**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 physicians orders for 1 out of 3 residents observed during medication administration (Resident Identifier #20). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. 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 10/29/24 at approximately 9:30 a.m. of Staff B (Medication Nursing Assistant) during medication preparation, revealed that Staff B poured one tablet of Docusate Sodium 50 milligrams (mg)/Sennosides 8.6 mg for Resident #20 into a medication cup. Review on 10/29/24 of Resident #20's physician orders revealed an order dated 10/15/2024: Sennosides 8.6 mg give 1 tablet by mouth one time a day. Interview on 10/29/2024 at approximately 9:35 a.m. with Staff B confirmed that he/she poured the wrong medication. Review on 10/29/2024 of facility policy titled, Medication Administration General Guidelines, dated 1/2021, revealed: .1. Medications are administered in accordance with written orders of the prescriber .

Based on observation, interview, and record review, it was determined that the facility failed to follow physician's orders for a nutritional intervention for 1 of 2 residents reviewed for nutrition in a final sample of 12 residents (Resident Identifier #19). Findings include: Review on 10/30/24 of Resident #19's Weight Summary revealed that the Resident's #19's weight was 104.9 pounds on 9/16/24. Further review revealed that on 10/21/24, Resident #19's weight was 101 pounds. Resident #19's first weight recorded after admission was on 9/1/24 was 109 pounds. Review on 10/30/24 of Resident #19's physician's orders revealed a current order dated 8/31/24 for Ensure three times a day for Ensure high plus protein 3 times a day with meals [sic]. Review on 10/30/24 of Resident #19's Nutritional Assessment, dated 9/3/24, revealed: .Has order for Ensure TID [three times a day], [discussed with] nurse, has not yet received it. Suggested homemade shake if accepted, nurse to review . Plan . Ensure or high calorie shake . This was signed by Staff C (Registered Dietician). Observation on 10/30/24 at 12:36 p.m. of Resident #19 eating lunch in the dining room revealed that there was no Ensure with his/her meal. Interview on 10/30/24 at 12:28 p.m. with Staff D (Licensed Nursing Assistant) revealed that Resident #19 does not ever get Ensure with their meals during the day shift. Interview on 10/30/24 at 12:28 p.m. with Staff E (Licensed Practical Nurse) confirmed that Resident #19 was not getting the Ensure as ordered by the physician and that the resident should be getting it with meals. Staff F revealed the order for the Ensure was not on the Medication Administration Record or on the resident's meal ticket. Interview on 10/30/24 12:36 p.m. with Staff G (Cook) revealed that he/she serves Resident #19 meals and does not get Ensure. Review on 10/30/24 of the facility's policy titled, Supplemental Nourishment Program Policy, effective 9/1/24, revealed: .The following protocol was developed to provide personalized medical nutrition therapy for those residents identified to be at nutritional risk (i.e. weight loss, decreased intake, wounds) . When a resident is added to the Supplemental Nourishment Program . The resident will then be added to the nourishment list that is sent to the unit .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure a resident was offered and/or provided the Pneumococcal vaccine for 1 of 5 residents reviewed for immunizations (Resident Identifier #18 ). Findings include: Review on 10/30/24 of Resident #18's medical record revealed that Resident #18 was admitted to the facility on [DATE]. Further review revealed that Resident #18 consented to receive the PPSV23 (pneumococcal polysaccharide vaccine) on 9/20/23 and no documentation was available to show Resident #18 received the vaccine. Interview on 10/30/24 at approximately 2:30 p.m. with Staff A (Infection Preventionist) revealed that Resident #18 had not been given the PPSV23 that Resident #18 consented to receive. Review on 10/31/24 of facility policy titled, Immunizations: Pneumococcal Vaccinations of Residents PPSV23, PCV20, PVC15, dated 6/9/22, revealed: . a. All residents age [AGE] years or older will be offered appropriate vaccination, if applicable, based on their prior pneumococcal vaccine status and new 2022 CDC recommendations .

Based on observation, interview and record review, it was determined that the facility failed to store food in accordance with professional standards for food service safety, to prevent food borne illness for one of one kitchens observed. Findings include: Observation on 11/6/23 at approximately 9:00 a.m. of the kitchen refrigerator revealed the following: 24 raw eggs with a manufacturer's best by date of 10/30/23; 2 raw eggs with a manufacturer's best by date of 10/19/23; 2 unopened sour cream containers with a manufacturer's use by date of 10/28/23. Observation on 11/6/23 at approximately 9:00 a.m. of the kitchen storage room refrigerator revealed a plastic container covered with plastic wrap labeled pumpkin puree 10/10/23 use by 10/31/23. Further observation of plastic container revealed whitish growth like substance on the pumpkin puree. Interview on 11/6/23 at approximately 8:45 a.m. with Staff G (Senior Cook) confirmed the above findings. Review on 11/6/23 of facility policy titled Food Storage and Labeling, revised on 6/29/23, revealed . Refrigerated items: .2. Unopened will be utilized bythe manufacturer's use by or expiration date .4. All opened or left over items must have a visible label that identifies the item, the date it was prepared or opened, and the use by date. This includes (but is not limited to) juice, salad dressing, leftovers, and portioned desserts . Review on 11/6/23 of the Food Code U.S. Public Health Service 2017 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food . Page 458 Manufacturer's use-by dates It is not the intent of this provision to give a product an extended shelf life beyond that intended by the manufacturer. Manufacturers assign a date to products for various reasons, and spoilage may or may not occur before pathogen growth renders the product unsafe. Most, but not all, sell-by or use-by dates are voluntarily placed on food packages the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons. It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind .

Observation on 11/6/23 at approximately 11:52 a.m. of the North Hall bathroom revealed a spray bottle of GC 2010 disinfectant to be hanging on the wall just inside the doorway. Interview on on 11/6/23 at approximately 12:00 p.m. of Staff F (Scheduler/Licensed Medication Nursing Assistant) revealed that there are 2 residents that wander on the North Hall. Review of Safety Data Sheets revealed: GC-2010 Safety Data Sheet - Section 2: Hazard(s) Identification - Acute toxicity (oral) Category 4 - Harmful if swallowed .Serious eye damage/eye irritation Category 1 - Causes serious eye damage. Based on observation and interview, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards as is possible regarding storage of chemical cleaning solutions on 3 of 3 units observed (North Hall, East Hall, South Hall). Findings include: Observations on 11/6/23 at 9:30 a.m. and 12:30 p.m. of the North Hall revealed that one of the shared residents bathroom door was open with a bottle of GC2010 chemical cleaning solution hanging on the wall within reach of residents. Observation on 11/6/23 at 12:35 p.m. of the corner of the East and South Halls revealed that the Shower Whirlpool Room door was open with a bottle of GC2010 chemical cleaning solution on a cart and a hot to the touch Hydrocollator that was on within reach of residents. Interview on 11/6/23 at approximately 1:00 p.m. with Staff A (Licensed Practical Nurse) revealed that 4 residents between the 3 halls have been identified to wander and that GC2010 was stored in the shared resident bathrooms. Observations on 11/7/23 at approximately 7:35 a.m. of the North Hall shared bathroom and the South Hall shared bathroom revealed that the doors were open each with a bottle of GC2010 chemical cleaning solution hanging on the wall within reach of residents. Interview on 11/7/23 at 8:38 a.m. with Staff B (Director of Nursing), confirmed the above findings, removed chemical cleaning solutions from bathrooms and locked the Shower Whirlpool Room. Interview on 11/8/23 at 9:45 a.m. with Staff C (Regional Nurse) revealed that the facility did not have a policy to ensure secure storage of chemical cleaning solutions.

Based on interview and record review it was determined that the facility failed to ensure that training and education was provided to staff on abuse, neglect, exploitation, and misappropriation of resident property for 2 of 5 staff reviewed (Staff Identifiers are Staff E and J). Finding include: Review on 11/7/23 of Staff E's (agency Licensed Nursing Assistant) education file revealed no training or education for abuse, neglect, exploitation and misappropriation of resident property. Review on 11/8/23 of Staff J's (agency Licensed Practical Nurse) education file revealed no training or education for abuse, neglect, exploitation, and misappropriation of resident property. Interview on 11/8/23 at approximately 10:30 a.m. with Staff B (Director of Nursing) confirmed that above findings. Staff B stated that they did not have an education process for the agency staff at this time. Review on 11/8/23 of facility policy titled Abuse Prevention and Reporting, revised on 10/24/22, revealed .2. Training- Employees will be educated on abuse prevention and reporting .Employees will be educated at orientation and through on-going programs on issues related to abuse prevention practices .

