**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow the seven rights of medication administration for 2 of 5 residents observed for medication administration. (Resident identifiers are #6 and #37). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021. Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation, and right indication . .Before administering medications, perform physical assessment, which will reveal physical findings for any indications or contraindications for medication therapy . Resident #6 Observation on 2/3/25 at approximately 8:25 a.m. with Staff E (Medication Nursing Assistant) during medication administration revealed that Staff E administered 1/2 tablet of Calcium Extra Strength 750 milligram (antacid) (dose administered: 375 mg) for Resident #6. Review on 2/3/25 of Resident #6 active physician's orders revealed an order for chewable Calcium 200 mg 1 tablet by mouth twice a day with a start date of 12/20/24. Interview on 2/3/25 at approximately 8:25 a.m. with Staff E confirmed the above findings. Resident #37 Observation on 2/3/25 at approximately 8:45 a.m. with Staff F (Licensed Practical Nurse) during medication administration observation revealed that Staff F placed a pulse oximeter on Resident #37's finger to take his/her pulse. Further observation revealed that Staff F did not utilized their stethoscope to take an apical pulse via the chest. Review on 2/3/25 of Resident #37's active physician's orders revealed an order for Metoprolol Succinate 100 mg extended release with instructions to hold the medication for an apical pulse less than 60. Interview on 2/3/25 at approximately 8:55 a.m. with Staff F confirmed that they did not check Resident #37's apical pulse. Review on 2/3/25 of the facility's policy titled Apical Pulse Monitoring, dated 9/1/22, revealed The purpose of this procedure is to determine the resident's heart rate and rhythm .Steps in the Procedure .5. Locate the apex of the resident's heart by placing the diaphragm of the stethoscope under the resident's left breast (at the fourth to fifth intercostal space). 6. Count the resident's pulse rate for one full minute (60 seconds) .

Based on interview and policy review, it was determined that the facility failed to develop and implement a water management program to prevent the growth of waterborne pathogens in their building with a census of 102 residents. Findings include: Review on 2/3/25 of the facility's water management program, not dated, revealed the following: 1. There was no detailed description and/or diagram of the facility's water system; 2. There was no identification of areas in the water system where legionella and other opportunistic pathogens could grow and spread; 3. Legionella testing was to be done January 2024 and June 2024. Legionella testing was done on January 2024 and there was no second Legionella testing performed in 2024; 4. There was no control measures for areas identified in the facility's water system where legionella and other opportunistic pathogens could grow and spread besides Legionella testing; 5. There was no procedure of monitoring of control measures; and 6. There was no procedure to intervene when control limits are not met. Interview on 2/3/25 at approximately 1:00 p.m. with Staff C (Director of Maintenance and Environmental Services) confirmed the above findings. Further interview with Staff C revealed that Staff C oversees the water management program at the facility. Staff C was unable to describe detailed description of the facility's water system and he/she was unable to identify areas in the facility's water system that could encourage growth and spread of legionella and other opportunistic pathogens. Staff C also stated Staff C did not know when the water management program had been updated. Interview on 2/3/25 at approximately 2:30 p.m. with Staff B (Director of Nursing) and Staff D (Infection Preventionist) revealed that they started working at the facility November 2024. Staff B and Staff D stated that they reviewed the water management program last December 2024. Staff B and Staff D was unable to explain the facility's water management program that included measures to minimize the risk of Legionella and other opportunistic pathogens as mentioned in the facility's legionella water management program. Interview on 2/3/25 at approximately 3:20 p.m. with Staff A (Administrator) revealed that they reviewed the facility's water management program last December 2024. Staff A was unable to explain the facility's water management program that included measures to minimize the risk of Legionella and other opportunistic pathogens as mentioned in the facility's legionella water management program.

Resident #31 Review on 3/6/24 of Resident #31's nurse's note dated 3/4/24 revealed that on 2/27/24 Resident #31 fell asleep while sitting in his/her wheelchair and fell forward to the floor. Note further stated that Resident #31's care plan was updated to include the intervention that if Resident #31 falls asleep in his/her wheelchair then staff should encourage Resident # 31 to go to bed. Review on 3/6/24 of Resident # 31's care plan revealed no intervention to encourage Resident #31 to go to bed if he/she falls asleep in his/her wheelchair. The care plan for falls was last updated on on 1/18/24. Interview on 3/7/24 at approximately 9:45 a.m. with Staff D (Licensed Practical Nurse) confirmed the above findings. Review on 3/8/24 of the facility's policy titled Comprehensive Care Planning dated 9/1/22, revealed the following: .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change . Based on observation, interview, and record review it was determined that the facility failed to revise care plans for 2 of 2 residents reviewed for care planning in a final sample of 24 (Resident Identifiers #31 and #63). Findings Include: Resident #63 Review on 3/7/24 of Resident #63's medical record revealed a provider order, with a start date of 12/22/23, for Eliquis [anticoagulant] 5 mg [milligram] Oral Twice Daily for atrial fibrillation. Further review on 3/7/24 of Resident #63's medical record revealed no care plan interventions for monitoring adverse drug reactions of the anticoagulant medication. Interview on 3/7/24 at approximately 7:50 a.m. with Staff E (Director of Nursing) confirmed the above finding. Review on 3/8/24 of the facility's policy titled Anticoagulant Medications dated 9/1/22, revealed the following: .a. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to follow professional medication administration standards for 1 medication administered out of 29 medications (Resident Identifier is #16). Findings include: Review on 3/7/24 of professional nursing standard: Fundamentals of Nursing, [NAME], [NAME] A., and [NAME]. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009 revealed: Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician ' s orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 3/6/24 at approximately 8:20 a.m. of Staff A (Registered Nurse) administering Resident #16's medications revealed that Staff A did not instruct the resident to rinse his/her mouth after inhaling corticosteroid medicine. Review on 3/6/24 of Resident #16's Physician Orders for this inhaler revealed instructions to Rinse mouth after use. Review on 3/7/24 of the manufacturer warnings and precautions for this corticosteroid inhaler, revealed Candida albicans infections of the mouth and pharynx may occur. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce risk. Interview on 3/7/24 at approximately 8:45 a.m. with Staff E (Director of Nursing) confirmed the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility failed to provide adequate supervision to prevent a resident from eloping from the facility and to ensure safety measures were in place for a resident who was at risk for elopement for 2 of 3 residents reviewed for accident hazards (Resident Identifiers are #1 and #2). Findings include: Resident #1 Review on 6/1/23 of Resident #1's medical record revealed that he/she was admitted to the facility on [DATE] with a diagnosis of unspecified symptoms and signs involving cognitive functions and awareness-memory, cognitive impairment. Review on 6/1/23 of Resident #1s Minimum Data Set (MDS) with an assessment reference date of 2/27/23 revealed Resident #1 had a Basic Interview for Mental Status (BIMS) score of 9 out of 15. Review on 6/1/23 of Resident #'1's Elopement Assessment, dated 4/10/23 revealed: . Elopement Risk 1. Prior to admission, did patient have a history of elopement or exit seeking behavior? No 2. Has patient exhibited wandering or exit seeking behavior in the last 90 days? Yes . 8. Has there been a change in patient's living arrangements within the last 30 days, including room change? Yes 9. Is patient cognitively impaired with poor decision making skills? Yes . Elopement Risk (Score of 1) Level (The patient is at risk for elopement). Proceed with appropriate safety intervention. Comment (Wander guard re-applied to walker). Review of 6/1/23 of Resident #1's Progress Notes revealed the following: 3/1/23 at 11:27 a.m. Resident noted to be exit seeking and wandering. Wander guard and care plan in place. DPOA [Durable Power of Attorney] in agreement and gave verbal consent. Wander guard placed to resident's LLE [Lower Left Extremity]. 