would be checked to ensure the consumption follows the use by date or be discarded, and the integrity of the package would be maintained until ready for use. The undated facility's policy titled Cleaning Dishes/Dish Machine revealed the high temperature dish machine final rinse would be verified at 180 degrees F prior to operation.

**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 drainage bag for a nephrostomy was placed below the kidney level, and physician orders were obtained for nephrostomy care for 1 of 12 sampled residents (Resident #76). The failure to keep the drainage bag below the kidney level and obtain orders for nephrostomy care had the potential to cause a kidney infection. Findings include: Resident #76 (R76) R76 was admitted on [DATE] with diagnoses including a history of ureterolithiasis (calculi in the ureter), left hydronephrosis (swelling in a kidney when the urine cannot drain out), left perinephric inflammation, acute renal failure, and urinary tract infection. On 02/28/23 at 3:33 PM, R76 was lying in bed. A urinary drainage bag was observed on the bed, on the patient's left side. The bag contained urine-like amber fluid. The resident indicated the drain bag was connected to a nephrostomy tube. The bag was not kept lower than the kidney level. A Certified Nursing Aid confirmed the observation and placed it in a lower level. On 03/01/23 at 12:39 PM, the urinary drainage bag was observed on the bed. The bag was not kept lower than the kidney level. A Licensed Practical Nurse (LPN) confirmed the observation and indicated the drainage bag should have been placed below the level of the resident's kidney to allow urine to drain by gravity. The LPN explained the drainage bag should be placed in a lower position to allow fluids to drain by gravity and to prevent urine back up to the kidney that could cause an infection. The care plan for nephrostomy care, dated 02/07/2023, documented the urostomy would remain patent and free from symptoms of infection. Approaches included assisting with the maintenance of the nephrostomy and providing nephrostomy care as needed. The medical record lacked documented evidence a physician order was obtained for the nephrostomy care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure hand hygiene was performed during a peripherally inserted central catheter (PICC line) dressing change, and an antiseptic was applied in the PICC line insertion site during the dressing change for 1 of 12 sampled residents (R73). The failure could potentially increase the risk of developing an insertion site and bloodstream infection. Findings include: Resident #73 (R73) R73 was admitted on [DATE] with diagnoses including discitis/osteomyelitis of the lumbar vertebra L4-L5. A PICC line was placed and started with intravenous antibiotic therapy with Vancomycin and cefepime. On 02/28/23 at 2:48 PM, a PICC was noted on R73's upper left arm. R73 explained it had been the third PICC line placed since the previous one had problems, including depth venous thrombosis. The resident said it was inserted on 02/24/2023. On 03/02/2023 at 1:00 PM, a PICC line dressing change was observed with R73 and a Registered Nurse (RN). The RN proceeded to change the dressing as follows: - Disinfected the bedside table used to place the dressing change kit. - Provided a face mask to the resident. - Washed the hands with soap and water. - Donned a gown, clean gloves, and face shield. - Removed the transparent dressing and the antibacterial dressing. - Removed the catheter sutureless securement device (StatLock). After removing the dirty dressing, the RN proceeded to remove the contaminated gloves and donned a new pair of sterile gloves. The RN did not perform hand hygiene after removing the contaminated gloves and before donning the sterile glove. The RN cleaned the insertion site with an alcohol swap, placed the new antibacterial dressing and a new StatLock, and applied the new transparent dressing. The RN did not perform antisepsis using the povidone swap included in the dressing change kit. On 03/02/2023 at 3:59 PM, the RN acknowledged hand hygiene should have been performed when gloves were changed. The RN confirmed the antiseptic povidone swap was dismissed during the procedure and should have been applied to prevent infections. The RN verbalized that formal PICC line care training had yet to be received. On 03/03/2023 at 3:00 PM, the Director of Nursing (DON) confirmed the facility did not have formal training for PICC line care and the staff would receive training from a vendor. The DON confirmed the facility did not have a specific policy for PICC line care. The facility policy titled Handwashing revised on 01/04/2023, revealed handwashing would occur before applying and removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and document review, the facility failed to ensure 1) the arbitration agreement was communicated to the residents and/or their authorized representative in a form and manner that they could comprehend for 2 of 12 sampled residents (Resident #75 and #76), and 2) the timeframe and mechanism to revoke the arbitration was fully explained for 35 of 35 residents. The failure could have the potential to deny the residents and/or surrogates their right to resolve their disputes in a court of law. It could also deny the resident or representative the right to withdraw from the agreement within the 30-day after the signature. Findings include: A facility document titled Arbitration Agreement documented that, by signing, a resident confirmed to have received a copy of the document, and the provisions of the Arbitration Agreement had been explained in a clear and understandable manner. The document indicated all of the questions formulated by the resident had been answered. The document revealed that by signing this arbitration agreement, the residents agreed to have any dispute between the resident and the facility decided by neutral arbitration, and the resident was giving up their right to a jury or court trial. The arbitration agreement documented the resident, nor their representative were required to sign the agreement as a condition of admission or as a requirement to continue receiving care at the facility. The arbitration agreement indicated the resident could revoke the agreement by providing written notice to the facility within 30 calendar days of signature. The document proposed that the Agreement Arbitration would be conducted per the American Health Lawyers Association Alternative Dispute Resolution Services Rules of Procedures for Arbitration. Resident #75 (R75) R75 was admitted on [DATE], with diagnoses including intractable low back pain related to discitis osteomyelitis of L5-S1. A review of R75 medical records revealed the resident signed the Arbitration Agreement on 02/24/2023. On 03/01/2023 at 1:16 PM, R75 was asked about understanding the arbitration process if a dispute arose between R75 and the facility. R75 did not know what the arbitration agreement was about. R75 confirmed they had signed certain documents at the time of admission, but due to their health condition and the pain they were experiencing, R75 did not realize what documents were signed. The resident claimed that no one warned them that they would waive their right to litigation in a court proceeding by accepting the arbitration agreement. R75 verbalized the facility should have explained the rights to terminate or withdraw from the agreement within 30 days of signing. R75 verbalized that the facility did not provide a copy of the signed agreement or the American Health Lawyers Association Alternative Dispute Resolution Services Rules of Procedures for Arbitration. Resident #76 (R76) R76 was admitted on [DATE] with diagnoses including a history of ureterolithiasis (calculi in the ureter), left hydronephrosis (swelling in a kidney when the urine cannot drain out), left perinephric inflammation, acute renal failure, and urinary tract infection. On 03/01/23 at 11:00 AM, R76 spoke in Spanish with the Surveyor, and it was the only language they spoke. R76 explained at the time of admission a nurse gave several documents in English to sign. The resident stated the documents were signed but not explained in Spanish. The resident acknowledged had no clue about the documents signed. The resident verbalized the nurse did not explain the arbitration agreement document in Spanish. R76 stated the facility did not provide a copy of the signed agreement in Spanish or an explanation or copy of the American Health Lawyers Association Alternative Dispute Resolution Services Rules of Procedures for Arbitration. 03/01/23 02:19 PM, the admission Nurse explained the facility had three admission nurses responsible for providing and explaining the arbitration agreement to the residents. The admission Nurse indicated none of the nurses working in the admission Department spoke Spanish. The admission Nurse stated a family of R#76 was contacted by phone to explain the agreement, and the family translated it to Spanish, then the resident signed. The arbitration agreement lacked documented evidence a call was conducted with R76's family member to translate the document. The admission Nurse acknowledged the call was not recorded in the document. The admission Nurse verbalized upon admission the agreement was provided to the residents, and the nurse who provided the document read a portion of the agreement which said the following: Notice: by signing this arbitration agreement you are agreeing to have any dispute between you and the facility decided by neutral arbitration, and you are giving up your right to a jury or court trial. Neither you nor your representative is required to sign this agreement as a condition of admission to, or as a requirement to continue to receive care at the facility. The admission Nurse did not know residents could revoke the agreement within 30 days after being signed and acknowledged that information was not verbally provided and explained to the residents. On 03/03/2023 in the morning, the admission Nurse provided the list of residents who signed the Arbitration Agreement. 35 out of 35 residents had signed the document.