**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 physician's order for documenting wound measurement for 1 of 1 pressure ulcer reviewed in a final sample of 12 residents (Resident identifier is #11). Findings include: Professional reference: [NAME] A. [NAME] and [NAME], Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physicians' 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 . Review on 12/21/22 of Resident #11's clinical note dated 10/26/22 revealed that Resident #11 had a recurrent right outer ankle abrasion. The right outer ankle area was cleaned and dressed with previous orders to the site. Review on 12/21/22 of Resident #11's initial alteration in skin integrity assessment dated [DATE] revealed a facility acquired right ankle bone abrasion and wound type of recurrent. Further review revealed no description of the right ankle bone abrasion such as appearance, measurements, shape, or drainage. Review on 12/21/22 of Resident #11's orders revealed a telephone order on 10/26/22 for a treatment to cleanse right ankle abrasion with normal saline, skin prep the edges, and add a small piece of Xeroform (cut to fit) to center redness, cover with dry dressing every day, measure, and document on Tuesdays. Review on 12/21/22 of Resident #11's medical records revealed no documentation of measurement for Resident #11's right outer ankle abrasion for 11/1/22, 11/8/22, 11/15/22, and 11/20/22 (Tuesday dates on November 2022). Review on 12/21/22 of Resident #11's clinical note dated 11/2/22 revealed that the right ankle was assessed, cleaned, and dressing changed as ordered. Further review revealed that the right ankle area had a small open, superficial break, partial skin loss. Review also revealed no measurements of the right ankle open area. Review on 12/21/22 of Resident #11's clinical note dated 11/20/22 revealed that Resident #11 was walking from the bathroom limping and he/she had pain to their right ankle where the open wound was located. Review of the clinical note dated 11/20/22 also revealed that the right ankle area was red and painful to touch. Review on 12/21/22 of Resident #11's clinical note dated 11/21/22 revealed that Resident #11 had a re-opened area on their right outer ankle measuring 0.1 centimeter (cm) in length by 0.1 cm in width by 0.1 cm depth with redness around the perimeter of the wound, tender to touch, possible infection. There was a new order obtained from the nurse practitioner for Doxycycline 100 milligram (mg) twice a day for 7 days for possible cellulitis. Review on 12/21/22 of Resident #11's initial alteration in skin integrity assessment dated [DATE] revealed Resident #11 had a facility acquired stage 2 pressure ulcer to their right outer ankle with granulation tissues/red, length of 0.1 cm, width of 0.1 cm, depth of 0.1 cm, no drainage, no tunneling, no undermining, peri-wound skin inflamed/indurated, wound edges was symmetrical, and round wound shape. Further review revealed that Resident #11 was started on antibiotic for possible infection. Interview on 12/21/22 at approximately 10:45 a.m. with Staff C (Registered Nurse) revealed that in September 2022 Resident #11 had developed an unstageable pressure ulcer on the right outer ankle, the pressure ulcer healed, and re-opened as an abrasion on 10/26/22. Interview on 12/21/22 at approximately 10:47 a.m. with Staff D (Director of Nursing) confirmed the above findings. Staff D also confirmed that Resident #11 had a right outer ankle abrasion on 10/26/22 and on 11/21/22 on the same location developed into a stage 2 pressure ulcer. Staff D also stated that on 10/26/22 there should have been a non-pressure ulcer skin assessment flow sheet initiated in regards to Resident #11's right outer ankle abrasion. Staff D was unable to provide further documentation of measurements and tracking of Resident #11's right ankle bone abrasion after 10/26/22 and before 11/21/22. Observation on 12/21/22 at approximately 11:11 a.m. with Staff B (Licensed Practical Nurse) revealed that Resident #11 had an open area to their right outer ankle at the bony prominence, round in shape and redness to the surrounding perimeter. Interview on 12/21/22 at approximately 11:11 a.m. with Staff B confirmed the above observation. Review on 12/21/22 of facility policy titled, skin care, with no date, revealed .SKIN CARE AND TREATMENTS .10. Document upon identification of potential or actual skin issues in the resident summary template and Chat. 11. Wound rounds are done weekly for all residents with wounds. Staging and measurement of wounds should be done at this time by a designated and consistent nurse. Ideally, a wound care team would be established that includes the charge nurse and LNA. The wound care team would meet weekly to assess skin care issues and preventative strategies. Wound rounds are not to exceed 7 days from the last rounds .14. Pressure ulcer and wound assessments will be performed by a consistent licensed nurse for treatment care selection. Wound characteristics will assist the physician and nurse in a treatment choice .SKIN CARE GUIDELINES PROCEDURE .6. When a skin issues is observed: redness, rash, skin tear, blister, or actual breakdown, open the skin process in Vision. The process will cue the nurse of the nest steps needed. This includes completing the Initial Alteration in Skin Integrity Assessment for min Vision Initiation of the process, will enable the DNS [Director of Nursing Services] and R.D. [Registered Dietician] to be notified of the wound .9 .During rounds, the wound nurse, and/or wound team will complete the Weekly Pressure Ulcer Assessment Form or the Non-Pressure Ulcer Skin Condition Report .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that medications were labeled and disposed of in 1 of 1 medication cart observed. the facility also failed to ensure that narcotics were properly stored in 1 of 1 medication storage room observed (Resident identifiers are #5 and #7). Findings include: Observation on 12/20/22 at approximately 10:44 a.m. of the medication cart with Staff B (Licensed Practical Nurse) revealed an opened Breo Ellipta inhaler for Resident #5 with no open date or open expiration date. Review on 12/20/22 with Staff B of the manufacturer's instructions on the inhaler revealed that once opened, the Breo Ellipta inhaler should be discarded after 6 weeks. Interview on 12/20/22 at approximately 10:45 a.m. with Staff B confirmed that Resident #5's inhaler was opened and had no open date or open expiration date. Staff B also confirmed that the manufacturer's instructions were to discard the inhaler after 6 weeks once opened. Observation on 12/20/22 at approximately 11:05 a.m. of the facility's medication room revealed an unlocked refrigerator. There was a padlock on the refrigerator that was not secured (locked). Inside the refrigerator was 1 vial (2 milligrams (mg) /1 milliliter(ml)) of Lorazepam concentrate (a schedule IV controlled substance) for Resident #7. Interview on 12/20/22 at approximately 11:08 a.m. with Staff B confirmed that the refrigerator was unlocked. Review on 12/21/22 of the facility's policy titled Medication Storage revised on 1/21 revealed, . 4.2 Controlled Medication Storage . 4. Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator.