Based on observation, interview, record review, it was determined that the facility failed to provide foot care for 1 of 1 resident reviewed for foot care in a final sample of 21 residents (Resident Identifier #87). Findings include: Observation on 9/24/24 at approximately 10:50 a.m. of Resident #87's toenails revealed long and overgrown toenails by approximately 1 inch over the toe. His/her toenails were thick and curling in and around his/her toes. Record review on 9/25/24 of Resident #87's Podiatry note, dated 5/20/24, revealed toenail care for thick, dystrophic, elongated nails B/L [bilaterally] and to follow up in 60 days. Interview on 9/24/24 at approximately 8:30 a.m. with Staff A (Unit Manager) confirmed that Resident #87's last podiatry visit was on 5/20/24. Staff A revealed the podiatrist was in the facility seeing residents yesterday (9/24/24) and the podiatrist did not see Resident #87. Record review on 9/26/24 of Resident #87's nurses note dated 9/8/24 revealed that Resident #87's toenails had been assessed as long and thick. Further review revealed that there was no evidence that nail care was provided on 9/8/24.

Based on record review and interview, it was determined that the facility failed to ensure that as needed (PRN) psychotropic drugs were limited to 14 days for 1 of 5 residents reviewed for unnecessary medications in a final sample of 21 residents (Resident Identifier #31). Findings include: Review on 9/24/24 of Resident #31's September 2024's Medication Administration Record revealed the following physician's order: Lorazepam 0.5 mg [milligram] Tablet by mouth every 2 hours as needed for restlessness/agitation, Start Date 6/2/24. Further review revealed that Resident #31 received a dose of the PRN medication on 9/11/24. Interview on 9/25/24 at approximately 1:45 p.m. with Staff D (Unit Manager) confirmed the above findings and that Resident #31's above order was not limited to 14 days. Review on 9/25/24 of the facility policy titled, Antipsychotic and Psychotropic Medications, Dated August 2023 revealed: .PRN orders for Psychotropic drugs (anti-psychotic, Anti-depressant, anti-anxiety, Hypnotic and or any medication ordered for psychotropic use) are limited to 14 days .

Based on observation and interview, it was determined that the facility failed to ensure that medications were disposed of properly, to prevent potential unauthorized access, during observation of medication administration in a survey sample of 16 medications prepared for administration. Findings include: Observation on 9/24/24 at approximately 8:30 a.m. of Staff G (Registered Nurse (RN)) revealed he/she disposed of a medication capsule in the open trash on the medication cart. Further observation revealed Staff G disposed of a second medication capsule in the open trash on the medication cart. Interview on 9/24/24 at approximately 8:30 a.m. with Staff G revealed his/her usual practice is to dispose medications in the trash. Interview on 9/25/24 at approximately 3:15 p.m. with Staff C (Administrator in Training) revealed medication disposal should be in the drug buster stored in the locked medication room.

Based on record review and interview, it was determined that the facility failed to follow an established antibiotic stewardship program and system of monitoring antibiotic use for 2 of 3 residents that were reviewed (Resident Identifiers are #36 and #7). Findings include: Review on 9/25/24 of facility policy titled, Antibiotic Stewardship Program (ASP), undated, revealed that the program support statement is to reduce the overuse of antibiotics. Further review revealed .Providers .Document conversation with residents and their representative regarding the current medical treatment plan and the appropriate use of antibiotics .Infection Preventionist .Help ensure antibiotics are prescribed only when appropriate. Review on 9/25/24 of facility policy titled, Policy for Infection Control Surveillance, dated 9/2023, revealed: .1.e ICC will identify using the McGeer's definitions to see if an antibiotic is ordered that met criteria . Interview on 9/26/24 at approximately 9:00 a.m. with Staff C (Administrator in Training) revealed that a discussion with medical providers takes place in the facilities Quality Assurance and Performance Improvement (QAPI) meetings regarding prophylactic antibiotic treatments. Resident #36 Review on 9/25/24 of the July 2024 antibiotic line list revealed Resident #36 was treated for a Urinary Tract Infection (UTI) following a urinalysis and culture, performed on 7/9/24, for a symptom of confusion with indwelling catheter use. Review on 9/25/24 of the July 2024 urinalysis and culture results dated 7/11/24 for Resident #36 revealed 1,000-9,000 colony forming units / milliliter (cfu/ml) of Escherichia coli bacteria growth. Review on 9/26/24 of Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria, OCTOBER 2012 , VOL. 33 , NO. 10, revealed: .B. For residents with an indwelling catheter .2. Urinary catheter specimen culture with at least 100,000 cfu/ml of any organism(s) . Interview on 9/26/24 at approximately 9:00 a.m. with Staff F (Infection Preventionist) revealed he/she utilizes McGeer's Criteria for antibiotic use and appropriateness, and confirmed Resident #36's UTI treatment did not meet McGeer's criteria, due to minimal growth of Escherichia coli (under 100,000 cfu/ml). Resident #7 Review on 9/25/24 of the August 2024 antibiotic line list revealed Resident #7 was treated for Cellulitis for symptoms of 1. redness 2. raised. Review on 9/26/24 of Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria, OCTOBER 2012 , VOL. 33 , NO. 10, revealed: .A. Cellulitis, soft tissue, or wound infection .2. New or increasing presence of at least 4 of the following sign or symptom subcriteria: a. Heat at the affected site b. Redness at the affected site c. Swelling at the affected site d. Tenderness or pain at the affected site e. Serous drainage at the affected site . Interview on 9/26/24 at approximately 9:00 a.m. with Staff F (Infection Preventionist) confirmed that only 2 of the 4 symptoms were present and did not meet McGeer's criteria.

