**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Responsible Party (RP) interviews, the facility failed to notify the RP of a significant change in a resident's condition that included transport and admission to the hospital for 1 of 4 residents reviewed for notification of change (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's medical record revealed his family member was his RP. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. The discharge MDS dated [DATE] showed Resident #1 was moderately cognitively impaired. Resident #1's active diagnoses included delirium. A nursing note dated 12/18/24, written by Nurse #1 revealed Resident #1 requested to be transported to the emergency room. At 11:40 PM the resident was transported to the hospital via stretcher. A nursing note dated 12/19/24, written by Nurse #2 documented she called the hospital to get a status update on Resident #1. The nurse documented she was told the resident was being admitted for intestinal obstruction. Nurse #2 reported the status update to Nurse #1. A phone interview with Resident #1's RP was conducted on 1/8/25 at 10:15 AM. She stated no one from the facility notified her Resident #1 was transported to the hospital on [DATE] or that he was admitted to the hospital. She learned of the situation on 12/20/24 when the hospital social worker called her. Attempts made to interview Nurse #1 who discharged Resident #1 to the hospital on [DATE] were unsuccessful. An interview with Nurse #2 on 1/8/25 at 1:57 PM revealed she did not notify the family when Resident #1 was transferred to the hospital on [DATE] as it would have been the responsibility of Nurse #1. The Administrator, the Director of Nursing and the [NAME] President of Clinical Services were interviewed on 1/8/24 at 4:00 PM. The Director of Nursing stated they had reviewed the progress notes and facilitated an in-service with Nurse #1 on the notification requirements for RPs. The Administrator stated her expectation would have been for the hall nurse to notify Resident #1's RP of transport and admission to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to replace a damaged bed mattress for 1 of 32 residents reviewed for environment (Resident #9). The findings included: Resident #9 was admitted on [DATE] with diagnoses that included right sided hemiplegia (paralysis), neuropathy (nerve pain), artificial knee joint, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Work order # 9213 created on 11/15/24 revealed a request had been entered by Med Aide (MA) #1 for Resident #9's current room for mattress extremely uncomfortable, has a deep dip in it. The notes stated Resident #9 is requesting a new mattress, it causes his back to hurt. He is out of bed right now if you can change it. The work order was assigned to the Maintenance Assistant, who referred the work order to central supply and set the status to completed. In an interview with MA #1 on 12/04/24 2:44 PM she stated on 11/15/24 Resident #9 told her he felt like he was down in a hole when he laid on his mattress. She stated she placed a work order, and the mattress had been replaced within about 15 minutes or so on 11/15/24. She stated the Central Supply Manager told her he replaced it with a new mattress, and the replacement mattress on 11/15/24 did not look worn to her. MA #1 stated Resident #9 told her that the replacement mattress was uncomfortable and he felt like he was sitting in a hole again. She stated she told Resident #9 the Central Supply Manager told her it was new so it was not the mattress, and she told Resident #9 it might be because he was so tall that it felt like that. MA #1 stated that she did not assess the mattress herself to see if it had an indentation in it. During an interview with the Maintenance Assistant on 12/04/24 at 1:45 PM he stated he received a work order placed on 11/15/24 for Resident #9's bed mattress and took the work order to the Central Supply Manager so a new mattress could be ordered. After he assigned it to the Central Supply Manager on 11/15/24 he marked the work order as completed. During an interview with the Central Supply Manager on 12/04/24 at 2:26 PM he stated that he replaced old mattresses on beds and if the mattresses were still in good condition, he placed them on another bed. He further indicated that he had not replaced a mattress on Resident #9's bed on 11/15/24. The Central Supply Manager stated if a resident complained about a mattress, he just replaced it regardless of condition. An observation was conducted on 12/02/24 at 12:06 PM of Resident #9's bed mattress. The mattress was observed to be without bed linens and the mattress slanted down from the left side of the mattress toward the right side of the mattress. A 15-inch by 15-inch in diameter indentation was visible midway of the mattress towards the right side. The cover of the mattress was observed to have a faded, rough, cracked, worn appearance as compared to the remainder of the mattress cover. During an interview with Resident #9 on 12/02/24 at 12:06 PM he stated he moved from another room to his current room about a month ago and his first mattress was in bad shape and had a sag in it that was like the sag in the current mattress. He stated he told Medication Aide (MA) #1 the mattress was uncomfortable, and he received a replacement mattress about 3 weeks ago. He stated the mattress was replaced with the current mattress and the man (did not know his name or title) who put it on his bed told him it was a new mattress but, within a few days he could tell it was not new because it sagged worse than the first mattress. Resident #9 stated when he laid on the second mattress, he felt like his buttocks dipped in a hole and it caused him to have discomfort in his back. He stated he had back surgery about 3 years ago and it aggravated his back. When asked if he had pain from laying on the mattress, he stated it felt like there was something pressing between his shoulder blades and it made him feel achy at times. Resident #9 stated a week ago he told another Nursing Assistant (NA) (could not recall her name) that the second mattress was uncomfortable, and she told him she talked to someone about it, but it never got changed. During an observation and interview with Nurse # 1 on 12/02/24 at 12:21 PM she stated she was unaware of the condition of Resident #9's bed mattress but it should not sag like it did and should be replaced. She stated she would put in a work order immediately to have it replaced. Housekeeper #1 assigned to Resident #9's hall was interviewed on 12/05/24 at 11:26 AM and stated she was responsible for inspecting the mattresses on her assigned hall when she deep cleaned the rooms, and if they were damaged or had sags in them, they would need to be replaced. Housekeeper #1 further indicated she had deep cleaned Resident #9's room before he moved in around 11/01/24. She stated she could not recall if the mattress had an indentation or damage and that she just wiped down the mattress. In an interview with the Housekeeping Supervisor, on 12/04/24 at 2:05 PM he stated the housekeepers kept him informed when a mattress needed to be replaced related to poor condition. He stated he was not informed about a mattress in poor repair for Resident #9 on 11/15/24 and had not changed the mattress on that date. He stated the Central Supply Manager changed mattresses on beds when needed. In an interview with the Maintenance Director on 12/04/24 at 9:28 AM he stated he had received a work order for Resident #9's room on 11/15/24. He stated the request was related to Resident #9's bed mattress. He stated the work orders were assigned to the Maintenance Assistant who would have made a referral to Central Supply so a new mattress could be ordered. In an interview with a family member of Resident #9 on 12/05/24 at 11:54 AM she stated she visited the resident sometime around 11/17/24. She stated that during her visit Resident #9's bed had been stripped of linen and the mattress was visible. The family member stated the mattress was cracked and broken up, and had a saggy look to it in the middle and stated she did not know another way to describe the appearance of the mattress. Resident #9's family member said no one should have to sleep on a mattress in that poor of a condition. She stated she told a NA (name unknown to her), and the NA told her she was new, and Resident #9 should not have had a mattress in that poor of a condition. In an interview with Nurse Practitioner # 1 on 12/05/24 at 10:59 AM she stated laying on a mattress with an indentation would not cause long lasting effects for Resident #9 because he got out of the bed to a wheelchair during the day, but he had right sided hemiplegia and neuropathy and had pain in general and it could have added to his pain. During a combined interview with the Administrator and the Central Supply Manager on 12/04/24 11:50 AM the Administrator stated if residents had a concern about a bed mattress the resident told the unit staff, and a work order would be placed and the Maintenance Director or the Administrator notified the Central Supply Manager so a new mattress could be ordered. The Central Supply Manager did not recall a replacement mattress being placed on Resident #9's bed on 11/15/24. He stated if a work order had been placed on 11/15/24 it would have been assigned to him to get a new mattress and he would have replaced the mattress. In interviews with the Administrator on 12/04/24 at 3:18 PM and 12/5/24 at 9:47 AM she shared she was unaware that Resident #9 had slept on a mattress in poor condition from 11/15/24 until 12/2/24, when it was observed by the surveyor. The Administrator stated a replacement mattress should be provided if a resident requested one. She further stated that if Resident #9 requested to have a mattress replaced because of discomfort, then it should have been replaced immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident, staff, pharmacist and physician interviews, the facility failed to protect a resident's right to be free from the misappropriation of medication for 2 of 2 residents (Resident #116, Resident #163) reviewed for misappropriation of resident property. Findings included: 1. Resident #116 was admitted to the facility on [DATE]. Her active diagnoses included diabetes mellitus. Review of Resident #116's orders revealed on 1/16/24 she was ordered Ozempic inject 0.25 mg (milligrams) subcutaneously one time a day every Tuesday for diabetes mellitus. A review of Resident #116's Medication Administration Record (MAR) revealed on 4/23/24 Nurse #8 documented Ozempic was not available to be administered. During an interview on 12/4/24 at 2:49 PM Nurse #8 who documented Ozempic as unavailable and not administered to Resident #116 on 4/23/24 stated she did work with Resident #116 on night shifts in 4/2024. She further stated at that time Resident #116's Ozempic was being administered once a week at night on Tuesdays. She stated it was a long time ago, but she believed she gave the resident her Ozempic a few times prior to 4/23/24 with no issues. She stated she did not recall that night (4/23/24) very well. She stated this was her only experience with Ozempic not being available for her to administer the medication. She stated Resident #116's blood sugars were baseline and the resident did not display any negative side effects from the lack of the medication. She concluded had Resident #116 developed hyperglycemia they had faster acting insulin available in their e-kit and would have been able to provide coverage per physician orders had it been necessary which it was not. A review of a pharmacy packing slip dated 4/24/24 revealed the facility received a pen containing 12 doses of Ozempic for Resident #116. A review of Resident #116's MAR revealed on 4/30/24 Nurse #10 documented Ozempic was not available to be administered. On 5/7/24 Nurse #9 documented Ozempic was not available to be administered. On 5/14/24 Nurse #10 documented Ozempic was not available to be administered. During a telephone interview on 12/5/24 at 9:53 AM Nurse #9 who documented Ozempic as unavailable and not administered to Resident #116 on 5/7/24 she stated she did not remember the incident as it was a long time ago. She reported that to her knowledge; Resident #116 did not have any negative side effect of not receiving Ozempic on her shift but she reiterated she did not remember the incident or that Resident #116 was on Ozempic but stated Resident #116 had always been stable when she worked with her. Nurse #10 who documented not having available or administering Ozempic to Resident #116 on 4/30/24 and 5/14/24 was unavailable for interview. During a telephone interview on 12/05/24 at 1:01 PM Pharmacist #2 stated the pharmacy dispensed a 3 milliliter Ozempic pen for Resident #116 on 4/24/24. This pen was reported as lost by the facility and was never returned by the facility. The facility was charged for the replacement which was dispensed on 5/15/24 and received by the facility. A review of the facility's investigational summary dated 5/18/24 completed by the Director of Nursing revealed on 5/16/24 the facility noted a pattern of Ozempic being unavailable for Resident #116 and conducted a 100% audit of all residents receiving GLP1 (a class of drugs used to treat type 2 diabetes and obesity) medications. During this audit all GLP1 medications were counted, and control substance count sheets were placed in the narcotic books. On 5/18/24 the facility initiated an in-service with the Minimum Data Set (MDS) nurses as it related to pulling reports to capture the past 24 hours of medications not available and medications not given. On 5/18/24 the facility initiated an in-services with all nurses and medication aides related to counting GLP1 injectable pens during shift/break changes including adding control substance count sheets on arrival of new supplies. During an interview on 12/3/24 at 8:20 AM Resident #116 stated sometime this year her Ozempic went missing, and she did not receive a few doses of it. She stated she gets the medication every Saturday currently. At the time, she was getting it every Tuesday. When the facility identified that her Ozempic was missing they changed the day it was being given to Saturday. They also reordered the medication. She had no issues since. On 12/04/24 at 9:10 AM the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were interviewed and stated during Inter-Disciplinary Team (IDT) morning meeting on 4/24/24 they noted Ozempic was documented as not available and not given to Resident #116 on 4/23/24 based on the report provided by the Minimum Data Set (MDS) nurses which was pulled each morning for the IDT morning meeting. This did not raise any concern at that time because upon review, the medication was to be delivered that evening on 4/24/24. Nurse Practitioner #1 was a part of this discussion and was following the resident for Diabetes Mellitus and blood sugars. They ensured they had coverage (medication to control blood sugar levels) for her blood sugars. The DON stated during morning IDT meeting on 5/1/24 it was noted that Resident #116's Ozempic was again not available and not given on 4/30/24. She then told the nurse to reorder it through the computer from the pharmacy. She stated at that time she believed it was due to pharmacy delivery error and did not think there would be any reason for someone to take the medication. The medication was not given and not available on 5/7/24 but this was not captured in the IDT morning meeting on 5/8/24 due to an error in the way the MDS nurses were pulling the report. They were unaware of this at that time and assumed the medication had come in and was being given correctly. The next dose was to be given on 5/14/24 and it was not available and not given. This time it did show up on the MDS report and was flagged. The IDT team noted it was not available and not given to Resident #116 on 4/23/24, 4/30/24, 5/7/24, and 5/14/24. This caused them to do a more in-depth review of the medication and try to discover what was going on. The ADON stated she went to the unit refrigerator and looked for the medication for Resident #116 and was unable to find it. All unit managers went and checked all of the facility carts and unit refrigerators to ensure the medication had not been misplaced in the facility. They were unable to find the medication. She then called the pharmacy and pulled the packing slip which came with the medication when it was delivered. The packing slip was found with a delivery date of 4/24/24 and one pen with 12 doses was delivered to the facility. When the nurse had reordered the medication via the computer on 5/1/24 the pharmacy had not sent the medication because it was too soon to refill. She then called the pharmacy, and the pharmacy told her it was not time for the medication to be reordered and if they wanted another delivery of a pen with 12 doses the facility would have to pay out of pocket for the medication. She stated she then went to the Administrator to get permission to reorder the medication from the pharmacy out of the facility's pocket. The medication was ordered and filled on 5/16/24 and arrived that night. On 12/4/24 at 1:27 PM the interview with the Administrator, DON, and ADON continued and the ADON stated at that point they felt the pen had been thrown away in error or misplaced. However, the next day they pulled a report on all residents that were prescribed antidiabetic medications and highlighted the residents prescribed GLP1 medications. Then they pulled the MAR for all those residents for the time range they were prescribed a GLP1. They then pulled all the packing slips from the pharmacy showing the amount and when the GLP1s were delivered to the facility for all residents identified as receiving GLP1 medications. They then compared the packing slip delivery quantities to the MARs to account for every dose that was received by the facility for the length of each GLP1 prescribed. They then checked all the medications currently in the facility to ensure what was in the facility was accurate compared to the delivery slips and what should be in the facility according to the packing slips. During this investigation it was also found that another resident (Resident #163) also had missing doses. These discrepancies were not captured by the MDS report for the IDT morning meetings the next day due to a mistake in how MDS pulled the records. At this point they felt this was not a pharmacy error or the pens were simply misplaced and initiated sign-in and out count sheets for all GLP1 medications currently in the facility and ensured locks were on the medication storage refrigerators. The nursing and medication aide staff were in-serviced on the use of the count sheets for GLP1 medications. The MDS nurses were educated on how to pull all missing medications to be reviewed in the morning IDT meetings. They implemented the process of signing in and out the countdown sheets for GLP1 medications and implemented a monitoring tool to check the medications daily. She stated from the point where they implemented the new count down sheet process and the monitoring tool, they had not had any discrepancies with GLP1 medications. She stated on 5/17/24 the police, Department of Health and Human Services, and Adult Protective Services were notified of the misappropriation of resident property. During a telephone interview on 12/5/24 at 1:58 PM Physician #1 stated he was made aware of the incident when the Ozempic pens were missing. He further stated he was notified by the nurses on the hall when the medication was not available to be given. He explained that Ozempic was not a medication that controlled blood sugars on a day-to-day basis, but it helped stabilize hemoglobin A1C (a blood test that measures your average blood sugar level over the past three months) over the course of multiple months. He stated he had no concerns about any negative outcomes due to the lack of the Ozempic in the facility and was monitoring Resident #115's bloods sugars and the resident had coverage available. They had no negative out comes because of the lack of Ozempic. During a follow up interview on 12/5/24 at 9:01 AM the Administrator stated following the investigation they concluded the facility was unable to substantiate the misappropriation of resident property because they were unable to determine the location of the Ozempic pens after they were last known to have been received by the facility from the pharmacy. The pens were replaced at no cost for both residents and the facility paid for the replacement pens. 2. Resident #163 was admitted to the facility on [DATE]. Her active diagnoses included diabetes mellitus. Review of Resident #163's orders revealed on 4/10/24 she was ordered Ozempic inject 2 mg (milligrams) subcutaneously one time a day every 7 days for diabetes mellitus. A review of a pharmacy packing slip dated 4/10/24 revealed the facility received a pen containing 4 doses of Ozempic for Resident #163. A review of Resident #163's Medication Administration Record (MAR) revealed on 4/24/24 and 5/15/24 Nurse #12 documented Ozempic was not available to be administered. On 5/1/24 Nurse #11 documented Ozempic was not available to be administered. On 5/8/24 Nurse #13 documented Ozempic was not available to be administered. During a telephone interview on 12/5/24 at 8:39 AM Nurse #12 who documented Ozempic as not available and not administered to Resident #163 on 4/24/24 and 5/15/24 stated she did not remember the incident or the resident. She indicated she did not know of any negative outcomes for Resident #163 due to not having Ozempic available. During a telephone interview on 12/5/24 at 8:17 AM Nurse #11 who documented Ozempic as not available and not administered to Resident #163 on 5/1/24 stated she did not remember that Resident #163 was on Ozempic. She further stated she did not recall specifically not having Ozempic for Resident #163. She stated Resident #163's bloods sugars never went out of baseline for the resident as far as she could recall, and she did have insulin coverage (medication to control blood sugar levels) if her blood sugars were elevated, and the resident did not have any negative outcomes due to Ozempic not being available. Nurse #13 who documented Ozempic as not available and not administered to Resident #163 on 5/8/24 was not available for interview. During a telephone interview on 12/05/24 at 1:01 PM Pharmacist #2 stated an 8mg Ozempic pen was dispensed on 4/10/24 for Resident #163 and arrived at the facility. This pen should have lasted 28 days per dosing. The pen was not returned. On 5/16/24 this pen was refilled, and the facility reported the 4/10/24 pen as lost and paid for the pen dispensed on 4/10/24. A review of the facility's investigational summary dated 5/18/24 completed by the Director of Nursing revealed on 5/16/24 the facility noted a pattern of Ozempic being unavailable for another resident (Resident #116) and conducted a 100% audit of all residents receiving GLP1 (a class of drugs used to treat type 2 diabetes and obesity) medications. During this audit all GLP1 medications were counted, and control substance count sheets were placed in the narcotic books. The audit identified Resident #163 had not had available or received her Ozempic on 4/24/24, 5/1/24, 5/8/24, and 5/15/24. On 5/18/24 the facility initiated an in-service with the Minimum Data Set (MDS) nurses as it related to pulling reports to capture the past 24 hours of medications not available and medications not given. On 5/18/24 the facility initiated an in-services with all nurses and medication aides related to counting GLP1 injectable pens during shift/break changes including adding control substance count sheets on arrival of new supplies. During an interview on 12/4/24 at 1:27 PM the Assistant Director of Nursing stated another resident had triggered concerns that GLP1 medications were not available and administered. On 5/16/24 they pulled a report on all residents that were prescribed antidiabetic medications and highlighted the residents prescribed GLP1 medications. Then they pulled the MAR for all those residents for the time range they were prescribed a GLP1. They then pulled all the packing slips from the pharmacy showing the amount and when the GLP1s were delivered to the facility for all residents identified as receiving GLP1 medications. They then compared the packing slip delivery quantities to the MARs to account for every dose that was received by the facility for the length of each GLP1 prescribed. They then checked all the medications currently in the facility to ensure what was in the facility was accurate compared to the delivery slips and what should be in the facility according to the packing slips. During this investigation it was also found Resident #163 had not had available or received her dose of Ozempic on 4/24/24, 5/1/24, 5/8/24, and 5/15/24. These discrepancies were not captured by the MDS report for the IDT morning meetings the next day due to a mistake in how MDS pulled the records. At this point they felt this was not a pharmacy error or the pens were simply misplaced and initiated sign-in and out count sheets for all GLP1 medications currently in the facility and ensured locks were on the medication storage refrigerators. The nursing and medication aide staff were in-serviced on the use of the count sheets for GLP1 medications. The MDS nurses were educated on how to pull all missing medications to be reviewed in the morning IDT meetings. They implemented the process of signing in and out the countdown sheets for GLP1 medications and implemented a monitoring tool to check the medications daily. She stated from the point where they implemented the new count down sheet process and the monitoring tool, they had not had any discrepancies with GLP1 medications. She stated on 5/17/24 the police, Department of Health and Human Services, and Adult Protective Services were notified of the misappropriation of resident property. During a telephone interview on 12/5/24 at 1:58 PM Physician #1 stated he was made aware of the incident when the Ozempic pens were missing. He further stated he was notified by the nurses on the hall when the medication was not available to be given. He explained that Ozempic was not a medication that controlled blood sugars on a day-to-day basis, but it helped stabilize hemoglobin A1C (a blood test that measures your average blood sugar level over the past three months) over the course of multiple months. He stated he had no concerns about any negative outcomes due to the lack of the Ozempic in the facility and was monitoring Resident #163's bloods sugars and the resident had coverage available. They had no negative out comes because of the lack of Ozempic. During a follow up interview on 12/5/24 at 9:01 AM the Administrator stated following the investigation they concluded the facility was unable to substantiate the misappropriation of resident property because they were unable to determine the location of the Ozempic pens after they were last known to have been received by the facility from the pharmacy. The pens were replaced at no cost for both residents and the facility paid for the replacement pens. The facility provided the following corrective action plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 4/23/2024, scheduled Ozempic pen was not available to administer to Resident #116 per physician order. On 4/24/24, the facility received 3ml (2mg/ml) Ozempic pen via pharmacy courier. On 4/30/24, the scheduled dose of Ozempic for resident #116 was noted as not available to administer per nursing documentation. On 5/1/24, the Assistant Director of Nursing (ADON) was notified of Resident #116 scheduled Ozempic medication was not available to administer. The ADON submitted a refill request via the computer. On 5/7/24 and 5/15/24, the scheduled dose of Ozempic medication for Resident #116 was documented as not available to administer per nursing documentation. The ADON notified the pharmacy for a refill of the medication at the cost of the facility. The medication arrived on 5/16/24. On 5/17/24, the physician was notified of scheduled Ozempic medication not available to administer on 4/23/24, 4/30/24, 5/7/24 and 5/14/24 with new order to resume medication on 5/18/24. On 5/18/24, Resident #116 was administered Ozempic per physician order. On 4/10/24, the scheduled Ozempic pen for Resident #163 was documented as not available to administer per nursing documentation. The assigned nurse notified the pharmacy for refill request. On 4/10/24, 3ml Ozempic (8mg/ml) pen were delivered to the facility via pharmacy courier. On 4/17/24, Resident #163 received Ozempic per physician order. On 4/24/24, Resident #163 was moved from station 4 to station 2. The nurse documents that the scheduled Ozempic dose as not available to administer. The assigned nurse requested a refill via the electronic record. On 5/16/24, the administrative nurse identified during the audit of residents receiving Ozempic that the resident had not received scheduled doses due to the drug not available to administer. The ADON notified the pharmacy for a refill of the medication at the cost of the facility. The medication arrived on 5/16/24. On 5/17/24, the physician was notified of scheduled Ozempic medication not available to administer on 4/10/24, 4/17/24, 4/24/24, 5/1/24 and 5/8/24 with new order to resume medication on 5/18/24. On 5/18/24, Resident #163 was administered Ozempic per physician order. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On 5/16/2024 Facility conducted an audit of all residents receiving (glucagon-like peptide 1 (GLP1) medications (Ozempic/Semaglutide and Trulicity/Dulaglutide). This audit was to ensure medications were administered per physician order and/or the physician notified for further recommendations. The Administrative nurses addressed all concerns identified during the audit to include ordering medication not available to administer, notification of the physician for further recommendations and/or education of the nurse. During this audit all GLP1 Medications (Ozempic/Semaglutide and Trulicity/Dulaglutide) were counted, and the facility proactively initiated Control Substance Count sheets and placed in the appropriate Narcotic Books. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On 5/18/2024 the Facility completed an in-service with the Minimum Data Set (MDS) nurses as it relates to pulling reports to capture the past 24 hours of medications documented as Not Available or Medications Not Given for review by the Interdisciplinary team (IDT). On 5/18/2024 the Staff Development Coordination initiated an in-service with all nurses and medication aides regarding (1) Counting GLP1 Injectables Pens during shift/break changes, including adding Control Substance Count Sheets on arrival of new Supplies (2) documentation on electronic medication record (eMAR) Administration note to include in detail reason the medication was not given or not available and (3) Misappropriation to include misappropriation or medications. In-services were completed by 5/18/2024. After 5/18/2024 any Nurse/Medication Aide to include agency nurses, agency medication aides, who have not worked nor received the in-service will review/sign prior to next scheduled shift. All newly hired staff members to include agency nurses, agency medication aids will be in-serviced during orientation by the SDC regarding Counting GLP1 Medications, documentation on eMAR when meds not available to administer and Misappropriation of Residents Property Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; On 5/17/24, the Administrator and Director of Nursing made the decision to monitor resident's receiving GLP1 medications and to ensure they were administered per physicians' order. The Unit Managers will audit all residents receiving GLP 1 medications to include Resident #116 and Resident #163 utilizing the GLP 1 Audit Tool 5 times a week x 4 weeks to ensure medication was administered per physician orders and/or the provider notified for further recommendations. Any identified areas of concern will be addressed with the Director of Nursing. The Director of Nursing will forward the results of the GLP 1 Audit tool to the Quality Assurance Performance Improvement (QAPI) Committee monthly x 1 month. The QAPI Committee will meet monthly x 1 month and review the GLP1 Audit tool to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring. Completion date 5/19/24 Onsite validation of the facility's corrective action plan was completed on 12/6/24. The initial audit results were reviewed. The in-service education record dated 5/18/24 were reviewed. Interviews with nurses and medication aides indicated they attended and/or received in-service training on misappropriation of resident property including medications and handling of GLP1 medications to include count sheets and reconciliation. The monitoring results were reviewed. The QA meeting minutes were reviewed. The facility's completion date of 5/19/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive care plan in the area of fall risk for 1 of 3 residents reviewed for accidents (Resident #81). The findings included: Resident #81 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of lower end of left radius, unspecified dementia and history of falling. A review of Resident #81's Minimum Data Set (MDS) dated [DATE] revealed he was coded as having had a fall in the previous 30 days. A review of Resident #81's comprehensive care plan did not reveal a care plan in the area of falls risk. In an interview with the Minimum Data Set (MDS) nurse on 12/5/24 at 8:04 AM she looked for Resident #81's falls risk care plan in his record and stated he did not have one. She stated the MDS nurse is responsible for completing the comprehensive care plan and the missing falls risk care plan was an oversight. An interview with the Director of Nursing (DON) on 12/5/24 at 10:45 AM revealed the MDS nurse was ultimately responsible for developing comprehensive care plans. She was unaware Resident #81 did not have a care plan to address his risk for falls. An interview with the Administrator was conducted on 12/5/24 at 10:45 AM where she stated she was not aware Resident #81 did not have a falls risk care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, physician, and pharmacist interviews, the facility failed to ensure two residents received Ozempic subcutaneous injections as ordered for 2 of 7 residents reviewed for medication errors. (Resident #116 and Resident #163) Findings included: 1. Resident #116 was admitted to the facility on [DATE]. Her active diagnoses included diabetes mellitus. Review of Resident #116's orders revealed on 1/16/24 she was ordered Ozempic inject 0.25 mg (milligrams) subcutaneously one time a day every Tuesday for diabetes mellitus. A review of Resident #116's Medication Administration Record (MAR) revealed on 4/30/24 Nurse #10 documented Ozempic was not available to be administered. On 5/7/24 Nurse #9 documented Ozempic was not available to be administered. On 5/14/24 Nurse #10 documented Ozempic was not available to be administered. During a telephone interview on 12/5/24 at 9:53 AM Nurse #9 who documented Ozempic as unavailable and not administered to Resident #116 on 5/7/24 stated she did not remember the incident as it was a long time ago. She further stated she if she did not have a medication available that was scheduled, she would call the physician to get a hold order or follow whatever orders he provided after being made aware as well as letting her supervisor know. She stated she would also call the pharmacy to check on the medication or reorder it. She concluded to her knowledge; Resident #116 did not have any negative side effect of not receiving a medication including Ozempic on her shift but she reiterated she did not remember the incident or that Resident #116 was on Ozempic but Resident #116 had always had stable blood sugars. During a telephone interview on 12/05/24 at 1:01 PM Pharmacist #2 stated the pharmacy dispensed a 3 milliliter Ozempic pen for Resident #116 on 4/24/24. This pen was reported as lost by the facility and was never returned by the facility. The facility was charged for the replacement which was dispensed on 5/15/24 and received by the facility. This pen would have lasted 12 weeks per dosing, however, per the manufacturer it would only be good for 56 days after opening. During a telephone interview on 12/5/24 at 1:58 PM Physician #1 stated he was made aware of the incident when the Ozempic pens were missing. He further stated he was notified by the nurses on the hall when the medication was not available to be given. It was not a medication that controlled blood sugars on a day-to-day basis, but it helped stabilize hemoglobin A1C (a blood test that measures your average blood sugar level over the past three months) over the course of multiple months. He stated he had no concerns about any negative outcomes due to the lack of the Ozempic in the facility and was monitoring Resident #163's bloods sugars and the resident had coverage available. They had no negative out comes because of the lack of Ozempic. He concluded he expected medications to be given as ordered. During an interview on 12/5/24 at 8:13 AM the Director of Nursing stated medications should be given as prescribed. Nurse #10 who documented not having available or administering Ozempic to Resident #116 on 4/30/24 and 5/14/24 was unavailable for interview. 2. Resident #163 was admitted to the facility on [DATE]. Her active diagnoses included diabetes mellitus. Review of Resident #163's orders revealed on 4/10/24 she was ordered Ozempic inject 2 mg (milligrams) subcutaneously one time a day every 7 days for diabetes mellitus. A review of Resident #163's Medication Administration Record (MAR) revealed on 4/24/24 and 5/15/24 Nurse #12 documented Ozempic was not available to be administered. On 5/1/24 Nurse #11 documented Ozempic was not available to be administered. On 5/8/24 Nurse #13 documented Ozempic was not available to be administered. During a telephone interview on 12/5/24 at 8:39 AM Nurse #12 who documented Ozempic as not available and not administered to Resident #163 on 4/24/24, and 5/15/24 stated she did not remember the incident or the resident. Stated if she was working and discovered a medication such as Ozempic was not available to be given and it was due, she would call the pharmacy to see if the medication was sent out or if it could be reordered. She stated she would let the physician or nurse practitioner know as well that it was not available to give. She concluded she did not know of any negative outcomes for Resident #163 due to not having Ozempic available. During a telephone interview on 12/5/24 at 8:17 AM Nurse #11 who documented Ozempic as not available and not administered to Resident #163 on 5/1/24 stated she did not remember that Resident #163 was on Ozempic. She further stated she did not recall specifically not having Ozempic for Resident #163 but whenever medication was not available when it was due, she would call the pharmacy to get it reordered and would check to see when it could be given, or she would get her manager to call the pharmacy. She stated she did not remember the incident but would notify the pharmacy and physician or nurse practitioner. She stated Resident #163's bloods sugars never went out of baseline for the resident as far as she could recall, and she did have insulin coverage if her blood sugars were elevated, and the resident did not have any negative outcomes due to Ozempic not being available. She stated she only worked with Resident #163 a short time and did not have concerns about not having the medication not being available regularly. During a telephone interview on 12/05/24 at 1:01 PM Pharmacist #2 stated an 8mg Ozempic pen was dispensed on 4/10/24 for Resident #163 and arrived at the facility. This pen should have lasted 28 days per dosing. The pen was not returned. On 5/16/24 this pen was refilled, and the facility reported the 4/10/24 pen as lost and paid for the pen dispensed on 4/10/24. During a telephone interview on 12/5/24 at 1:58 PM Physician #1 stated he was made aware of the incident when the Ozempic pens were missing. He further stated he was notified by the nurses on the hall when the medication was not available to be given. It was not a medication that controlled blood sugars on a day-to-day basis, but it helped stabilize hemoglobin A1C (a blood test that measures your average blood sugar level over the past three months) over the course of multiple months. He stated he had no concerns about any negative outcomes due to the lack of the Ozempic in the facility and was monitoring Resident #163's bloods sugars and the resident had coverage available. They had no negative out comes because of the lack of Ozempic. He concluded he expected medications to be given as ordered. During an interview on 12/5/24 at 8:13 AM the Director of Nursing stated medications should be given as prescribed. Nurse #13 who documented Ozempic as not available and not administered to Resident #163 on 5/8/24 was not available for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and Nurse Practitioner (NP) #1 interview the facility failed to follow professional standards of practice and infection prevention measures when a nurse failed to perform hand hygiene between the removal of soiled gloves and the application of sterile gloves, when Nurse #4 touched the outside of the tracheostomy packaging with sterile gloves and did not change them and when she dropped a sterile q-tip onto the residents nightgown and proceeded to use it to clean the tracheostomy site. She further failed to keep sterile technique when she touched the new, sterile, inner cannula with contaminated sterile gloves that had touched the outside of the tracheostomy tray. This was for 1 of 1 resident (Resident #85) reviewed for respiratory care. Findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia (low blood oxygen level), history of neoplasm (tumor) of nasal cavity and mid ear and chronic tracheostomy. Resident #85's Annual Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and required complete assistance with all activities of daily living. He was documented to receive tracheostomy care in the facility. Resident #85's care plan revealed him to be at risk for ineffective breathing pattern related to having a tracheostomy. A continuous observation of tracheostomy care was observed on 12/4/24 at 10:00 AM with Nurse #4. At 10:10 AM she donned (put on) clean gloves and removed the residents soiled split gauze that rests between the skin and the tracheostomy collar, and removed the residents used inner cannula and threw both away. She then doffed (removed) the soiled gloves and immediately donned (put on) sterile gloves without performing hand hygiene first in between. After donning the sterile gloves, she touched the outside of the tracheostomy care tray that held the sterile supplies needed for the care. At 10:23 AM, while wearing the same gloves, she picked up a sterile q-tip, dipped it into sterile water, dropped it onto the residents clothing covered chest, picked it up again and used it to clean around the tracheostomy stoma (entry into the windpipe from the outside). Wearing the same gloves she then opened the inner cannula package by touching the outside, removed the sterile inner cannula and inserted it into the residents outer cannula. In an interview with Nurse #4 on 12/4/24 at 10:47 AM she stated only sterile items should be touched with sterile gloves and the q-tip that she dropped should have been thrown away and a new one used. Nurse #4 indicated she should have performed hand hygiene between doffing soiled gloves and donning sterile gloves by washing her hands with soap and water. She further indicated she should have removed the sterile gloves after touching the outside of packaging, performed hand hygiene and donned new sterile gloves. An interview with the Staff Development Coordinator (SDC) on 12/5/24 at 8:45 AM revealed she trained all nurses who worked with Resident #85 on tracheostomy care. She stated she trained Nurse #4 on 12/4/24. In a follow-up interview on 12/6/24 at 8:32 AM the SDC stated she performed a hands-on demonstration with Nurse #4 on 12/4/24 at the beginning of the shift, before the investigation observation. In a follow-up telephone interview with Nurse #4 on 12/6/24 at 9:27 AM she stated she was not provided training on tracheostomy care by the SDC until the afternoon of 12/4/24, after the investigation observation of tracheostomy care. In an interview with the Director of Nursing (DON) and Administrator on 12/4/24 at 11:41 AM they stated if non-sterile items are touched with sterile gloves, the contaminated sterile gloves should be removed, hand hygiene performed and new sterile gloves donned. They indicated sterile items that become contaminated, such as the q-tip, should be discarded immediately, and hand washing with soap and water should be performed after doffing soiled gloves and before donning sterile ones. They further stated sterile technique in tracheostomy care is important to prevent bacteria from being introduced into the airway and causing respiratory illness. During an interview on 12/5/24 at 8:20 AM the infection preventionist (IP) stated Nurse #4 should have washed her hands with soap and water after removing the dirty gloves and before donning the sterile gloves. She further stated the outside of the tracheostomy care tray should not have been touched with sterile gloves as it is not sterile. Nurse #4 should have performed hand hygiene and donned new sterile gloves after touching the outside of the tracheostomy tray. The IP indicated the q-tip should have been thrown away and a new one should have been used after it fell on the residents clothing covered chest and hand hygiene should have been performed and new sterile gloves donned before getting a new sterile q-tip. She further indicated that bacteria could be introduced into the residents airway and this could lead to infection if sterile procedure is not followed. In an interview with NP #1 on 12/5/24 at 8:30 AM she stated that Resident #85 had a permanent tracheostomy and no current respiratory infection. NP #1 further stated it is important to follow infection control prevention procedures when performing tracheostomy care to avoid introducing bacteria into the residents airway and potentially causing an infection such as Pneumonia. NP #1 would have expected Nurse #1 to perform hand hygiene by washing her hands between doffing dirty gloves and donning sterile ones. She indicated that nonsterile items should not be touched with sterile gloves, and the sterile q-tip that was contaminated by falling onto the residents clothing should have been discarded and a new one should have been used after performing hand hygiene and donning new sterile gloves.

Based on observation and staff interview the facility failed to ensure a Nurse was competent to provide tracheostomy care for 1 of 1 resident reviewed for tracheostomy (surgically created airway in the front of the neck) care (Resident #85). Findings include: A continuous observation of tracheostomy care was observed on 12/4/24 at 10:00 AM with Nurse #4 (agency). At 10:10 AM she donned (put on) clean gloves and removed the residents soiled split gauze that rests between the skin and the tracheostomy collar, and removed the residents used inner cannula and threw both away. She then doffed (removed) the soiled gloves and immediately donned (put on) sterile gloves without performing hand hygiene first in between. After donning the sterile gloves, she touched the outside of the tracheostomy care tray that held the sterile supplies needed for the care. At 10:23 AM, while wearing the same gloves, she picked up a sterile q-tip, dipped it into sterile water, dropped it onto the residents clothing covered chest, picked it up again and used it to clean around the tracheostomy stoma (entry into the windpipe from the outside). Wearing the same gloves she then opened the inner cannula package by touching the outside, removed the sterile inner cannula and inserted it into the residents outer cannula. In an interview with Nurse #4 on 12/4/24 at 10:47 AM she stated only sterile items should be touched with sterile gloves and the q-tip that she dropped should have been thrown away and a new one used. Nurse #4 indicated she should have performed hand hygiene between doffing soiled gloves and donning sterile gloves by washing her hands with soap and water. She further indicated she should have removed the sterile gloves after touching the outside of packaging, performed hand hygiene and donned new sterile gloves. Nurse #4 revealed she worked for agency and had not had hands on training for tracheostomy care at the facility. An interview with the Staff Development Coordinator (SDC) on 12/5/24 at 8:45 AM revealed completed hands on tracheostomy training with all nurses who work with Resident #85 before they work with him. She stated she trained Nurse #4 on 12/4/24. In a follow-up interview on 12/6/24 at 8:32 AM the SDC stated she performed a hands-on demonstration with Nurse #4 on 12/4/24 at the beginning of the shift, before the investigation observation. In a follow-up telephone interview with Nurse #4 on 12/6/24 at 9:27 AM she stated she was not provided training on tracheostomy care by the SDC until the afternoon of 12/4/24, after the investigation observation of tracheostomy care. In an interview with the Director of Nursing (DON) and Administrator on 12/4/24 at 11:41 AM they stated new Nurses, including agency Nurses were trained on tracheostomy care before working with Resident #85. They indicated the SDC provided the education upon hire.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident, staff, physician, physician assistant, and pharmacist interviews the facility failed to ensure ear drop medication was administered via the correct route into the ears and not into the eyes. This was for 1 of 7 residents (Resident #2) reviewed for medication errors. Findings included: Resident #2 was admitted to the facility on [DATE] with a diagnosis of left arm fracture. A review of Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Her vision was impaired. She could see large print but not regular print in newspapers/books. She had functional limitation in range of motion in her upper and lower extremities on one side. She was independent with eating and personal hygiene. A review of Resident #2's comprehensive care plan revealed a focus area initiated on 7/23/24 of inability to read regular sized print without glasses. The goal was for Resident #2 to have no injuries and to feel safe and secure in her environment through the next review. An intervention was to use large print items for Resident #2. A review of a physician's order for Resident #2 revealed an order dated 8/8/24 for lubricant eye drops (carboxymethylcellulose sodium ophthalmic (eye) solution) instill one drop in both eyes two times a day for dry eyes. A review of a physician's order for Resident #2 revealed an order dated 9/17/24 for ciprofloxacin (an antibiotic medication) 0.3 percent-dexamethasone (a steroid medication) 0.1 percent instill 2 drops in left ear every 12 hours for 5 days for ear infection. A review of Resident #2's September 2024 Medication Administration Record (MAR) revealed documentation indicating the ciprofloxacin -dexamethasone ear drops were administered to Resident #2 by Nurse #5 on 9/18/24 at 8:00 AM and by Nurse #7 on 9/18/24 at 8:00 PM. On 12/3/24 at 4:51 PM a telephone interview with Nurse #5 indicated although she could not recall the date, she had been orienting with Nurse #6 on the 7:00 AM to 7:00 PM shift. Nurse #5 stated Resident #2 had both eye drops and ear drops due and she brought both of these with her into Resident #2's room. She reported Nurse #6 told her that Resident #2 could give her eye drops to herself. She went on to say she had gone into Resident #2's room by herself, explained to Resident #2 that the bottle she was handing her was her ear drops, and she stood at Resident #2's bedside. Nurse #5 stated when Resident #2 started to put the drops into her eyes, she tried to stop Resident #2, but the medication had already gone into Resident #2's eyes. She reported she had immediately notified Nurse #6 what happened, and Nurse #6 reported it to the Director of Nursing (DON). Nurse #5 stated Physician #1 had been notified, and Resident #2's eyes had been flushed. She reported she received some education after the incident regarding ensuring the correct route for medications. On 12/4/24 at 9:59 AM a telephone interview with Nurse #6 indicated Nurse #5 had been on her second or third day of orientation (Nurse #6 could not recall the date) and he had asked Nurse #5 if she wanted to observe him administer medications, but she had said she was comfortable and could do this herself. Nurse #6 stated Resident #2 had both eye drops, and ear drops to be administered that day. He reported he saw Nurse #5 knock on Resident #2's door, enter the room and introduce herself, and explain to Resident #2 that she had both eye drops and ear drops for her. Nurse #6 explained from where he was standing in Resident #2's room doorway, he could see Nurse #5 administer drops into Resident #2's eyes and set the bottle down on Resident #2's table, then administer ear drops to Resident #2 and set the bottle down. Nurse #6 stated as Nurse #5 picked the bottles up from Resident #2's table, he heard Resident #2 state, You gave my ear drops in my eyes. He reported he entered Resident #2's room and reassured her he didn't think Nurse #5 had done this, but Resident #2 became upset and replied that she knew her medications and she wouldn't lie. He stated at that point he just went to notify the DON. Nurse #6 stated from where he had been standing in the doorway, he couldn't really tell which drops were which. On 12/4/24 at 8:56 AM an interview with the Staff Development Coordinator (SDC) indicated on 9/18/24 Resident #2 reported that Nurse #5 administered her ear drops into her eyes. She stated Nurse #5 had still been in her 90-day orientation period at that time, so she asked Nurse #5 to demonstrate to her which drops she administered in Resident #2's ear, and which drops she administered into Resident #2's eyes. The SDC reported she asked Nurse #5 to read the medication labels, and they discussed what optic (eye) versus otic (ear) meant with regards to routes of administration. She stated Nurse #5 indicated to her that she had administered the ear drops (ciprofloxacin-dexamethasone) into Resident #2's ear, and the eye drops (carboxymethylcellulose sodium) into Resident #2's eyes. The SDC recalled Nurse #5 reported she had administered the medications to Resident #2, and denied having administered Resident #2's ear drops into her eyes. The SDC reported education had only been completed with Nurse #5 regarding this issue. On 12/4/24 at 8:00 AM a telephone interview with Nurse #7 indicated she was assigned to care for Resident #2 on 9/18/24 on the 7:00 PM until 7:00 AM shift. She stated when she spoke with Resident #2 on that day, Resident #2 told her the nurse on the day shift that day put her ear drops into her eyes and she was very concerned about it. She went on to say she had gone to notify the DON, but the DON was already aware of this. Nurse #7 stated Resident #2 had not been complaining of any symptoms, and she had not observed any eye concerns. On 12/2/24 at 11:57 AM in an interview Resident #2 stated on 9/18/24, the nurse assigned to care for her put the drops that were supposed to be for her ear into her eyes. She indicated she could not recall the name of this nurse, as it was this first time this nurse worked with her. She reported the nurse had not said anything to her, but she knew the nurse was about to put her eye drops in because of the motion the nurse made with the bottle. Resident #2 went on to say she had not paid much attention, because she trusted the nurse to do the right thing. She reported the drops that this nurse put into her eyes had been thicker than her eye drops usually were, and although she had not felt any pain at the time, her vision had been blurry since then. Resident #2 stated when the nurse set the bottle down on her table, she could see that it was the ear drops and not the eye drops bottle. She reported this nurse had been working with Nurse #6 that day, and she went out into the hallway to let Nurse #6 know what had happened. Resident #2 stated no one seemed to pay any attention when she reported this, and she felt everyone acted like it was nothing. Resident #2 indicated she had seen an eye doctor after the incident, and the doctor told her the blurry vision was not from the ear drops going into her eyes but was from age related changes. She stated she didn't believe this, because she had not had any blurry vision prior to the incident. Resident #2 went on to say she asked to see a second eye doctor and the second eye doctor had also told her having her ear drops administered into her eyes wouldn't cause any vision changes. On 12/5/24 at 1:55 PM a telephone interview with Physician #1 indicated he had been notified that Resident #2's ear drops had potentially been administered into her eyes. He stated Resident #2's eyes were flushed with saline, and he had seen Resident #2 at the facility that same day. Physician #1 stated Resident #2 had not had any eye redness, or irritation. Physician #1 reported if a medication was ordered to be administered into a resident's ear, he would expect it to be administered into the resident's ear and not their eye. A review of a physician's order for Resident #2 dated 9/18/24 revealed consultation for blurry vision at eye clinic. A review of the eye clinic examination note for Resident #2 dated 12/23/24 written by Physician #2 revealed she was being seen due to having ear drops administered into her eyes. She did not have any symptoms. On 12/4/24 at 11:30 AM a telephone interview with Physician #2 indicated he examined Resident #2's eyes on 9/23/24. He stated Resident #2 was concerned after having ear drops administered into her eyes. He reported that the ciprofloxacin 0.3 percent-dexamethasone 0.1 percent designed to be administered into Resident #2's ear would not have caused any vision changes if it had been administered into Resident #2's eyes. He went on to say while it could cause mild transient irritation and burning, it would not cause any vision damage. Physician #2 stated it had been the right thing to flush Resident #2's eyes with saline as this would help prevent any irritation. A review of a physician's order for Resident #2 dated 9/24/24 revealed to schedule a second opinion consultation at an eye clinic due to blurry vision. A review of the eye clinic visit note for Resident #2 dated 10/2/24 written by Physician's Assistant (PA) #1 revealed Resident #2 was being seen for complaints of blurry vision. Resident #2 reported that a couple of weeks ago, a nurse administered her ear drops into her eyes. The impression from the examination was mild anterior basement membrane dystrophy (a genetic disorder of the cornea that causes recurrent erosions and blurred vision). PA #1 did not think ear drops caused Resident #2's current symptoms. On 12/4/24 at 9:50 AM a telephone interview with PA #1 indicated she had seen Resident #2 in the eye clinic on 10/2/24 and examined her eyes. She stated Resident #2 was certain that having her ear drops administered into her eyes was causing her to have blurry vision. PA #1 went on to say she had reassured Resident #2 that while this could cause mild temporary irritation, it would not cause her to have any vision changes or permanent damage to her eyes. On 12/5/24 at 12:35 PM a telephone interview with the facility's consultant Pharmacist indicated she had been made aware that Resident #2 was reporting her ear drops were mistakenly administered into her eyes. She stated while ciprofloxacin 0.3 percent-dexamethasone 0.1 percent designed to be administered into Resident #2's ears could potentially cause a mild irritation if administered into her eyes, it would not cause any vision damage. The Pharmacist reported Resident #2 had been seen by an eye doctor, and no lasting ill effects had been confirmed. On 12/4/24 at 8:42 AM an interview with the DON indicated on 9/18/24 she was notified that Resident #2 reported Nurse #5 put her ear drops into her eyes. She stated she immediately went to Resident #2's room, and Resident #2 was holding the ear drop medication package in her hand and was speaking with someone from the facility's consulting pharmacy. She reported after Resident #2 finished with her telephone call, she asked Resident #2 what happened, and how she knew it was the ear drops that went into her eyes. The DON stated Resident #2 told her she knew what her medications looked like, and which one was which. The DON reported Resident #2 had not been having any eye redness or irritation at the time, but she spoke with Resident #2's Physician (Physician #1) and was told to flush Resident #2's eyes with saline, which was done. She went on to say Resident #2's Physician #1 had seen her that same day. She reported Resident #2 had requested to see an eye doctor, so a consultation appointment was made. She went on to say Resident #2 had not been happy with the results of this eye consultation, so Resident #2 asked for a second opinion eye consultation which was also done. On 12/5/24 at 1:20 PM an interview with the Administrator indicated Nurse #5 had denied putting Resident #2's ear drops into Resident #2's eyes during the facility's investigation of the incident. She stated Nurse #5 had been in her orientation period at the time of the incident and had denied this occurred. She reported the SDC had completed education with Nurse #5 regarding the proper routes of medication administration. The Administrator stated incorrect routes of ear drop administration had not been a trend at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview the facility failed to maintain walls and resident beds in good repair for 6 of 6 resident rooms (Room # 104, 105, 106, 111, 301 and 602) reviewed for provision of a safe, clean, homelike environment. The findings included: A. room [ROOM NUMBER] bed A was observed on 11/27/23 at 11:32 AM. During the observation it was revealed the footboard was completely disconnected from the bed. It was resting perpendicular on the frame of the bed which could cause injury to the resident if it fell onto the Resident's feet while in bed. A second observation of room [ROOM NUMBER] bed A was made on 11/30/23 at 12:30 PM with the Maintenance Director. The observation revealed the footboard of bed A was completely disconnected and resting on the frame. room [ROOM NUMBER] bed B was observed on 11/27/23 at 11:32 AM. During the observation it was revealed the Resident's headboard was damaged in one corner. The corner piece was being held on by clear office tape. The Resident in room [ROOM NUMBER] bed B stated she had asked for her headboard to be repaired or replaced a couple of months ago and had not received a response. She stated she had put the broken piece back on with strips of clear office tape in the meantime. A second observation of room [ROOM NUMBER] bed B was made on 11/30/23 at 12:30 PM with the Maintenance Director. The observation revealed a piece of broken headboard being held on by clear office tape. B. An observation of room [ROOM NUMBER] bed A on 11/27/23 at 12:30 PM revealed damage to the wall at the head of the bed where wallpaper was torn away and there were deep scratches with drywall visible. A second observation of room [ROOM NUMBER] bed A on 11/30/23 at 9:10AM revealed no change in the damage to the wall at the head of the bed where the wallpaper was torn away and there were deep scratches with drywall visible. C. An observation of room [ROOM NUMBER] bed A on 11/27/23 at 12:34 PM revealed wallpaper missing and peeling along the wall at the side of the bed. Drywall was visible with scratches approximately 3 feet long and 3 inches wide. A second observation of room [ROOM NUMBER] bed A on 11/30/23 at 9:15 AM revealed the damaged wall to be unchanged, with missing and peeling wallpaper and visible scratches. D. An observation of room [ROOM NUMBER] bed B on 11/27/23 at 12:40 PM revealed peeling and missing wallpaper and gouges in drywall behind the bed as well as a large area of missing wallpaper and scratched drywall under the window. A second observation of room [ROOM NUMBER] bed B on 11/30/23 at 9:20 AM revealed there was no change in the condition of the damaged walls with peeling and missing wallpaper and scratched drywall. E. An observation of room [ROOM NUMBER] (private room) on 11/27/23 at 12:10 PM revealed a circular area measuring about 1 x 1 foot where the wallpaper was scratched off and the drywall was deeply gouged. The Resident in room [ROOM NUMBER] stated on 11/27/23 at 12:10 PM the deep gouge in the wall to the right of her bed had been there for at least a year. She indicated she had asked staff about having it fixed and stated she had received no response. A second observation of room [ROOM NUMBER] on 11/30/23 at 9:40 AM revealed no change in damage to wall to the right of the bed. There continued to be missing wallpaper and gouged drywall. In an interview with Nurses Aide #1 on 11/30/23 at 10:00 AM it was revealed all maintenance work orders were to be entered into the facility maintenance request system. She further stated any employee could put in a request. An interview with Nurse #1 on 11/30/23 at 10:08 AM revealed she put all maintenance work orders into the facility maintenance request system. She further stated she would enter requests such as televisions not working, water leaks or beds not working properly. An interview with the Unit Manager on 11/30/23 at 10:20 AM revealed staff would put maintenance requests into the facility maintenance request system. The Unit Manager stated that there used to be 3 maintenance staff, but they had lost one sometime in the last 6 months. An interview with the Maintenance Manager on 11/30/23 at 12:30 PM revealed he received maintenance requests through the maintenance request system, and it appeared on his phone in real time. Maintenance does not inspect rooms for issues, they rely on the request system. He further stated he was aware of the condition of the walls in some rooms. The maintenance staff they lost recently was the one who fixed the walls. He further stated they were not currently looking for a third maintenance staff person until the building census increased. In an interview with the Director of Nursing on 11/30/23 at 11:08 AM she indicated that all maintenance work requests would be entered into the facility maintenance request system by any staff member. She further stated that the facility lost a maintenance worker about 3 months ago. She was unaware if the facility was trying to replace him. F. room [ROOM NUMBER] was observed on 11-27-23 at 11:59am. The observation revealed 4 linear indented lines on the wall behind the resident's bed that revealed plaster. The resident's headboard to his bed was also observed to only be attached on one side allowing the headboard to hang and move freely which could cause injury to the resident if he tried to hold onto the headboard while moving in bed. A second observation occurred on 11-29-23 at 8:53am with the Maintenance Director. The observation revealed 4 linear indented lines on the wall behind the resident's bed that revealed plaster and the resident's headboard to his bed was also observed to only be attached on one side. The Maintenance Director was interviewed on 11-29-23 at 8:55am. The Maintenance Director discussed the damage to room [ROOM NUMBER]'s wall and stated he was aware the wall needed repair. He explained the maintenance department was short handed and they were trying to repair the walls when they had a chance. When the Maintenance Director examined the resident's headboard on his bed, he stated the headboard had lost a screw. He said he was not aware of the loose headboard and explained staff would report maintenance issues in their computer system and did not know why the staff had not reported the resident's headboard being loose. The Administrator was interviewed on 11-29-23 at 2:40pm. The Administrator discussed the maintenance department being short-staffed and confirmed staff requested maintenance repairs through their computer system. She stated she was aware of the need for repairs to the resident's wall but was unaware of the loose headboard. The Administrator discussed the loose headboard could cause injury to the resident if he attempted to grab the headboard while repositioning in the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interviews the facility failed to perform incontinence care on 1 of 1 resident (Resident #24) who was dependent on staff for incontinence care, in a manner to prevent the likelihood of an infection. Resident #24 was observed for Activities of Daily Living (ADL) care. Findings included: Resident #24 was admitted to the facility on [DATE] with multiple diagnoses that included dementia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was severely cognitively impaired and required extensive assistance with one person for toileting, bed mobility and personal hygiene. Resident #24's care plan dated 11-21-23 revealed Resident #24 had urinary incontinence related to cognitive impairment. The goal for Resident #24 included to be free of infection and skin breakdown. The interventions for the goal were to encourage good hygiene and receive peri care after each incontinent episode. Observation of ADL care occurred on 11-29-23 at 9:09am with Nursing Assistant (NA) #1. Resident #24's skin was observed to be intact with no redness. NA #1 was observed cleaning Resident #24's peri area. The NA cleaned Resident #24's peri area from back to front two times. During an interview with NA #1 on 11-29-23 at 9:30am, the NA discussed having to ask another NA on the proper way of cleaning a woman's peri area because I could not remember, and they told me to clean back to front. NA #1 also stated he thought if he cleaned the peri area from front to back, he would cause bacteria to enter the vaginal cavity. The Staff Development Coordinator (SDC) was interviewed on 11-29-23 at 9:49am. The SDC explained when a new NA was hired, the NA would spend two days in the classroom discussing incontinence care and then the NA would be checked off on the skill of incontinence care by their preceptor. She also explained that staff performed random audits on the NAs to ensure proper technique was being used when cleaning a woman's peri area. The SDC stated NA #1 had received education on incontinence care and did not know why he would have used a back to front cleaning technique on Resident #24. An interview with the Director of Nursing (DON) was conducted on 11-29-23 at 2:13pm. The DON discussed NA #1 being nervous during the observation but stated she would have expected the NA to clean Resident #24's peri area from front to back. The Administrator was interviewed on 11-29-23 at 2:30pm. The Administrator stated she believed NA #1 was nervous during the observation and knew how to clean a woman's peri area correctly. She said she expected residents to be cleaned from front to back during incontinence care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to place palm guards on the left and right hands for 1 of 1 resident (Resident #3) reviewed for range of motion. Findings included: Resident #3 was admitted to the facility on [DATE] with multiple diagnoses that included right hand contracture. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was severely cognitively impaired. Resident #3's care plan dated 10-6-23 did not have any goals or interventions for palm guards. An observation of Resident #3 occurred on 11-27-23 at 11:20am. Resident #3's right and left hand were observed to be contracted with no palm guards present. Another observation of Resident #3 occurred on 11-28-23 at 4:00pm. The observation revealed there were no palm guards placed on the resident's left or right hand. Resident #3 was observed on 11-29-23 at 8:15am. Resident #3 was observed laying in the bed without palm guards to her left or right hand. During an interview with Nursing Assistant (NA) #2 on 11-29-23 at 8:42am, the NA discussed being familiar with Resident #3 and being aware the resident had contractures to her left and right hands. She explained Resident #3 had braces and palm guards about 2 years ago and stated for the past few months Resident #3 had not had any braces or palm guards to her left and right hands. Nurse #1 was interviewed on 11-29-23 at 8:46am. The nurse discussed being familiar with Resident #3 and stated the resident used to have palm guards to her left and right hands. Nurse #1 explained she did not know why Resident #3 no longer had the palm guards. She said she tried to remember to remind the NAs to place a rolled washcloth in Resident #3's hand to prevent her fingernails cutting into the palms of her hands. The Rehab Director was interviewed on 11-29-23 at 10:14am. The Rehab Director explained Resident #3 had last received services in September 2022. She further explained Resident #3 was to receive restorative services to continue working on the resident's bilateral hand contractures. The Rehab Director stated at the end of Resident #3's rehab services, the resident was ordered bilateral palm guards. She discussed the restorative program switching to a functional maintenance program around January 2023 but stated Resident #3 should have continued with services. The Rehab Director said Resident #3 had fallen through the cracks. An interview with the Staff Development Coordinator (SDC) occurred on 11-29-23 at 11:02am. The SDC confirmed she was responsible for coordinating the residents from the restorative program to the functional maintenance program. The SDC explained when the restorative program was changed to the functional maintenance program, Resident #3 should have been referred to therapy for an evaluation. She further explained the MDS nurses were responsible for making the referral to the therapy department. During an interview with MDS Nurse #1 on 11-29-23 at 11:16am, the MDS Nurse explained that she had never received an order to place Resident #3 on the restorative program back in September 2022, so she was unaware Resident #3 needed a referral to therapy when the program changed to the functional maintenance program. The Director of Nursing (DON) was interviewed on 11-29-23 at 2:02pm. The DON discussed the restorative program changing to the functional maintenance program but stated she did not know when that occurred. She discussed managers and department heads having a meeting each morning and talking about what residents were being released from therapy and if the resident would be placed on the functional maintenance program. The DON stated she could not remember if Resident #3 had been discussed and was unaware Resident #3 had not been receiving services. During an interview with the Administrator on 11-29-23 at 2:25pm, the Administrator discussed meeting each morning with management and the department heads to talk about the residents being released from therapy and if the resident would need to follow the functional maintenance program. She stated she was unaware Resident #3 had no longer been receiving services and would have expected Resident #3 to receive services through the functional maintenance program and had her bilateral palm guards placed per therapies recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interviews, the facility failed to ensure that smoking materials were secured by staff for three of three sampled residents observed for accidents (Resident #101, Resident #107, and Resident #119). Findings included: The facilities smoking policy dated 2019 stated all resident smoking materials were maintained in a secured area and were accessible only through the assistance of the facility staff. Assessment of Residents ability to smoke in a safe manner would occur prior to smoking in designated outdoor areas. Safe smokers would be reassessed at least monthly utilizing the Smoking Evaluation by a Licensed Nurse. The interdisciplinary team would review the care plans of smokers and update based on the Smoking Evaluation. 1. Resident #101 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia (one sided weakness), Seizure disorder and Diabetes Mellitus II. A review of the care plan dated 10/26/23 revealed that Resident #101 was an independent and safe smoker of cigarettes. The goal was for the Resident to continue to smoke safely in designated areas and would continue to use smoking materials safely through the next review. Interventions included staff assistance obtaining smoking materials from a secured storage area upon request, evaluate resident's continued ability to smoke safely on a consistent and regular basis, and for staff to observe for potential violations of the smoking policy. It further stated staff were to document and report observations to Administrator and/or Administrative staff and to provide education on safe smoking to the resident. Resident #101's smoking evaluation dated 11/3/23 indicated the Resident was a safe smoker and may smoke in designated areas without supervision. A review of the Resident's smoking evaluations revealed they were performed monthly since admission to the facility in June 2023. Resident #101 was observed walking alone out to the smoking area on 11/28/23 at 8:25 AM without stopping at the lock box area. He then removed smoking materials from his front shirt pocket and proceeded to light a cigarette. In an interview with Resident #101 on 11/28/23 at 8:30 AM he revealed he smoked several times a day. He further stated there were lock boxes for Residents to keep their smoking materials in, and each box had a key that was kept by the Resident it was assigned to. He was unaware if staff knew he kept his smoking materials on his person. An observation of the smoking area on 11/30/23 at 08:25 AM revealed metal shelving with lock boxes secured to the shelves. Each box was individually numbered. An interview with Nursing Assistant (NA) #1 on 11/30/23 at 9:30 AM stated she believed Residents were prohibited from keeping smoking materials on their person or in their rooms. She was unaware of where Resident #101 kept his smoking materials. An interview with Nurse #2 revealed Residents had a smoking evaluation done on admission and then monthly by Nursing to assess if the Resident could remain an independent smoker, or if they needed supervision for safety. She further stated she was unaware of where Resident #101 kept his smoking materials. In an interview with the Director of Nursing (DON) on 11/30/23 at 10:00 AM, she indicated that staff should notify her if a Resident had smoking materials on their person or had not utilized the lock box system. She stated she was unaware that Resident #101 kept smoking materials on his person instead of using the lock box. The DON indicated that staff had a duplicate key for each box in case a key was lost. An interview with the Administrator on 11/30/23 at 1:00 PM indicated that staff smoked outside in the same area as the Residents. She further stated staff were able to supervise the smoking area from inside the building in case of emergency. She indicated there was no system in place to check if independent smokers were using the lock boxes and she was unaware of any Residents not using the lock boxes for smoking materials safe keeping. 2. Resident #107 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus II, Chronic Obstructive Pulmonary Disease and Heart Failure. A review of Resident #107's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. It also indicated the Resident was a tobacco user. A review of Resident #107's care plan dated 8/7/23 revealed the Resident was an independent and safe smoker of cigarettes. The goal was for the Resident to continue to smoke safely in designated areas and would continue to use smoking materials safely through the next review. Interventions included staff assistance obtaining smoking materials from a secured storage area upon request, evaluate resident's continued ability to smoke safely on a consistent and regular basis, and for staff to observe for potential violations of the smoking policy. It further stated staff were to document and report observations to Administrator and/or Administrative staff and to provide education on safe smoking to the resident. Resident #107's smoking evaluation dated 11/1/23 indicated the Resident was a safe smoker and may smoke in designated areas without supervision. A review of the Residents smoking evaluations revealed they were performed monthly since admission to the facility in August 2023. Resident #107 was observed wheeling himself out to the smoking area in his wheelchair on 11/28/23 at 8:45 AM. He then removed smoking materials from his front shirt pocket and proceeded to light a cigarette without first going to the lock box area. An observation of the smoking area on 11/30/23 at 8:25 AM revealed metal shelving with lock boxes secured to the shelves. Each box was individually numbered. In an interview with Resident #107 on 11/28/23 at 8:50 AM he revealed he smoked several times a day. He stated in the interview there were lock boxes for Residents to keep their smoking materials in, and each box had a key that was kept by the Resident it was assigned to. The Resident stated he did not use the lock box. He further stated staff knew he kept smoking materials on his person as he had refused to give them to staff or use the lock box. In an interview with Nursing Assistant (NA) #1 on 11/30/23 at 9:37 AM, she stated she believed Residents were prohibited from keeping smoking materials on their person or in their rooms, and she believed Resident #107 kept his smoking materials at the Nurses station. An interview with Nurse #1 revealed Residents had a smoking evaluation done on admission and then monthly by Nursing to assess if the Resident could remain an independent smoker, or if they needed supervision for safety. She further stated Resident #107 kept his smoking materials on his person as he had refused to give them to Nursing in the past. Nurse #1 further revealed a large plastic toolbox that was kept at the Nurses station that had three packs of cigarettes inside that had no names on them. She further stated they used to use this toolbox to keep Resident smoking materials before they implemented the lock box system. Nurse #1 did not know to whom the cigarettes belonged. It was observed that the toolbox was not kept locked. In an interview with the Director of Nursing (DON) on 11/30/23 at 10:00 AM, it was revealed that staff should have notified her if a Resident had smoking materials on their person or were not utilizing the lock box system. She was unaware there were cigarette packs in the toolbox at the nurse's station. She further stated she was unaware that Resident #107 kept smoking materials on his person instead of using the lock box. The DON indicated that staff had a duplicate key for each box in case a key was lost. An interview with the Administrator on 11/30/23 at 1:00 PM indicated that staff smoked outside in the same area as the Residents. She further stated staff were able to supervise the smoking area from inside the building in case of emergency. She indicated there was no system in place to check if independent smokers were using the lock boxes and she was unaware of any Residents not using the lock boxes for smoking materials safe keeping. 3. Resident #119 was admitted to the facility on [DATE] with diagnoses that included acquired absence of right leg below the knee, Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. A review of Resident #119's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. It also indicated the Resident was a tobacco user. A review of the care plan dated 10/26/23 revealed that Resident #119 was an independent and safe smoker of cigarettes. The goal was for the Resident to continue to smoke safely in designated areas and would continue to use smoking materials safely through the next review. Interventions included staff assistance obtaining smoking materials from a secured storage area upon request, evaluate resident's continued ability to smoke safely on a consistent and regular basis, and for staff to observe for potential violations of the smoking policy. It further stated staff were to document and report observations to Administrator and/or Administrative staff and to provide education on safe smoking to the resident. Resident #119's smoking evaluation dated 11/1/23 indicated the Resident was a safe smoker and may smoke in designated areas without supervision. A review of the Residents smoking evaluations revealed they were performed monthly since admission to the facility in February 2023. In an interview with Resident #119 on 11/28/23 at 12:10 PM he revealed he smoked on days he did not have dialysis. He stated in the interview there were lock boxes for Residents to keep their smoking materials in, and each box had a key that was kept by the Resident it was assigned to. The Resident stated he does not use the lock box as he only smokes a few times a week. He was unaware if staff knew he kept his smoking materials on his person. An observation of the Resident on 11/30/23 at 08:19 AM revealed Resident was outside in the designated smoking area when I arrived. He had not yet started to smoke. Resident #119 removed a pack of cigarettes from the back of his wheelchair. An observation of the smoking area on 11/30/23 at 08:25 AM revealed metal shelving with lock boxes secured to the shelves. Each box is numbered. An interview with Nursing Assistant (NA) #1 on 11/30/23 at 9:30 AM stated she believed Residents were prohibited from keeping smoking materials on their person or in their rooms. She was unaware of where Resident #119 kept his smoking materials. An interview with Nurse #2 revealed Residents had a smoking evaluation done by Nursing before being allowed to smoke at the facility. This evaluation was to assess if the Resident can be an independent smoker, or if they need supervision for safety. The evaluation was completed monthly. She further stated she was unaware of where Resident #119 kept his smoking materials. In an interview with the Director of Nursing (DON) on 11/30/23 at 10:00 AM, it was revealed that staff should have notified her if a Resident had smoking materials on their person or were not utilizing the lock box system. She further stated she was unaware that Resident #119 kept smoking materials on his person instead of using the lock box. The DON indicated that staff had a duplicate key for each box in case a key was lost. An interview with the Administrator on 11/30/23 at 1:00 PM indicated that staff smoked outside in the same area as the Residents. She further stated staff were able to supervise the smoking area from inside the building in case of emergency. She indicated there was no system in place to check if independent smokers were using the lock boxes and she was unaware of any Residents not using the lock boxes for smoking materials safe keeping.

Based on observation and staff interviews, the facility failed to maintain clean dishes that were ready for use and failed to dry small rectangular bowls prior to stacking on the tray line ready for use during 1 of 2 kitchen observations. This practice had the potential to affect food served to all residents. Findings included: During a follow up observation tour of the kitchen on 11-29-23 at 11:42am with the Dietary Manager, the following concerns were observed. There were 12 dinner plates on the tray line ready to be used for the lunch meal that contained yellow and/or black particles. The lunch tray line had small rectangular bowls that were ready to be used for the lunch meal. The observation revealed 57 of the bowls were stacked wet and contained yellow/black particles. The Dietary Manager was interviewed on 11-29-23 at 12:10pm. The Dietary Manager confirmed the 12 dinner plates, and 57 small rectangular bowls were on the tray line ready to be used for the lunch meal. He explained the dishes went through a two-step check for cleanliness and dryness. The Dietary Manager stated the staff member who ran the dishwasher would be the first person to check all dishware for cleanliness and ensure the dishes were dry prior to placing them on the tray line. He said he was the second person to check the dishware to ensure the dishes were clean and dry once they were on the tray line. The Dietary Manager explained he had been too busy to check the dishware today (11-29-23). He also explained the kitchen staff had been in-serviced in the past that dishware could not be stacked wet, and he did not know why staff would have stacked the small rectangular bowls wet on the tray line. The Dietary Manager stated he expected staff to ensure dishes were clean and dry prior to placing them on the tray line for use. During an interview with the Administrator on 11-29-23 at 2:37pm, the Administrator explained that the Dietary Manager was new and that the Corporate Dietary Consultant was training him. The Administrator stated she would expect dishes to be clean and dry prior to the dietary staff serving food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF ABN) by omitting the estimated out of pocket cost for care for 3 of 3 residents reviewed for beneficiary notices (Residents #70, #134, #393). Findings included: a. Resident #70 was admitted to the facility on [DATE]. Review of Resident #70's record indicated the SNF ABN dated 11/8/23 had no estimated out of pocket cost for care documented on the form. Resident #70 remained in the facility with benefit days remaining. b. Resident #134 was admitted to the facility on [DATE]. Review of Resident #134's record indicated the SNF ABN dated 11/22/23 had no estimated out of pocket cost for care documented on the form. Resident #134 remained in the facility with benefit days remaining. c. Resident #393 was admitted to the facility on [DATE]. Review of Resident #393's record indicated the SNF ABN dated 11/21/23 had no estimated out of pocket cost for care documented on the form. Resident #393 remained in the facility with benefit days remaining. During an interview with Social Worker #1 on 11/30/23 at 3:00 PM, she indicated she had been in her position for 11 years and had never been made aware the estimated out of pocket cost for care needed to be on the SNF ABN. She further stated the SNF ABN came prefilled from the corporate office. She indicated that the Social Work office was the only one to distribute the SNF ABN to Residents. An interview with Social Worker #2 on 11/30/23 at 3:00 PM revealed she also was unaware the estimated out of pocket cost for care needed to be included on the SNF ABN. She further stated that Social Work was the only office to distribute the SNF ABN to Residents and that they came prefilled from the facility Corporate Office. During an interview with the Administrator on 11/30/23 at 1:30 PM, she indicated she was unaware that the estimated out of pocket cost or care was to be included on the SNF ABN and that she would have the forms updated going forward.

Based on record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place. This was for one repeat deficiency in the area of Medicaid/Medicare Coverage Liability Notice (F582) originally cited on 7/29/21 during a recertification and complaint investigation survey and subsequently recited on 11/30/23 during the recertification and complaint investigation survey. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. Findings included: This tag is cross referenced to: F582: Based on record review and staff interviews, the facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF ABN) by omitting the estimated out of pocket cost for care for 3 of 3 residents reviewed for beneficiary notices (Residents #70, #134, #393). During the recertification and complaint investigation survey of 7/29/21, the facility failed to provide an acknowledged Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and a Notice of Medicare Non-Coverage prior to discharge from Medicare Part A skilled services. During an interview on 11/30/23 at 12:14 PM, the Administrator revealed she was unaware of the need to complete the cost rate on the SNF ABN form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and interview with Dialysis Treatment Center staff, the facility failed to revise the care plan for 1 of 1 resident reviewed for dialysis. (Resident # 128) Findings included: Resident #128 was admitted to the facility on [DATE] with diagnoses including end stage renal disease. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #128 was moderately cognitively impaired and received dialysis. The revised care plan dated 10/5/2022 revealed Resident #128 received dialysis on Monday, Wednesday and Friday. Interventions included communicating with the Dialysis Treatment Center as indicated for adjustments in Resident #128's care and/or treatment plan. On 11/17/2022 at 10:53 a.m. in an interview with Nurse #1, she stated Resident #128 was unable to tolerate four hours in the dialysis chair three times a week and went to Dialysis every day for two hours Monday through Friday. On 11/18/2022 at 9:39 a.m. in an interview with the Dialysis Treatment Center Nurse #1, she stated Resident #128 had been receiving dialysis five days a week Monday through Friday for two hours daily for the last three weeks. On 11/18/2022 at 2:46 p.m. in an interview with MDS Nurse #1, she stated Resident #128 receiving dialysis five days a week instead of three days a week as ordered was discussed in an interdisciplinary team (IDT) morning meeting and was unsure why Resident #128's care plan was not updated after the IDT morning meeting. She stated Resident #128 was not one of her assigned residents; Resident #128 was assigned to the MDS Nurse #2. On 11/18/2022, MDS Nurse #2 was not available for interview. On 11/18/2022 at 2:59 p.m. in an interview with the Scheduler, she stated she was informed by the Dialysis Treatment Center to start scheduling Resident #128 to the center daily Monday through Friday on November 8, 2022 until further notice. On 11/18/2022 at 3:43 p.m. in an interview with the Director of Nursing, she stated due to Resident #128 being frigidity, dialysis appointments were decreased to two hour visits Monday through Friday and was discussed during an IDT morning meeting. She stated Resident #128's care plan should had been updated to communicate the change in his dialysis treatment plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interviews, the facility failed to administer the tube feeding formula at the correct rate as ordered by the physician and label the tube feeding formula with a date and time when opened for use for 1 of 1 resident (Resident #64) reviewed for tube feedings. Findings included: Resident #64 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 received tube feedings for nutrition for greater than 51% of total calories. Dietary notes dated 11/8/2022 revealed Resident #64 was receiving an enteral feeding at 55 milliliters(mL) per hour(hr) and a plan to decrease enteral feeding to 50 mL/hr for weight management. Physician orders dated 11/8/2022 revealed an order for Diabetasource, an enteral feeding, every twenty-four hours at 50 mL/hr, and Nurse #10 acknowledged the order on 11/8/2022. On 11/18/2022 at 2:54 p.m. in an interview with Nurse #10, she stated she was working as the unit manager on 11/8/2022 and acknowledged and signed offed the physician order dated 11/8/2022 to decrease Resident #64's enteral feeding to 50 mL/hr and entered the order into the electronic MAR. She stated she did not decrease the enteral feeding to 50 mL/hr, and she was unable to recall the nurse assigned to Resident #64 she told to decrease the enteral feeding to 50mL/hr. There was no nursing documentation revealing the enteral feeding was decreased to 50mL/hr on 11/8/2022. A review of the November 2022 Medication Administration Record (MAR) revealed the day shift nursing staff verified Resident #64's continuous enteral feeding, Diabetasource, was infusing at 50 mL/hr every 24 hours from 11/8/2022 to 11/16/2022. The care plan dated 11/10/2022 revealed Resident #64 required a feeding tube for nutritional improvement and maintenance. Interventions included administering tube feeding formula as ordered by the physician. On 11/15/2022 at 10:24 a.m., the enteral feeding, Diabetasource, was observed infusing at 55 mL/hr. There was no resident name and no date and time the eternal feeding formula was opened for infusion observed on the enteral formula bag. On 11/15/2022 at 10:29 a.m. in an interview with Nurse #7, she stated Resident #64 received continuous enteral feedings and received two bags of formula a day. She stated the enteral formula bag that was hanging was started by the night shift (7 p.m. to 7 a.m.), and the nurse starting a new bag of enteral formula was to write the Resident #64's name, room number, date and time the enteral formula was started and the rate of the enteral feeding on the enteral formula bag. On 11/15/2022 at 10:30 a.m. after checking Resident #64's electronic medical record, Nurse #7 was observed writing 11/14/2022 and 9 p.m. on Resident #64's enteral formula bag that was infusing at 55mL/hr. On 11/17/2022 at 7:22 a.m. prior to a medication pass observation, Resident #64's enteral feeding was observed infusing at 55mL/hr. Nurse #4 was observed stopping the enteral feeding to administer Resident #64's medications and restarting the enteral feeding at 55 mL/hr after medication administration. On 11/17/2022 at 7:22 a.m., the physician order on the electronic MAR was reviewed with Nurse #4. Nurse #4 stated the enteral feeding was decreased to 50 mL/hr on 11/8/2022 and stated, what is she set at. Nurse #4 was observed re-entering Resident #64's room and changing the enteral feeding rate from 55 mL/hr to 50 mL/hr. On 11/17/2022 at 10:10 a.m. in an interview with Nurse #4, she stated each nurse was responsible for checking that the enteral feeding was infusing per physician's orders. She stated Resident #64's enteral feeding was infusing at 50 mL/hr yesterday (11/16/22) and she documented on the MAR Resident #64's enteral feeding was infusing at 50mL/hour and did not know why the enteral feeding was set at 55 mL/hr this morning. On 11/18/2022 at 10:55 a.m. in a phone interview with Nurse #8, she stated the nurse acknowledging the physician order should had decreased the enteral feeding for Resident #64. In a follow up phone interview on 11/18/2022 at 11:00am, Nurse #8 stated she gave Resident #64 her medications on 11/14/2022 during the 7p.m. and 7a.m. shift and did not hang the enteral feeding because was there was 300mL left in the enteral formula bag. She stated Nurse #9, who worked the 11 p.m. to 7 a.m. shift, would have started the enteral feeding for Resident #64 on 11/14/2022. She stated the infusion rate of the enteral feeding was automatically set on the machine and was unable to recall Resident #64's infusing rate. Attempts to reach Nurse #9 were unsuccessful. On 11/18/2022 at 3:43 p.m. in an interview with the Director of Nursing, she stated when a new enteral feeding bag was started, nurses were to write the date and time the enteral bag was started and the nurse's initials. She further stated Resident #64 should have been receiving the enteral feeding at 50 mL/hr per physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to remove a peripheral intravenous catheter at the completion of therapy for 1 of 1 resident (Resident #98) whose records were reviewed for intravenous therapy. Findings included: The facility's policy Removal of a Peripheral IV Catheter lasted revision dated June 2020 stated a catheter should be removed when therapy is completed. Resident #98 was admitted to the facility on [DATE]. Physician orders revealed an order dated 11/10/2022 read in part sodium chloride solution 0.9% use 75milliters (ml)/hour for one liter intravenously one time. Review of the Medication admission Record (MAR) dated 11/10/2022 showed sodium chloride solution 0.9% use 75ml/hour intravenously one liter was administered. On 11/16/2022 at 9:10 A.M., Resident #98 was observed to have a yellow peripheral venous catheter inserted in the back of her left hand. The site was not labeled with nursing initials, date, or time. An interview was conducted with Nurse #4 on 11/16/2022 at 1:45 P.M. Nurse #4 indicated she observed Resident #98 to have an IV (intravenous peripheral catheter) in her left hand when she began her shift. She indicated the IV site was not red, swollen, or warm on assessment. She indicated the IV should have been removed when Resident #98's sodium chloride solution had finished and there were no orders for lab work to be collected. Physician orders revealed an order start date 11/16/2022 at 2:30 P.M. read in part discontinue IV from left hand. An interview was conducted the Director of Nursing (DON) on 11/18/2022 at 8:24 A.M. During the interview, she indicated staff were responsible to ensure peripheral catheters were removed at the end of therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to obtain a physician order when the dialysis treatment plan changed for 1 of 1 sampled resident reviewed for dialysis (Resident #128). Findings included: Resident #128 was admitted to the facility on [DATE] with diagnoses including end stage renal disease. The care plan dated 9/23/2022 revealed Resident #128 received hemodialysis for end stage renal disease three times a week on Monday, Wednesday and Friday. Interventions included communicating with the dialysis treatment center, assessing the resident upon return from dialysis and monitoring vital signs. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #128 was moderately cognitively impaired and received dialysis. A review of the physician progress notes dated 10/21/2022 revealed Resident #128 was receiving dialysis treatments on Monday, Wednesday and Friday. A review of the faxed Dialysis Treatment Center orders log sheet dated 11/1/2022 revealed to start hemodialysis treatments five days per week for two hours. Physician orders dated 11/8/2022 revealed Resident #128 was ordered dialysis on Monday, Wednesday and Friday. In an interview with the Scheduler on 11/18/2022 at 2:59 p.m., she stated she was informed by the Dialysis Treatment Center to schedule Resident #128 daily for dialysis Monday through Friday until further notice, and Resident #128 had been scheduled Monday through Friday two-hour dialysis appointments since November 8, 2022. In an interview with Nurse #1 on 11/17/2022 at 10:53 a.m., she stated Resident #128 was receiving dialysis daily Monday through Friday for two hours because Resident #128 was unable to sit in the dialysis chair for the usual four-hour requirement. In a phone interview with Dialysis Treatment Center Nurse #1 on 11/18/2022 at 9:39 a.m., she stated Resident #128's dialysis treatment plan changed three weeks ago from receiving dialysis on Monday, Wednesday and Friday to Monday through Friday for two hours. In an interview with Nurse #11 on 11/18/2022 at 1:52 p.m. assigned to Resident #128, she stated Resident #128 had received dialysis since admission, and the physician order for dialysis was for Monday, Wednesday and Friday. In an interview with the Director of Nursing on 11/18/2022 at 2:59 p.m., she stated due to Resident #128 not tolerating the dialysis chair for four hours, his dialysis appointments were changed to Monday through Friday for two hours. She stated the facility was notified by the Dialysis Treatment Center of the change in dialysis appointments, and the change was discussed in the interdisciplinary meeting. She stated Resident #128's assigned nurse, or the unit manager should have obtained a verbal order from the physician to communicate the change in Resident #128's dialysis treatment plan. She stated she was unable to recall when the change in Resident #128's dialysis occurred, or the nurse assigned to Resident #128 during that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, staff interviews and pharmacy interviews, the facility failed to provide administration of a prescribed anti-rheumatic medication for 1 of 2 residents reviewed for medication errors. (Resident #13) Findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic pain. The care plan dated revised on 7/14/2021 revealed Resident #13 had acute and chronic pain related to Rheumatoid Arthritis. Interventions included administering pain medications per physician's orders. A review of the monthly Medication Administration Record (MAR) from February 2022 to November 2022 revealed Methotrexate was not documented as administered to Resident #13 on 5/6/2022 and 5/13/2022. Physician orders dated 2/18/2022 revealed the order to inject intramuscularly one milliliter(mL) of Methotrexate Sodium 50 milligrams per 2 mL every Friday was discontinued on 5/18/2022 and was reordered on 5/25/2022 for administration weekly on Wednesdays. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 was cognitively intact and required assistance with activities of daily living. The MDS further indicated Resident #13 was frequently in pain, was on a pain regimen and had received one injection during the seven-day look back period. Physician progress notes dated 3/10/2022 and 5/26/2022 revealed Resident #13 was receiving Methotrexate, an anti- rheumatic medication, 25 milligrams intramuscular injections every week for chronic rheumatoid pain. Nursing documentation revealed no reason in Resident #13's medical record why Methotrexate was not documented as administered on 5/6/2022 and 5/13/2022. On 11/16/2022 at 8:53 a.m., during a medication pass, Nurse #4 was observed not administering Methotrexate to Resident #13. Nurse #4 stated the medication was not available on the medication cart to administer to Resident #13, and she would have to reorder the medication from the pharmacy. Nurse #4 obtained a new physician order for Methotrexate and documented administered to Resident #13 on 11/17/2022. Attempts to interview Nurse #13 who was assigned Resident #13 on 5/6/2022 and 5/13/2022 were unsuccessful. On 11/17/2022 at 5:10 p.m. in an interview with Nurse #4, she stated the medication, Methotrexate, was reordered electronically using the electronic medical record system weekly after administering the scheduled dose. She stated if nursing staff did not reorder the medication, it would not be available the following week for administration. On 11/17/2022 at 5:25 p.m. in an interview with Resident #13, she stated there had been times when she did not get the Methotrexate injections and her hands would cramp when she did not receive the Methotrexate injection. She stated she could not recall the exact dates when she did not receive Methotrexate and did not understand why she had to wait a week if the medication was not available for administration. On 11/18/2022 at 3:03 p.m. in an interview with Nurse #7, she stated she reordered Resident #13's Methotrexate on 11/9/2022 by placing a sticker on a form for the medication and faxing to the pharmacy. On 11/18/2022 at 4:45 p.m. in an interview with the Operation Manager for Pharmacy, she stated pharmacy medication orders renewed were requested through the electronic medical record, and the pharmacy did not show receiving a fax or an order requesting Resident #13's Methotrexate medication since 11/9/2022. She stated in May 2022, pharmacy only showed an order to discontinue Methotrexate on 5/18/2022 and re-ordered on 5/25/2022. On 11/18/2022 at 5:40 p.m. in an interview with the Director of Nursing, she stated Resident #13's Methotrexate medication should be re-ordered weekly through the electronic medical record system and documented when administered.

Based on observations, record review, and staff interviews, the facility failed to perform hand hygiene after removing a dirty dressing with drainage on it and before cleansing the wound with wound cleanser-soaked gauze and applying a clean dressing for 1 of 1 nurse reviewed for wound care (Treatment Nurse #1). Findings included: Review of the facility's infection control policy, Handwashing/Hand Hygiene read in part, Good hand hygiene is essential and is the primary means to prevent the spread of infection. Alcohol-based handrubs (ABHR) may be substituted when soap and water is not indicated. It listed in part that handwashing/hand hygiene should be performed immediately after gloves are removed and when moving from a contaminated body site to a clean body site such as when changing a brief or wound dressing. An observation of wound care by Treatment Nurse #1 was completed on 11/17/2022 at 1:48 PM. Treatment Nurse #1 gathered her dressing supplies on a piece of wax paper and washed her hands and donned gloves. Nurse Assistant #2 assisted the resident to roll on her right side, so the wound would be exposed on the left buttock. Treatment Nurse #1 removed the old dressing which had a small amount of serous drainage on it and disposed of it in plastic bag. Treatment Nurse #1 cleansed the wound with wound cleanser on gauze, loosely packed the wound with calcium alginate, and applied an absorbent dressing. She secured the dressing with paper tape that had been lying on the resident's bed and then put it in her pocket. Treatment Nurse #1 then removed her gloves, disposed of dirty supplies, and then washed her hands. An interview with Treatment Nurse #1 occurred on 11/17/2022 at 2:15 PM. Treatment Nurse #1 stated that she was nervous and forgot to change her gloves during the dressing change. She further stated that the paper tape was used for other residents' dressing changes. An interview was completed with the Director of Nursing on 11/17/2022 at 3:40 PM. The DON stated the facility's Infection Preventionist (IP) had quit 2 weeks ago, and she was filling in until the new IP started. She further stated that Treatment Nurse # 1 was new to the facility, and she was probably nervous because of the surveyor observing the dressing change. She further indicated that Treatment Nurse #1 should have changed her gloves and performed hand hygiene after removing the old dressing and prior to applying the new dressing. The DON stated that if the tape was laying on the resident's bed, then it should be designated for that resident and not shared with other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and Pharmacist interviews, the facility failed to act upon repeated pharmacy recommendations to assess for abnormal involuntary movements and laboratory tests for a resident receiving daily antipsychotic medications for 1 of 5 residents (Resident #32) reviewed for unnecessary medications. Findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses including schizophrenia and Diabetes Mellitus. Nursing documentation dated 7/23/2022 revealed Resident #32 displayed sporadic movements, gestures and temperaments in behaviors exhibited. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 was severely cognitively impaired, displayed physical behaviors directed toward others and received antipsychotics routinely and as needed. The care plan dated 11/1/2022 revealed a focus for the use of psychotropic drugs with the potential for side effects of the neuromuscular system. Interventions included administering medications per physician's orders and Dyskinesia Identification System: Condensed User Scale (DISCUS), an assessment of abnormal involuntary movements, evaluation per facility protocol. Physician orders dated 11/8/2022 revealed Resident #32 was receiving Haloperidol Lactate, an antipsychotic medication, 5 milligrams(mg) every eight hours as needed for severe agitation related to schizophrenia and an order dated 10/11/22 for Quetiapine Fumarate, a psychotic medication to treat schizophrenia, 50 mg orally twice a day. a. A review of the Pharmacy Consultant's monthly medication regimen reviews revealed the following nursing recommendations for a DISCUS evaluation for Resident #32: * 8/23/2021: Update DISCUS due to Risperdal Consta, medication used to treat mental disorders. * 9/28/2021: Updated DISCUS due to Risperdal Consta and recent use of intramuscular Haloperidol Lactate. * 10/27/2021: Update DISCUS due to Risperdal Consta and Recent use of Intramuscular Haldol. * 11/28/21: Update due to Risperdal Consta and Latuda, a medication to treat schizophrenia. * 12/30/21: Update due to due to Risperdal Consta and Latuda. * 1/27/2022: Update DISCUS due * 2/22/2022: Update DISCUS due * 3/30/2022: Update DISCUS due * 4/26/2022: Update DISCU due DISCUS assessments dated 5/27/22, 6/23/22, and 9/6/22 all indicated Resident #32 had no abnormal involuntary movements. b. Pharmacy Consultant's monthly medication regimen reviews revealed nursing recommendations for routine labs were due: A1C test, a blood test that measures the average blood sugar level over the past three months, and a basic metabolic panel, test that measures eight different substances in the blood and provided information about the body's chemical balance and metabolism on 12/30/2021, 1/27/2022, 2/22/2022, 3/30/2022 and 4/26/2022. A review of Resident #32's laboratory tests revealed a A1C test was not conducted until 8/4/2022 with an A1C level reported as 7.9. There was no documentation in Resident #32's medical record that a basic metabolic panel test was conducted. On 11/18/2022 at 2:00 p.m. in a phone interview with Pharmacist #1, she stated three copies of pharmacy recommendations were sent to the facility on the first of each month: one copy was sent to the DON. She stated when nursing recommendations were not completed by the next medication regimen review, pharmacy continued to make the recommendations and conference with the DON as needed if the recommendation was life threatening. She stated DISCUS assessments were not a high priority and pharmacy would not have called the DON when the DISCUS assessments and laboratory tests were not completed. On 11/18/2022 at 3:15p.m. in an interview with Nurse #7, she stated DISCUS assessments were automatically triggered in the electronic medical record and did not know how often DISCUS assessments were performed on residents receiving antipsychotic medication. She stated Resident #32 behaviors were monitored daily, and the physician was notified when a change in her baseline or health status was identified. On 11/18/2022 at 1:40 p.m. in an interview with the Director of Nursing (DON), she stated pharmacy recommendations were emailed to her and provided to the nurse, weekend supervisor or Quality Improvement (QI) Nurse #1 by the fourth of every month to complete. She stated pharmacy sometimes followed up with emails and phone calls when recommendations were not completed. She stated nurses were able to order laboratory tests per pharmacy recommendations and Resident #32's pharmacy recommendations for a DISCUS evaluation and laboratory tests should have been acted on as soon as they were received from the pharmacy. On 11/18/2022 at 1:47 p.m. in an interview with QI Nurse #1, she stated when she received pharmacy recommendations from the DON, she addressed within one to two days and documented on the printed copy of the nursing recommendation that the recommendations were completed. When asked why Resident #32's DISCUS assessment and laboratory tests recommendations had not been addressed, she stated she assumed the position as QI nurse on 7/12/2022, and the QI nurse prior to her no longer worked at the facility.

Based on observations and staff interviews, the facility failed to label insulin medication vials with a date the medication was opened and an expiration date on 2 of 5 medication carts observed (combined 800, 900 and 1100-hall and 700-hall medication cart) and failed to discard expired medications on 1 of 5 medication carts observed (combined 800, 900 and 1100-hall medication cart). The facility also failed to discard expired medications in 2 of 4 medication storage rooms (Station 4 and Station 1 medication storage room) inspected for storage of medications. Finding included: 1. a. An observation was conducted on 11/17/2022 at 2:28 p.m. of the combined 800, 900 and 1100-hall medication cart located in Station 4 in the presence of Nurse #1. An opened Lantus Insulin bottle dispensed from the pharmacy for Resident #128 was observed with no label indicating when the bottle of insulin was opened and there was no expiration date. An opened Humalog Insulin bottle dispensed from pharmacy for Resident #81 was observed labeled with an expiration date 10/22/22. There was no date on the Humalog Insulin label indicating when the medication was opened. In an interview with Nurse #1 on 11/17/2022 at 2:30 p.m., she stated she checked the combined 800, 900 and 1100-hall medication cart on 11/16/2022 for expirations. She stated the date Resident #128's vial of Lantus Insulin was opened should have been written on the label, and the expiration date, which should have been written on the label also, would have been twenty eight days after the opening date. She did not know when Resident #128's vial of insulin was opened and removed the vial of Lantus Insulin for Resident #128 from the combined 800, 900 and 1100-hall medication cart. Nurse #1 stated Resident #81 had been discharged from the facility last week, and the expired vial of Humalog Insulin for Resident #81 should had been removed from the combined 800, 900 and 1100-hall medication cart. Nurse #1 was observed removing the expired vial of Humalog Insulin for Resident #81 from the combined 800, 900 and 1100-hall medication cart. b. On 11/17/2022 at 2:48 p.m. an observation of 700-hall medication cart was conducted with Nurse # 15. An opened vial of Humulin 70/30 insulin for Resident #36 was observed with no opened date and expiration date on the label on the insulin vial and expired in 28 days was observed on the label. On 11/17/2022 at 2:48 p.m. in an interview with Nurse #15, she stated she opened the vial of Humulin 70/30 insulin for Resident #36 on 11/16/2022 and should have written the opened date on the vial of insulin. She stated sometimes the opened date and expiration dates of the insulin were written on the label of the plastic bottle the vial of insulin was dispensed in by the pharmacy. Resident #36's plastic bottle label was observed with 11/16/2022 written on the label with no information identifying what the date 11/16/2022 was representing. On 11/18/2022 at 4:41 p.m. in an interview with the Director of Nursing, she stated the label on the vial of insulin should be dated when opened and with an expiration dated of twenty-eight days after opening and expired medications should be returned to pharmacy. 2. a. An observation of the facility's Station 4 medication storage room was conducted on 11/17/2022 at 2:40 p.m. with Nurse #1. Eight Ampicillin, an antibiotic medication, bulbs for intravenous (IV) administration for Resident #95 were observed in a large clear bag dated by pharmacy issued on 11/11/22 with an expiration date of 11/14/2022. Another eight Ampicillin IV bulbs for Resident #95 were observed in another large clear bag dated by the pharmacy issued on 11/13/2022 with an expiration date of 11/16/2022. Three Ampicillin 2 grams IV bulbs dated issued by the pharmacy on 11/7/2022 with an expiration date of 11/10/2022 were observed in a clear bag for Resident #336 in the refrigerator. On 11/17/2022 at 2:40 p.m. in an interview with Nurse #1, she stated Resident #95 was receiving IV antibiotics every four hours and she checked the expiration date on the label of the Ampicillin bulbs prior to administering the IV antibiotics. She stated she was not assigned to Resident #336. Nurse #1 removed the expired Ampicillin bulbs from the refrigerator for Resident #36 and Resident #336 to return to the pharmacy. b. On 11/17/2022 at 3:04 p.m. an observation of the facility's Station 1 medication storage room was conducted with Nurse #14. An unopened bottle of Docusate Liquid 50 milligrams per 5 milliliters was observed at the front of a medication shelf with 4/2022 as the expiration date. Nurse #14 removed the bottle of Docusate Liquid from the medication room to return to the pharmacy. On 11/17/2022 at 3:04 p.m. in an interview with Nurse #14, she stated the medication room and medications in the refrigerator were checked daily and she checked medications for expirations prior to administering to the residents. She stated Nurse #10 checked the medication room for expirations on 11/16/2022. On 11/17/2022 at 3:10 p.m. in an interview with Nurse #10, she stated she checked Station 1 medication storage room on 11/16/2022 and it was an oversight and missed the expired bottle of Docusate Liquid. On 11/18/2022 at 4:41p.m. in an interview with the Director of Nursing, she stated medication storage rooms were checked daily by unit managers and nurses and was unsure why expired medications were in the medication rooms on 11/17/2022. She stated expired medication should be returned to the pharmacy.

Based on record review, observations, staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implement procedures and monitor for interventions the committee put into place following the recertification and complaint survey conducted on 7/29/2021 and 2/14/2020 for two deficiencies cited in the areas of Pharmacy Services (F761) and Infection Control (F880). The duplication of citations during multiple federal surveys of record showed a pattern of the facility's inability to sustain an effective QAA program. Finding included: This tag is cross reference to: F-761 Based on observations and staff interviews, the facility failed to label insulin medication vials with a date the medication was opened and an expiration date on 2 of 5 medication carts observed (combined 800, 900 and 1100-hall and 700-hall medication cart) and failed to discard expired medications on 1 of 5 medication carts observed (combined 800, 900 and 1100-hall medication cart). The facility also failed to discard expired medications in 2 of 4 medication storage rooms (Station 4 and Station 1 medication storage room) inspected for storage of medications. During the recertification and complaint survey of 2/14/2020 the facility failed to dispose of expired drugs or biologicals on one of four medication carts inspected for expired medications (400 hall medication cart). F-880 Based on observations, record review, and staff interviews, the facility failed to perform hand hygiene after removing a dirty dressing with drainage on it and before cleansing the wound with wound cleanser-soaked gauze and applying a clean dressing for 1 of 1 nurse reviewed for wound care (Treatment Nurse #1). During the recertification and complaint survey of 7/29/2021 the facility failed to implement the facility 's infection control measures for the quarantine unit when 1) Nurse # 2 was observed entering a resident 's room wearing only an N-95 mask for 1 of 21 residents on the 1000 hall of the quarantine unit, a Social Worker was observed entering a resident 's room wearing only an N-95 and an isolation gown on the 1100 hall of the quarantine unit, and the Nurse Aide #2, Social Worker and Physician were observed exiting 3 of 21 residents rooms on the 1100 hall quarantine unit wearing the isolation gowns and removing the isolation in the hallway of the quarantine unit, 2) change a peripherally inserted central catheter (PICC) dressing weekly as ordered by the physician for 1 of 1 resident (Resident# 111) reviewed, and 3) maintain social distancing in the smoking area for 2 of 2 residents reviewed. (Residents # 69, #76) This occurred during the COVID pandemic. During the recertification and complaint survey of 2/14/2020 the facility failed to wash hands with soap and water prior to exiting the room for 1 of 1 resident on contact precautions for Clostridium Difficile. (Resident # 168) In an interview with the Administrator on 11/18/2022 at 5:39 p.m. with the Regional Nursing Consultant present, the Administrator stated the unit managers conducting weekly audits on the medication storage rooms and monthly audits were conducted on the medication storage rooms, medication carts and on narcotics storage. She stated the supervisor on the night shift randomly checked the medication carts for expired medications. She stated the facility had conducted in-services on handwashing during the COVID pandemic and continued to monitor handwashing. She stated the Quality Improvement (QI) team monitored pressure wounds and the care provided to assure correct procedures were in place for the care of the wound. The Regional Nursing Consultant stated when the consultant team visited the facility each month, medication storage rooms and medications carts were checked by the consultant team for compliance and conducted observations of wound care. The Administrator and Regional Nurse Consultant stated no concerns were identified with the audits for medication storage on the medication carts, in the medication storage room and handwashing during wound care.