4/11/23 at 12:43 a.m. Resident wandering and exit seeking throughout the shift. 4/15/23 at 8:34 p.m. Noted with exit seeking behavior this AM [morning] X1 [one time]. 4/19/23 at 11:38 a.m. Resident wandering and exit seeking throughout the shift. 4/20/23 at 2:35 a.m. Resident attempting to exit building multiple times today. Stating he is signing himself out and borrowing someone's car. Going to door and trying to leave. 4/20/23 at 11:30 p.m. Reported to this writer that resident frequently exit seeking . Resident continues to remove wander guards from person or walker and dispose of them so wander guard discontinued. Resident on 15 minute checks for safety. 4/21/23 at 5:59 a.m. Reported to this writer that resident was exit seeking. Resident called 911 on 4/20 at 11:30 attempting to get out of facility. 4/22/23 at 9:48 p.m.exit seeking x1 . 5/13/23 at 2:13 p.m.resident was found outside the facility, a staff member saw the resident and brought back to the facility safety . Interview on 6/1/23 at 11:30 a.m. with Staff A (Director of Nursing) revealed that Resident #1 was let out of the facility by a visitor. Resident #1 told the visitor that his/her ride was outside. The visitor observed Resident #1 asking for a ride so the visitor told a staff member. Interview further revealed that Resident #1 was brought back inside the building within minutes by a staff member. Review on 6/1/23 of Resident #1's current care plan revised 4/14/23 revealed the following problem, goal, and approach: .Problem: .Exit seeking behavior as evidenced by: Wandering and exit seeking behaviors. No wander guard in place. 15 min checks in place .Goal: . Will be safe and secure in their environment .Approach: .15 mins checks in place related to exit seeking. No wander guard in place, Resident noted to cut off wander guard . Review on 6/1/23 of Resident #1's 15 Minute Check Log dated 5/13/23 revealed that no 15 minute checks were documented between 12:00 a.m. and 3:00 p.m. Interview on 6/1/23 at 1:15 p.m. with Staff A revealed that there were no 15 minute checks documented prior to the resident eloping the facility on 5/13/23. Review on 6/1/23 of facility policy titled Elopement Prevention Procedure revised on 9/2022, revealed .Procedure: . C. Communication and monitoring of Patient Response to Invention: . 2. Individualized monitoring based on assessed risk level and interventions planned . Resident #2 Review on 6/1/23 of Resident #2's medical record revealed that he/she was admitted to the facility on [DATE]. Review on 6/1/23 of Resident #2's Elopement Assessment, dated 12/12/22 revealed: . Elopement Risk 1. Prior to admission, did patient have a history of elopement or exit seeking behavior? Yes 2. Has patient exhibited wandering or exit seeking behavior in the last 90 days? Yes . 5. Was or is resident patient resistive to Nursing Home placement? Yes 6. Does patient verbally express desire to leave center or go home? Yes . 9. Is patient cognitively impaired with poor decision making skills? Yes . Elopement Risk (Score of 4) Level (The patient is at risk for elopement). Proceed with appropriate safety intervention. Review on 6/1/23 of Resident #2's nursing notes revealed: 12/24/22: 12:37 a.m.Was wandering on unit this evening. Stated [pronoun omitted] was going home. 1/4/23: 10:39 p.m. Was wandering throughout the shift stating [pronoun omitted] wanted to go home. 1/9/23: 12:25 p.m. Exit seeking multiple times this shift, . 1/10/23 11:27 a.m. [pronoun omitted] continues to exit seek . 1/11/23 7:20 a.m. Exit seeking at times . 1/12/23 9:55 a.m. Resident wandering this shift, exit seeking and searching for wife . Review on 6/1/23 of Resident #2's care plans revealed the following: Problem Start Date, 1/16/23 Exit seeking behavior as evidenced by: Resident noted to exit seek and wander at times Interview at approximately 1:00 p.m. with Staff A revealed that there were no elopement interventions put into place for Resident #2 from 12/12/22 to 1/16/23. Review on 6/1/23 of the facility policy titled, Elopement Prevention Procedure, Revision Date 9/22 revealed: Purpose: To identify patients who are at risk for elopement and to develop and implement the lease restrictive appropriate intervention to reduce the probability of elopement. Procedure: All patients will receive a comprehensive nursing assessment within 24 hours from admission. All patients who identify at risk or we feel poses a risk for elopement will have a care plan with appropriate interventions.

Based on observation, interview, and record review, it was determined that the facility failed to assess residents' ability to self-administer medications for 2 of 2 residents reviewed for self-administration of medication in a final survey sample of 21 residents (Resident identifiers are #46 and #150). Findings include: Resident #150 Observation on 2/15/23 at 10:28 a.m. and on 2/16/23 at 9:05 a.m. in Resident #150's room revealed an opened tube of Dibucaine topical anesthetic on his/her night stand. Interview on 2/5/23 at 10:28 a.m. with Resident #150 revealed that he/she used the ointment whenever he/she wanted to and at times needed staff assistance. Interview on 2/16/23 at 9:10 a.m. with Staff E (Licensed Practical Nurse) confirmed Resident #150 did not have an order for self-administration of the topical anesthetic. Resident #46 Observation on 2/15/23 at 10:40 a.m. in Resident #46's room revealed 3 loose pills (2 tablets and 1 capsule) on his/her night stand. Interview on 2/15/23 at 10:40 a.m. with Resident #46 revealed staff had left the pills for him/her at approximately 8:30 a.m. Interview on 2/16/23 at 9:10 a.m. with Staff E (Licensed Practical Nurse) confirmed Resident #46 did not have an order for self-administration of medication. Review on 2/16/23 of the facility policy titled, Self-Administration of Medications revealed: 1. Residents who wish to self-administer medications are assessed by the licensed nurse to determine cognitive and physical abilities initially; then quarterly thereafter to determine whether self-administrating medications is safe and clinically appropriate for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #75 Review on 2/16/23 at approximately 9:22 a.m. of Resident #75's medical record revealed that they had admitted to the facility on [DATE] with diagnosis of Bipolar disorder, Obsessive Compulsive Disorder (OCD), personal history of Traumatic Brain Injury (TBI) and PTSD. Further review of Resident #75's medial record revealed an active order for Clozapine [Antipsychotic] 350 mg at night time for Bipolar, with a start date of 11/15/22. Review on 2/17/23 at approximately 8:50 a.m. of Resident#75's medial record revealed no PCL-C was completed for Resident #75. Review on 2/17/23 at approximately 9:10 a.m. of Resident #75's medical record revealed no indication that psychiatric or psychological services had been initiated. Interview on 2/17/23 at approximately 9:15 a.m. with Staff C (Assistant Director of Nursing) confirmed the above information. Interview on 2/17/23 at approximately 9:20 a.m. with Staff B (MDS nurse) stated that they are responsible for psychiatric services referrals and that they had sent one over on Resident #75 a few weeks ago, but Resident #75 had not been seen yet as the provider wanted to know more about their extensive psychiatric and medication history. Review on 2/17/23 at approximately 9:30 a.m. of Resident #75's care plan revealed no identified behaviors or PTSD triggers. Interview on 2/17/23 at approximately 9:30 a.m. with Staff D (Social Services) confirmed that no referral had been made for Psychological services for Resident #75 and that no behaviors are identified on care plan or PTSD triggers. Based on interview and record review the facility failed to ensure that residents who were diagnosed with a mental disorder or have a history of trauma and/or Post-Traumatic Stress Disorder (PTSD) received appropriate treatment and services for 2 of 3 residents reviewed for behaviors and emotions in a final survey sample of 21 (Resident identifiers are #50 and #75). Findings include: Resident #50 Review on 2/17/23 at approximately 8:40 a.m. of Resident #50's medical record revealed that Resident #50 was admitted to the facility on [DATE] with diagnosis of anxiety, depression, and PTSD. Further review of Resident #50's medical record revealed that on 11/2/21 Resident #50 completed the Post Traumatic Stress Disorder Checklist-Civilian Version (PCL-C) with a score of 8.0 on the 2 item version. An individual is considered to have screened positive if the sum of the items is 4.0 or greater. Review on 2/17/23 at approximately 9:00 a.m. of Resident #50's physician orders revealed that Resident #50 is taking Sertraline 25 milligrams (mg) 1 time a day, and Trazadone 150 mg give 50 mg at bedtime for depression. Interview on 2/17/23 at with Staff C (Social Services Director) who revealed that if a resident has a positive score on the PCL-C then the resident is offered psychological services and psychiatric services which is contracted through two different providers. Staff C also revealed that Staff C is responsible for referrals for psychological services and that Staff B (Minimum Data Set Nurse) was responsible for referrals to psychiatric services. Interview on 2/17/23 at approximately 9:20 a.m. with Staff B (MDS Nurse) confirmed that Resident #50 had not been offered psychiatric services. Review on 2/17/23 of the facility policy titled Post-Traumatic Stress Disorder Screening Policy Statement: The facility will complete the PCL-C screen upon admission. Policy Interpretation and Implementation: Residents who indicate a positive score on the PCL-C screening will be care planned and offered additional mental health services once consent is obtained.

Based on interview and record review, it was determined that the facility failed to ensure a resident was provided with education on the risks and benefits of the Pneumococcal vaccination for 5 of 5 residents reviewed for Pneumococcal immunizations (Resident identifiers are #2, #48, #69, #85 and #94). Findings include: Resident #2 Review on 2/17/23 at approximately 10:30 a.m. of Resident #2's medical record revealed their admission to the facility was on 6/17/16. Further review of Resident #2's medical record revealed they had received the Pneumococcal vaccination on 9/15/17. Review on 2/17/23 at approximately 10:45 a.m. of Resident #2's medical record revealed no consent for Pneumococcal vaccination and no indication that further vaccination was offered or that education was provided on the Pneumococcal vaccination. Resident #48 Review on 2/17/23 at approximately 10:30 a.m. of Resident #48's medical record revealed their admission to the facility was on 3/5/20. Further review of Resident #2's medical record revealed they had received the Pneumococcal vaccination on 6/10/16. Review on 2/17/23 at approximately 10:45 a.m. of Resident #48's medical record revealed no consent for vaccination and no indication that further vaccination was offered or that education was provided on the Pneumococcal vaccination. Resident #69 Review on 2/17/23 at approximately 10:30 a.m. of Resident #69's medical record revealed their admission to the facility was on 1/24/23. Further review of Resident #69's medical record revealed no information regarding Pneumococcal vaccination or consent for Pneumococcal vaccination. Resident #85 Review on 2/17/23 at approximately 10:30 a.m. of Resident #85's medical record revealed their admission to the facility was on 9/15/22. Further review of Resident #85's medical record revealed no information regarding Pneumococcal vaccination or consent for Pneumococcal vaccination. Resident #94 Review on 2/17/23 at approximately 10:30 a.m. of Resident #94's medical record revealed their admission to the facility was on 12/23/22. Further review of Resident #94's medical record revealed no information regarding Pneumococcal vaccination or consent for Pneumococcal vaccination. Interview on 2/17/23 at approximately 10:45 a.m. with Staff A (Infection Preventionist) confirmed the facility could not provide evidence that education was provided to each of the above listed residents regarding the risks and benefits of the Pneumococcal vaccination or that Pneumococcal vaccination was offered. Review on 2/17/23 of the facility policy titled Pneumococcal Vaccine Policy, with no initiation date, revealed .the resident or responsible party will receive information and education regarding benefits and potential side effects of vaccine .Vaccinations will be administered and offered in accordance with current recommendations from the CDC [Centers for Disease Control and Prevention]. Review of the CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, effective 01/28/22, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV [Pneumococcal Conjugate Vaccine] 15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV [Pneumococcal Polysaccharide Vaccine] 23 at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults 65 years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults 65 years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended . For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete .

Based on interview and record review, it was determined that the facility failed to offer and provide education to the risks and benefits of the COVID-19 vaccination for 4 of 5 residents reviewed for COVID-19 immunizations (Resident identifiers are #2, #48, #69 and #94). Findings include: Resident #2 Review on 2/17/23 at approximately 10:30 a.m. of Resident #2's medical record revealed their admission to the facility was on 6/17/16. Further review of Resident #2's medical record revealed they had not received the COVID-19 vaccination, and there was no information regarding the education and offering of the COVID-19 vaccination or declination of the COVID-19 vaccination. Resident #48 Review on 2/17/23 at approximately 10:30 a.m. of Resident #48's medical record revealed their admission to the facility was on 3/5/20. Further review of Resident #48's medical record revealed they had not received the COVID-19 vaccination, and there was no information regarding the education and offering of the COVID-19 vaccination or declination of the COVID-19 vaccination. Resident #69 Review on 2/17/23 at approximately 10:30 a.m. of Resident #69's medical record revealed their admission to the facility was on 1/24/23. Further review of Resident #69's medical record revealed they had not received the COVID-19 vaccination, and there was no information regarding the education and offering of the COVID-19 vaccination or declination of the COVID-19 vaccination. Resident #94 Review on 2/17/23 at approximately 10:30 a.m. of Resident #94's medical record revealed their admission to the facility was on 12/23/22. Further review of Resident #94's medical record revealed they had not received the COVID-19 vaccination, and there was no information regarding the education or offering of the COVID-19 vaccination. Interview on 2/17/23 at approximately 12:22 p.m. with Staff C (Assistant Director of Nursing) confirmed that no proof of education or declination could be provided for the COVID-19 vaccination for the above residents. Review on 2/17/23 of the facility policy titled COVID-19 Immunization, revised on 11/12/22, revealed .the patient's medical record will include that they were provided education regarding the benefits and potential risks associated with the COVID-19 vaccine, each dose of the COVID-19 vaccine administered, and if they did not receive the vaccine due to medial contraindication or refusal .