Based on record review, interview, and policy review, it was determined that the facility failed to establish a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records are in order; and that an account of all controlled drugs is maintained in 3 of 4 narcotic books reviewed. Findings include: Review on 7/18/22 of the facility's policy titled Narcotic Count and Book Policy Version C dated August 2017 revealed, .Policy: Narcotics are to be counted and the narcotic book signed by both oncoming and outgoing shift at the beginning and end of every shift and anytime the keys to the med carts are passed to another licensed nursing staff .Procedure: When doing count: off duty nurse does the narcotic book reading the resident, drug, and dosage. Nurses must be side by side so they both can see the page and medication cart .The back pages of the narcotic book are designated for signatures. Entry must be dated, timed, yes or no indicated if count is correct, and both nurses must sign with their title. If you leave early, arrive late, or are called away, you must make note of this record .Count must be done when leaving and then again upon return . Review on 7/17/23 at 9:45 a.m. of the Odd Side 200 Medication Cart Narcotic Shift Count Book revealed that on 7/17/23 Staff D (Registered Nurse) had pre-signed her/his name in the column as the Nurse Going Off Duty prior to her/his shift ending around 3:00 p.m. Interview on 7/17/23 at 9:47 a.m. with Staff D confirmed that he/she had pre-signed the Narcotic Shift Count Book that morning for coming on duty and for going off duty (which would be at around 3:00 p.m.). Staff D stated that the practice of signing before the shift was over was not facility policy. Review on 7/17/23 at 2:50 p.m. of the Odd Side Medication Cart Narcotic Shift Count Book for June 2023 and July 2023 revealed the following: - Time AM/PM was not documented on 6/1, 6/4, 6/12, 6/16, 6/17, 6/19, 6/20, 6/25, 6/28, and 7/13; - Status Of Count Exact Yes/No was not documented on 6/1, 6/4, 6/16, 6/17, 6/18, 6/19, 6/21, 6/22, 6/25, 6/27, 6/30, 7/10, 7/13, 7/15, 7/16, and 7/17; - Nurse Coming On Duty was not documented on 6/18; - Nurse Going Off Duty was not documented on 6/21, 7/11, 7/13, and 7/16. Interview on 7/17/23 at 2:55 p.m. with Staff D confirmed the above findings. Review on 7/17/23 at 3:00 p.m. of the Even Side Medication Cart Narcotic Shift Count Book for June 2023 and July 23 revealed the following: -Date was not documented six times during June and July; - Time AM/PM was not documented on 6/1, 6/13, 6/14, 6/25, 6/27, 6/28, and 7/4; - Status Of Count Exact Yes/No was not documented on 6/1, 6/7, 6/8, 6/11, 6/13, 6/14, 6/15, 6/17, 6/18, 6/22, 6/24, 6/25, 6/26, 6/27, 6/28, 6/30, 7/4, 7/5, 7/8, and 7/14; - Nurse Coming On Duty was not documented on 6/2, 6/30, and 7/7; - Nurse Going Off Duty was not documented on 6/1, 6/20, 6/30, and 7/7. Interview on 7/17/23 at 3:05 p.m. with Staff C (Licensed Practical Nurse (LPN)) confirmed that the above.Review on 7/17/23 at 2:10 p.m. of the Fourth floor Medication Cart Narcotic Shift Count Book revealed that on 7/17/23 Staff B (LPN) had already signed as the nurse going off duty despite still being on duty. Continued review of this form revealed that columns for time, status of the exact count, and nurse coming on duty were completed. Further review of this narcotic book revealed the following: - Nurse Coming On Duty was not documented on 7/2 and 7/4 - Nurse Coming Off Duty was not documented on 7/2 and 7/7 Interview on 7/17/23 at 2:10 p.m. with Staff B confirmed that he/she had pre-signed the Narcotic Shift Count Book that morning as the Nurse Going Off Duty. Staff B stated that he/she should have signed the book when count was completed and not at the beginning of his/her shift. Interview on 7/17/23 at 3:30 p.m. with Staff A (Director of Nurses) revealed that Narcotic Shift Count Books should be signed and dated by the nursing staff when the actual counts are done.

**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 ensure that narcotics were properly stored in 1 of 4 medication storage rooms observed. Findings include: Observation on 7/17/23 at 9:25 a.m. of the Second Floor Medication Room (room [ROOM NUMBER]) revealed an unlocked refrigerator. There was a padlock resting on top of the refrigerator. Inside the refrigerator were 4 vials (2 milligrams/1 milliliter) of Lorazepam injection (a Schedule IV controlled substance). Interview on 7/17/23 at 9:30 a.m. with Staff C (Licensed Practical Nurse) confirmed that the refrigerator was unlocked. Staff C stated that medications must have been removed from the refrigerator that morning and the refrigerator should have been locked after the medications were removed. Review on 7/18/22 of the facility's policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles revised on 10/31/16 revealed, . 3. General Storage Procedures: 3.1 Facility should store Schedule II Controlled Substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device .12. Controlled Substances Storage: 12.1 Facility should ensure that Scheduled II-V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility. 12.2 After receiving controlled substances and adding to inventory, Facility should ensure that Scheduled II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law). 12.3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security .

Based on observation, record review, and interview, it was determined that the facility failed to assess a resident's ability to self-administer medications for 2 out of 2 residents reviewed for self-administration of medication in a final sample of 23 residents. (Resident Identifiers are #15 and #96.) Findings include: Resident #96 Observation on 8/30/22 at approximately 11:32 a.m. of Resident #96's room revealed one bottle of Systane eye drops and one bottle of saline nasal spray on the over-bed table. Interview on 8/30/22 at approximately 11:33 a.m. with Resident #96 revealed that he/she uses the eye drops and nasal spray up to 4 times per day as needed. Interview on 8/30/22 at approximately 11:35 a.m. with Staff J (RN) confirmed that Resident #96 had one open bottle of eye drops with no open date or expiration date and one open bottle of saline nasal spray with no open date. Review on 8/31/22 of Resident #96's medical record revealed no assessment for self-administration of medication and no order for self-administration of medications. Interview on 8/31/22 at approximately 2:25 p.m. with Staff G (Unit Manager) revealed that the physician's orders for the eye drops and normal saline spray said Administration Instructions: May keep at bedside. Staff G confirmed that there was no assessment or order for self-administration of medications. Review on 9/1/22 of the facility's policy 2.1 Self Administration of Medications with revision date of 11/28/16 revealed . 2.Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. 5. Facility should ensure that orders for Self-Administration list the specific medication(s) the resident may Self-Administer . Resident #15 Observation on 8/31/22 at approximately 8:08 a.m. of Resident #15's room revealed one bottle of nasal mist extra strength and one bottle of saline nasal spray on the over-bed table. Interview on 8/31/22 at approximately 8:08 a.m. with Resident #15 revealed that he/she uses both nasal sprays approximately 3-4 times per day as needed. Review on 8/31/22 of Resident #15's August 2022 Medication Administration Record (MAR) revealed the following order: Drug: Saline Nasal Spray 0.65% solution Dose: (1 spray) nasal (both) every 4 hours as needed. There was no documentation of the nasal spray being administered during the month. Review on 8/31/22 of Resident #15's medical record revealed no assessment for self-administration of medication and no order for self-administration of medication. Interview on 8/31/22 at approximately 2:15 p.m. with Staff G confirmed that Resident #15 had both nasal sprays in their room. Staff G confirmed that Resident #15 had a physician's order for saline nasal spray with 'Administration instructions: May keep at bedside but no order for nasal mist extra strength or assessments to self-administer the medications. Staff G confirmed that there were no entries in the August 2022 MAR of administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Based on observation, interview and record review, it was determined that the facility failed to follow physician orders for 1 out of 2 residents reviewed for mood and behavior and for 1 of 4 residents reviewed for weight loss in a final sample of 23 Residents (Resident Identifier is #35 and #39). Findings Include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed., St. Louis, Missouri, Mosby Elsevier, 2009, pp. 336 - Physician's 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 . Resident #35 Review on [DATE] of Resident #35's medical record revealed a consult with (pronoun omitted) Geriatrics on [DATE]. Resident #35's consultation note revealed: .Reason for Consultation: Management of psychiatric issues.Medical Decision-Making: At this time, I would not change the medications. Given the fact that the patient has had sleep problems for some time and is on trazodone, which has worked well for (pronoun omitted), I would recommend maintaining that for right now and then, tracking the behavioral issues, we will be able to address the treatment plan. I will follow up with the patient in 3 months or p.r.n. (as needed) Review on [DATE] of Resident #35's medical record revealed no other consultation notes or follow up notes with (pronoun omitted) Geriatrics. Review on [DATE] of Resident #35's medical record revealed a behavior nursing note stating Upon approaching resident for (pronoun omitted) HS (bed time) meds, (pronoun omitted) stated that (pronoun omitted) does not want anything (from me). (pronoun omitted) stated (pronoun omitted) was upset about last night, because (pronoun omitted) wanted a pain pill and I was questioning (pronoun omitted) about why (pronoun omitted) needed it. I explained to (pronoun omitted) that because (pronoun omitted) Norco is not scheduled, I have to ask (pronoun omitted) about (pronoun omitted) pain (ie. Location, scale/rating, ect). (pronoun omitted) told me that (pronoun omitted) should not need to ask for it or tell people every night about how (pronoun omitted) is feeling. (pronoun omitted) then moved away from me and cursed at me before returning to (pronoun omitted) room. Interview on [DATE] at approximately 9:05 a.m. with Staff G (Unit Manager) revealed he/she was unable to produce documentation of a follow up visit with psychiatric services. Resident #39 Record review revealed that the Dietitian's August's dietary progress note dated [DATE] stated resident previously lost significant weight and is followed for nutrition risk. (Pronoun omitted) is on level 2 ground mechanical Soft diet that is low fat and avoids ice cream r/t gallbladder dx. (Pronoun omitted) is also on a CC (consistent carbohydrate) diet with SF (sugar free) jelly and syrups, no sugar. Intakes recently have been 50% breakfast, 64% lunch and 89% supper w/55% intakes of snacks. Weight is now 141.2 on 8/9 vs 140.9 on 6/14 and 141.5 on 2/22. Further record review revealed a physician order on [DATE] to begin weekly weights until [DATE]. Further review revealed that the physician order for weekly weights was discontinued on [DATE]. Review of the monthly weights on [DATE] revealed the following: [DATE] 148.1 lbs [DATE] 147.2 lbs [DATE] 145.8 lbs [DATE] 139.0 lbs [DATE] 144.8 lbs [DATE] 139.2 lbs [DATE] 142.2 lbs [DATE] 142.2 lbs [DATE] 140.9 lbs [DATE] 141.2 lbs There were no additional weights documented. Interview on [DATE] at 2:03 p.m. with Staff D, Minimum Date Set Coordinator (MDS) and Staff B, License Practical Nurse (LPN) confirmed that there was no physician order to discontinue the weight in the resident's chart. They also confirmed that the resident's weight for [DATE] was missing. Interview was performed at [DATE] at 10:57 AM with Staff A, (Dietitian). Staff A stated that he/she was aware of the resident's plan of care relating to his/her nutrition. He/she said that they did not know why his/her weekly weights would have been dc'd. When asked if he/she initiated the dc, he/she said that they hadn't and wasn't sure who would have done it. Interview on [DATE] at 1:44 p.m. with Staff L, Infection Preventionist, revealed that he/she discontinued the physician order by mistake and that the order should have remained active. Review on [DATE] of the facility's policy titled Monitoring Resident Body Weight dated July-2020, read, in part .Based on a resident's comprehensive assessment, the facility must ensure that a resident: (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; .Goal: To prevent weight loss/gain .7. The RD will assess all residents for weight changes quarterly following the MDS schedule and will update documentation in the medical record and care plan . 8. Daily or weekly weights may be ordered at the discretion of the MD/PA/APRN, NM or RD, to include instruction for parameters of loss gain. 1. Based on observation, interview, and record review, it was determined that the facility failed to ensure that medical supplies used for blood draws (blood container tubes) were stored and not expired according to professional standards for 1 out of 2 medication rooms observed. Findings include: Observation on [DATE] at 9:25 a.m. of the Second Floor Even Side Medication Room with Staff J (Licensed Practical Nurse) revealed a plastic box labeled lab box that contained a red capped blood container tube with a manufacturer's expiration date of [DATE]. Further review of the medication room revealed in a cabinet drawer a red capped blood container tube with a manufacture's expiration date of [DATE] and a blue capped blood container tube with a manufacturer's expiration date of [DATE]. Interview on [DATE] at 9:25 a.m. with Staff J confirmed that the blood container tubes were expired. Staff J stated that the tackle box was used for blood draws by the nurses, and that the vials in the drawer would also be used (once the vials in the tackle box were used). Staff J stated that the blue capped blood container tubes were used for Prothrombin time and international normalized ratio (PT/INR). Staff J stated that the expired vacutainers should not be used. Interview on [DATE] at 10:49 a.m. with Staff I (Director of Nurses) confirmed that the facility would not want to use the expired vacutainers. Interview on [DATE] at 2:58 p.m. with Staff I confirmed that all blood work was drawn by the facility's nursing personnel. Review on [DATE] of BD Vacutainer Evacuated Blood Collection System retrieved from https://www.fda.gov/media/151687/download revealed . Storage Do not use tubes after their expiration date. Tubes expire on the last day of the month and year indicated .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that narcotics were properly stored in 1 of 2 medication storage rooms observed (4th floor 'Open' side). Findings include: Observation on 8/30/22 at 9:40 a.m. of the Fourth Floor Open Side medication room revealed an unlocked refrigerator. There was a padlock on the refrigerator that was not secured (locked). Inside the refrigerator were 5 vials (2 milligrams/1 milliliter) of Lorazepam injection (a schedule IV controlled substance) for Resident #400. Interview on 8/30/22 at 9:40 a.m. with Staff B (Licensed Practical Nurse) and Staff H (Medication Nursing Assistant) confirmed that the refrigerator was unlocked and should have been (locked). Both staff stated that they had access to the medication room. Interview on 8/30/22 at 10:49 a.m. with Staff I (Director of Nursing) confirmed that the above refrigerator should be locked. Review on 8/30/22 of the facility's policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles revised on 10/31/16 revealed, . 3. General Storage Procedures: 3.1 Facility should store Schedule II Controlled Substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device .12. Controlled Substances Storage: 12.1 Facility should ensure that Scheduled II-V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility. 12.2 After receiving controlled substances and adding to inventory, Facility should ensure that Scheduled II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law). 12.3 Facility should ensure that all controlled substances area stored in a manner that maintains their integrity and security .

Based on record review and interview, it was determined that the facility failed to ensure laboratory services were provided when ordered by a physician for 1 out of 4 residents reviewed for nutrition in a final sample of 23 residents. (Resident identifier is #51.) Findings include: Review on 9/15/22 of Resident #51's physician orders revealed the following order dated, 6/21/22: 1. Increase metolazone to 2.5 mg (milligrams) po (by mouth) QD (daily) . 3. Review in 1 week 4. BMP (Basic Metabolic Panel) 7/5/22 Review on 9/14/22 of Resident #51's lab (laboratory) results revealed that there was no bloodwork drawn on Resident #51 until on 7/12/22. Interview on 9/15/22 at approximately 12:15 p.m. with Staff D (Registered Nurse) revealed that the staff member that draws laboratory samples was not at the facility on 7/5/22 and the labs were delayed until 7/12/22. Staff D could not provide any documentation that the physician was notified of the delay in the lab draw. Review on 9/15/22 of the facility policy titled, Laboratory Testing, dated October 2017 revealed: Procedure: 1. Routine laboratory blood work to be done as stated below or as ordered by a physician 4. Routine laboratory test slips are completed by the Unit Assistants, and the blood work drawn by the [pronoun omitted] laboratory technician on specialized days 5. All other blood work is to be drawn by Nursing personnel 8. Other labs drawn as required