**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record review, the facility failed to offer a bed bath for two days, provide nail care, and shave a resident dependent on staff for activities of daily living (ADL). This failure occurred for 1 of 4 sampled residents reviewed for ADL (Resident #63). The findings included: Resident #63 was admitted to the facility on [DATE]. Diagnoses included heart failure, dilated cardiomyopathy, presence of automatic cardiac defibrillator, and shortness of breath. A care plan revised 9/5/24 identified Resident #63 was dependent on staff for ADL and refused care at times. Interventions included staff would provide personal hygiene, inspect skin and notify nurse of any abnormal changes. Additionally, staff were to inform Resident #63 of ADL care to be provided ahead of time, give options of times care would be done to allow for flexibility and accommodate his mood, and if refused, reattempt at another time. A 9/13/24 significant change MDS recorded Resident #63 had adequate hearing and vision, clear speech, able to be understood by others and able to understand, and his cognition was intact. Review of Resident #63's Shower, Tub, Bath Sheets revealed the following: - 10/3/24, documented Resident #63 refused a shower, received a bath instead, but it did not indicate if nails were cleaned or clipped or if the nurse was notified of his refusal. The form was not signed by staff. - 10/7/24, documented Resident #63 refused a shower, it did not indicate if nails were cleaned or clipped. The form was not signed by staff. - 10/10/24, documented Resident #63 refused a shower, received a bath instead, but it did not indicate if nails were cleaned or clipped or if the nurse was notified of his refusal. The form was not signed by staff. - 10/14/24, documented Resident #63 refused a shower, but it did not indicate if the nurse was notified of his refusal. - 10/17/24, documented Resident #63 refused a shower because that day was not his assigned shower day and that he wanted a shower on the next day. The document did not indicate if his nails were cleaned or clipped. - 10/21/24 documented Resident #63 refused a shower, but did not indicate if a bed bath was offered, if his nails were cleaned or clipped or if the nurse was notified of his refusal. Resident #63 was observed in bed and interviewed on 10/21/24 at 11:31 AM. He stated, Look at my fingernails, how long they are, they need to be trimmed, and I need a shave. Resident #63 was observed with a thick beard that extended from both cheeks to his chin. The fingernails on each hand were observed extended over the skin. He stated that he was taken to the shower room on Monday, 10/21/24, for a shower, but that the shower room was full, he was cold, so he asked staff to bring him back to his room and to give him a shower on Friday, 10/25/24. He said no when asked if he was offered a bed bath, or to have his fingernails trimmed. Resident #63 was observed in bed on 10/23/24 at 9:21 AM with a thick beard that extended from both cheeks to his chin and the fingernails on each hand were observed extended over the skin. During a 10/23/24 9:23 AM observation with Medication Aide (MA) #1 of Resident #63 in bed, his fingernails and facial hair was observed. MA #1 stated each of his fingernails were long and asked Resident #63 if he wanted them trimmed, and if he wanted to be shaven, Resident #63 stated yes. During a 10/23/24 9:25 AM interview with Nurse Aide (NA) #6, he stated he was a regular NA for Resident #63 and offered him a shower on Monday, 10/21/24, but he refused and did not want to be bothered. NA #6 stated he reported the refusal to the nurse, but did not offer Resident #63 a bed bath, to have his fingernails trimmed or to be shaven because Resident #63 said he did not want to be bothered. Nurse #7 observed Resident #63 on 10/23/24 at 9:29 AM at the request of the surveyor. Nurse #7 stated during the observation that the fingernails of Resident #63 were long and asked him if he wanted to have his nails trimmed, and if he wanted to be shaven. Resident #63 replied Yes and further stated that his fingernails were too long. During a 10/23/24 1:20 PM interview with Unit Manager #2 (UM #2), she stated that the NA should report to the nurse if a resident refused ADL care. She further stated that fingernails should be trimmed by the NA and if the resident refused, the NA should report to the nurse so that the nurse could go to the resident to encourage care and provide the care if necessary. UM #2 stated that ADL care did not have to be provided when a resident received a shower but should be provided when needed. UM #2 stated the nurse should check the resident's nails during weekly skin checks and provide nail care as needed. UM #2 stated she was the charge nurse for Resident #63 on Monday, 10/21/24 and that she was not notified that he refused care. During a 10/23/24 3:53 PM interview with NA #7, she stated she was a new NA, she was the assigned NA for Resident #63 on Tuesday, 10/22/24, which was her second assignment since her training. NA #7 stated on Tuesday, 10/22/24 she thought that another team member was assigned to give showers/bed baths to residents, so that was the reason she did not offer him a shower/bed bath, to be shaven or nail care. The Scheduler stated in a 10/23/24 5:37 PM interview that on Tuesday, the NA schedule was updated before 7:00 AM that between 11:00 AM to 2:00 PM, NA #8 would take as many residents as she could to activities and assist as many residents as she could to be shaven. The Scheduler stated that the original plan was to have a shower team on Tuesday, but that was changed on the schedule before 7:00 AM and since Tuesday was not a scheduled shower day for Resident #63, ADL care should have been provided by NA #7. A 10/23/24 5:55 PM interview with NA #8 revealed she came in at 11:00 AM, Tuesday 10/22/24 and that she was assigned to take residents to activities, assist with showers, and to shave as many residents as she could until 2:00 PM. NA #8 stated that she did not make it to all the halls, and that she did not make it to Resident #63 on Tuesday, 10/22/24 to offer him ADL care. A 10/23/24 4:42 PM interview with the Interim Director of Nursing (DON), she stated a NA could trim the fingernails of residents and she expected the nurse to include nail assessments on weekly skin check audits. The Interim DON stated that fingernail care, and shaving should be provided when the staff identified that a resident needed this care. She further stated that staff did not have to wait until the resident received a shower to provide the ADL care that was needed. The Interim DON stated that the ADL care refusals should be reported to the nurse and the nurse should go and talk to the resident and offer the care again, so that care was offered about 3 times to give the resident an opportunity to receive the care. The Interim DON further stated that fingernail care should be provided as needed, especially if the resident refused a shower/bath. The Interim DON stated that if a resident refused a shower, the NA should inform the nurse, and the nurse should offer the resident alternatives like a different shower/bath schedule and offer a bed bath if the resident declined a shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews with a resident and staff, the facility failed to provide larger portions per physician order to a resident at risk for weight loss due to a history of weight loss (Resident #73). The findings included: Resident #73 admitted to the facility on [DATE]. Diagnoses included Alzheimer's dementia, mild cognitive impairment, hyperlipidemia, and hypertension. Review of his medical record revealed Resident #73's monthly weight was assessed on 4/4/24 as 187.4 pounds. Review of his medical record revealed Resident #73's monthly weight was assessed on 5/10/24 as 180.6 pounds, approximately a seven-pound weight loss or approximately 3.7% weight loss in a month. A 5/16/24 Interdisciplinary Team progress note recorded Resident #73 was discussed for weight loss, decreased food intake, and disengagement with meals. A physician order was written to decrease the morning dose of Depakote (a mood stabilizer) to promote alertness and encourage food intake. Review of the medical record revealed a 7/3/24 physician order that recorded to provide 4 ounces of a high calorie nutritional supplement twice a day with breakfast and lunch. A nutrition care plan revised 7/12/24 documented Resident #73 at risk for nutritional decline due to weight loss related to a decline in intake. Interventions included to provide an appetite stimulant, high calorie supplements, encourage consumption of meals and provide a regular diet with double portions as ordered. Review of his medical record revealed Resident #73's monthly weight was assessed on 7/16/24 as 183.6 pounds. Review of his medical record revealed Resident #73's monthly weight was assessed on 8/7/24 as 178.6 pounds, a five-pound weight loss or 2.7% weight loss in a month and approximately 4.8% weight loss in four months. A 10/2/24 quarterly Minimum Data Set assessment indicated Resident #73 had clear speech, adequate vision, adequate hearing, usually understood by others, usually understood others, severely impaired cognition, and fed himself after staff set-up assistance with meals. Review of his medical record revealed Resident #73's monthly weight was assessed on 10/21/24 as 178.4 pounds or approximately 4.8% weight loss in six months. Review of the facility's Diet Order Report dated 10/21/24 recorded Resident #73 received a regular diet with larger portions, milk, and a peanut butter sandwich with each meal. Resident #73 was observed on 10/22/24 at 9:05 AM and 10/23/24 at 9:18 AM in his room, feeding himself breakfast. During each observation, he received a 4-ounce bowl of grits. The breakfast meal tray card recorded a diet order for larger portions. Resident #73 did not receive larger portions of grits for breakfast on 10/22/24 or 10/23/24. During each observation, Resident #73 was asked if he would like to receive a larger portion of grits, and he responded yes and stated that grits were the best part of his breakfast. During a 10/23/24 12:00 PM interview with the Physician, he stated that Resident #73 required encouragement to eat because his nutritional status had declined due to his worsening dementia. The Registered Dietitian (RD) was interviewed on 10/23/24 at 2:57 PM and stated that Resident #73 received an appetite stimulant, milk, and a peanut butter sandwich with each meal, a high calorie nutritional supplement twice a day and double portions for nutritional support due to his history of weight loss and dementia. She stated that in the last six months, Resident #73 had some weight loss, but had not experienced significant weight changes. The RD stated that residents with diet orders for larger/double portions should receive larger/double portions of vegetables, starches and meats. The RD stated that Resident #73 should have received an 8-ounce portion of grits for breakfast on 10/22/24 and 10/23/24 per his diet order. The Certified Dietary Manager (CDM) was interviewed on 10/23/24 at 4:00 PM. The CDM stated that a resident with a diet order for larger/double portions should receive larger/double portions of meats, starches, and vegetables. She stated that a 4-ounce portion of grits was the standard portion, but that Resident #73 should have received an 8-ounce portion of grits for breakfast from the dietary staff. The CDM stated that it was an oversight that Resident #73 did not receive a double portion of grits on 10/22/24 and 10/23/24 and that the terminology on the tray cards would be changed from larger portions to double portions so that dietary staff would provide the correct portion. The Interim Director of Nursing stated on 10/24/24 at 12:22 PM that residents should receive the portion size of foods as ordered.

Based on observations, record reviews and staff interviews, the facility failed to protect resident privacy by leaving an unattended resident roster with personal health information (PHI) on top of a medication cart in the hallway and visible to the public. This was for 1 of 3 medication carts (700 Hall Medication Cart) reviewed for privacy and confidentiality. This deficient practice had the potential of effecting 22 residents on the 700 hall (Resident #98, #12, #96, #54, #82, #90, #97, #57, #33, #204, #88, #203, #55, #99, #91, #13, #83, #7, #20, #51, #35, and #60). The findings included: A continuous observation was completed on 10/21/2024 from 8:40 AM to 9:02 AM of the 700 Hall Medication Cart. Nurse #8 was working the medication cart, walked away from the cart, and left the resident roster unattended on top of the cart which had PHI and entered a resident's room. Two residents and one visitor were observed to pass by the medication cart. One resident was walking, and the other resident was propelling herself in a wheelchair. The visitor walked by the unattended medication cart. The resident roster was composed of room numbers, names, code status, history of diagnoses, and report items for 22 residents: Resident # 98, Resident # 12, Resident # 96, Resident # 54, Resident #82, Resident # 90, Resident # 97, Resident # 57, Resident # 33, Resident # 204, Resident # 88, Resident # 203, Resident # 55, Resident # 99, Resident # 91, Resident # 13, Resident # 83, Resident # 7, Resident # 20, Resident # 51, Resident # 35, and Resident # 60. During the continuous observation on 10/21/24 from 8:40 AM to 9:02 AM, Nurse #8 came back to the medication cart and was interviewed about the resident roster. The Nurse stated she was supposed to turn the resident roster paper over before she left the cart, but she just forgot. Then Nurse #9 approached the medication cart and was shown the resident roster that contained the PHI that was left visible to the public. Nurse #9 indicated the roster should not have been left visible to the public because it was a violation of the residents' privacy. An interview conducted with Unit Manager (UM) #10 at 12:48 PM on 10/23/2024 indicated nurses were expected to maintain resident privacy by turning over any PHI in view of the public. An interview conducted with Interim Director of Nursing (DON) on 10/24/2024 at 10:05 AM indicated the nurses were expected to turn the resident roster paper upside down on the medication carts or to take it with them when leaving the medication carts to protect the privacy of the residents.

Based on record review, and interviews with residents and staff, the facility failed to provide an ongoing individual activity program per resident's preference (Residents #49 and #76) and an ongoing group activity program per Resident Council (Residents #1, #5, #77 and #88) when residents expressed a request to play more Resident-led bingo. This failure occurred for 6 of 6 sampled residents reviewed for individual and group activities. The findings included: 1a. Resident #49 re-admitted to the facility 6/13/24. A 2/19/24 annual Minimum Data Set (MDS) assessment indicated Resident #49 had adequate hearing/vision, clear speech, able to understand and be understood, intact cognition and that it was very important to participate in her favorite activities and participate in group activities. A care plan revised 9/3/24, recorded Resident #49 was able to structure her day and enjoyed both individual and group activities. Interventions included to encourage individual activities of interest and to notify of group activities of interest which included bingo. Resident #49 was observed on 10/21/24 and 10/24/24 at 1:30 PM participating in bingo. Resident #49 attended a Resident Council Meeting on 10/22/24 at 1:30 PM with the state surveyor. During the meeting Resident #49 stated that residents expressed during a Resident Council meeting a few months ago that they wanted to play bingo more often, and would prefer to play it daily, but they were told that twice per week was the limit. She stated that the residents expressed they offered to call bingo themselves, if it would allow them to play more often and then Resident-led bingo was added to the activity calendar on Saturdays, but that wasn't enough. She expressed residents still wanted to play more, daily if possible and would be willing to call bingo themselves, but when they expressed this during Resident Council, they were told three times per week was enough. 1b. Resident #76 was admitted to the facility 4/22/22. A 1/23/24 annual MDS assessment indicated Resident #76 had adequate hearing/vision, clear speech, able to understand and be understood, intact cognition and that it was very important to participate in her favorite activities and participate in group activities. A care plan revised 7/25/24, recorded Resident #76 was able to structure her day and enjoyed both individual and group activities. Interventions included to encourage individual activities of interest and to notify of group activities of interest which included bingo. Resident #76 was observed on 10/21/24 and 10/24/24 at 1:30 PM participating in bingo. Resident #76 attended a Resident Council Meeting on 10/22/24 at 1:30 PM with the state surveyor. During the meeting Resident #76 agreed when residents expressed that during a Resident Council meeting a few months ago residents stated that they wanted to play bingo more often, and would prefer to play it daily, but they were told that twice per week was the limit. She agreed that the residents expressed they offered to call bingo themselves, if it would allow them to play more often and then Resident-led bingo was added to the activity calendar on Saturdays, but that wasn't enough. She expressed that she still wanted to play more, daily if possible and that the residents would be willing to call bingo themselves, but when they expressed this during Resident Council, they were told three times per week was enough. 1c. Review of 2/8/24 Resident Council Meeting minutes, recorded by the Activity Director (AD) revealed the residents in attendance expressed they wanted to play more bingo, but the AD let them know two is our limit per week. Review of the 4/10/24 Resident Council Meeting minutes, recorded by the AD revealed the residents in attendance expressed they wanted to play more bingo. The AD recorded in the minutes that they would try Resident-led bingo on Saturdays two to three times per month. Review of the activity calendars February 2024 to April 2024 revealed bingo was offered twice per week. Review of the activity calendars May 2024 to October 2024 revealed bingo was offered three times per week; twice during the week and once on Saturdays. A Resident Council Meeting occurred with the state surveyor on 10/22/24 at 1:30 PM. Residents #1, #5, #77 and #88 voiced during the meeting that they expressed a few months ago that they wanted to play bingo more often, and would prefer to play it daily, but they were told that twice per week was the limit. The Residents expressed they offered to call bingo themselves, if it would allow them to play more often and then Resident-led bingo was added to the activity calendar on Saturdays. The Residents expressed they appreciated being able to play bingo three times per week, but that they still wanted to play more, daily if possible and would be willing to call bingo themselves, but when they expressed this during Resident Council, they were told three times per week was enough. The AD was interviewed on 10/22/24 at 3:14 PM. He stated he facilitated Resident Council Meetings and recorded the minutes. The AD stated that Residents expressed during a Resident Council Meeting in February 2024 that they wanted bingo more often, so a Resident-led bingo activity was added in May 2024 on Saturdays to offer bingo three times per week. The AD stated he asked Residents during the June 2024 Resident Council Meeting how did they like having a third bingo and they said they liked it. He further stated, some of the residents would play bingo every day if they could, but I want them to have a variety of activities and I think bingo three times a week is enough. During an interview on 10/24/24 at 12:01 PM with the Administrator and Interim Director of Nursing (DON), the Interim DON stated the activity program should be reasonable and based on resident preference. The Administrator stated that residents should be allowed to play bingo daily if they wanted and especially if they were willing to lead the activity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff and resident interviews, the facility failed to ensure residents' toenails were trimmed and podiatry services were arranged for 3 of 4 residents (Resident #28, Resident #1 and Resident #63) reviewed for foot care. Findings included: 1. Resident 28 was admitted to the facility 08/07/24 with diagnoses that included diabetes type 2, and vascular dementia. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had no cognitive impairment. He was independent for eating and oral hygiene. He required moderate assistance to toilet and maximum assistance with bed mobility. Care plans reviewed for Resident #28 initiated 08/15/23 and revised on 08/27/24 included Resident #28 required assistance to put on and remove his socks and shoes related to a decline in functional status. Another care plan included that Resident #28 had diabetes type 2, was at risk for complications, had an intervention to monitor skin integrity and report abnormalities to the nurse or physician. On 10/22/24 at 8:01 AM an observation and interview conducted with Resident #28 revealed he was seated in his wheelchair with socks and shoes on both feet. Resident #28 reported he had not been seen by the facility podiatrist since admission and he needed his toenails clipped. On 10/23/24 at 3:00 PM Nurse Aide (NA) #3 removed the shoe and sock on Resident #28's left foot. The observation revealed Resident #28 had dry scaly skin on his left foot, his toenails were thick and extended over the ends of each toe. Resident #28 revealed that the toenails on his right foot looked the same and his skin was dry. Resident #28 verbalized he had not had a podiatry consult and he really needed one, but his toenails did not cause pain. NA #3 reported she had never observed Resident #28's toenails but she would have reported the condition of his toenails to the nurse. NA #3 explained that NAs were not able to cut or clip any resident's finger or toenails. On 10/24/24 at 10:31 AM Nurse #1 was interviewed. Nurse #1 reported that NAs were not allowed to provide finger or toenail care to any resident and were supposed to report nail care concerns to the nurse. Nurse #1 revealed she had not received any report of Resident #28 needing any nail care. A phone interview with Nurse #2 conducted on 10/23/24 at 3:14 PM revealed she had completed weekly skin checks of Resident #28 on 10/15/24 and 10/22/24. Nurse #2 revealed she did not identify any concerns with the toenails of Resident #28 and reported if she did have concerns they would have been reported to the physician and Social Worker (SW) to obtain a podiatry consult. An interview with the Social Worker on 10/23/24 at 9:36 AM revealed nurses were responsible to give her a referral for a podiatry consult for each resident and then she forwarded the resident information to the consulting podiatrist who would schedule a podiatrist consult on the next visit to the facility which was scheduled at the beginning of November. The SW revealed she did not recall a podiatry consult referral from nurse staff for Resident #28 to be seen by the podiatrist. The SW confirmed the podiatrist was expected to be at the facility monthly. A follow up interview with the SW conducted 10/23/24 at 3:46 PM revealed Resident #28's name was not listed on the podiatrist lists for September 2024 or October 2024. The SW reported she would notify Unit Manager (UM #2) and physician that Resident #28 requested a podiatry consult and she would add Resident #28's name to the November schedule. An interview with nurse Unit Manager (UM) #2 on 10/23/24 at 1:20 PM included that only licensed nurses were to provide any nail care to residents. UM #2 revealed that the nurse would check the resident's toenails during weekly skin checks and the NAs were to report the need of resident nail care on resident shower days and either clip the nails or notify the SW that the resident needed a podiatrist consult. UM #2 revealed that on review of Resident #28's weekly skin checks completed by Nurse #1 dated 09/09/24, 10/15/24, and 10/22/24 there were no finger or toenail concerns. UM #2 revealed she was not certain if Resident #28 had ever been consulted by the podiatrist. The facility physician was interviewed at 11:55 AM on 10/23/24. He revealed he was not aware that Resident #28 needed podiatry care. The physician explained the facility did have standing orders for residents to have podiatry consults. He was not aware that Resident #28 needed to be seen by the podiatrist, and he would follow up with Unit Manager #2. On 10/23/24 the Director of Nurses (DON) revealed during an interview at 4:39 PM that both NAs and nurses could provide finger and toenail care to Residents if the Resident did not have diabetes Type 2. The DON provided shower sheets dated 10/01/24 and 10/10/24 signed by an NA for Resident #28. No finger or toenail concerns were documented on the shower sheets. A follow up interview conducted with the DON on 10/24/24 at 11:41AM revealed both NAs and nurses could perform finger and toenail care to any resident if the resident had no diabetes type 2 diagnosis. The DON reported the nurse was responsible to notify the SW nail care was needed by the podiatrist for any reason. The DON expected the nurse staff to include toenail assessments on weekly skin check reports and make referrals for toenail care as indicated. 2. Resident #1 was admitted to the facility 1/9/24. Diagnoses included atherosclerotic heart disease, cerebrovascular accident, chronic kidney disease, stage 4, chronic pain, and neuromuscular disorder. An 8/5/24 quarterly Minimum Data Set (MDS) assessment, indicated Resident #1 had adequate hearing and vision, clear speech, able to be understood by others and able to understand, and his cognition was intact. A care plan revised 8/29/24 identified Resident #1 was dependent on staff for activities of daily living (ADL) and at risk for a decline in skin integrity due to his diagnoses of a neuromuscular disorder. Interventions included staff would provide personal hygiene and weekly evaluation/assessment of skin with notification to the nurse or physician as necessary. A review of weekly Skin Check records dated 10/2/24, 10/9/24 and 10/16/24 completed by Nurse #7 recorded Resident #1's assessments were completed with no new skin concerns documented. A review of the medical record for Resident #1 revealed no documentation of podiatry services or for a podiatry referral. Resident #1 attended a Resident Council meeting with the state surveyor on 10/22/24 at 1:30 PM. During the meeting, Resident #1 stated that he had not received podiatry services since his admission and that he needed his toenails trimmed. He stated that staff looked at his skin and feet weekly but had not offered him podiatry services. A 10/23/24 11:00 AM observation with Nurse #7 of Resident #1 in his room revealed he was seated in his wheelchair with bilateral leg braces in place and both feet rested on the footrests on his wheelchair. When asked by Nurse #7 to assess his feet, Resident #1 agreed. Nurse #7 stated that she last observed his feet during a skin audit on 10/16/24, but that she did not recall the specific length of his toenails. During the assessment of the left foot, Resident #1 expressed that the left great toenail was painful. After assessing his left foot, Nurse #7 stated that the left great toenail was thick and long and could be trimmed. The left great toenail was observed to extend over the skin and curled towards his skin. Nurse #7 assessed the right foot and stated that the fourth toenail on the right foot was long and should be trimmed. The toenail was observed to extend over the skin and curled towards the skin. Nurse #7 stated that his toenails were the same length as she saw when she completed the skin assessments on 10/2/24, 10/9/24 and10/16/24, but that she did not offer to trim his nails or offer a podiatry referral because she was new to the facility and to the facility's process. She stated that due to the thickness of his nails and his complaints of pain he should be referred for podiatry services. Nurse #7 stated when she completed the skin audit for Resident #1 on 10/16/24 it was after 6:30 PM and the social worker (SW) had already left. Nurse #7 further stated that she did not communicate the need for a podiatry referral for Resident #1 to the SW, but that was the process. Nurse #7 stated that staff should communicate to the SW if staff observed that a resident needed podiatry services, but that she was new to the facility, and still learning the process. She stated that she should have left a note for the SW about the length of Resident #1's toenails so that the SW could add Resident #1 to the list for podiatry services, and stated, But I did not do that. Resident said yes when asked if he wanted a podiatry referral. He stated that his toenails were last trimmed by a nurse over a month ago, but he did not recall exactly when that was. He stated he did not know the podiatrist was in the facility in September 2024, so he did not ask to be seen. An interview with the Social Worker (SW) on 10/23/24 at 9:36 AM revealed nurses were responsible to give her a referral for a podiatry consult for each resident and then she forwarded the resident information to the consulting podiatrist who would schedule a podiatrist consult on the next visit to the facility. The SW confirmed the podiatrist was expected to be at the facility monthly. The SW reviewed the list of residents seen by the podiatrist in September 2024, and confirmed Resident #1 was not included. The SW stated she was not informed that Resident #1 needed a podiatry referral and so Resident #1 was not on the podiatry list for the next podiatry visit planned at the facility for 11/12/24 and 11/13/24, but he would be added. During a 10/23/24 1:20 PM interview with Unit Manager (UM) #2, she stated that only licensed nurses were to provide any nail care to residents. UM #2 revealed that the nurse should check the resident's toenails during weekly skin checks and notify the SW if a resident needed a podiatrist consult. A 10/23/24 12:30 PM interview with the physician revealed he was not aware that Resident #1 needed podiatry care, but that the facility did have standing orders for residents to have podiatry consults. A 10/23/24 4:42 PM interview with the Interim Director of Nursing (DON), she stated the nurse was responsible to notify the SW if podiatry care was needed. The DON expected the nurse to include toenail assessments on weekly skin check audits and make referrals for toenail care as indicated. The DON stated she could not find any record that Resident #1 had been referred for podiatry services. She stated that Resident #1 was not a diabetic, but if his toenails were thick, long and painful and required podiatry services then the SW and MD should be informed so that that the referral paperwork could be completed, and a referral for services made to the provider. 3. Resident #63 was admitted to the facility on [DATE]. Diagnoses included onychomycosis (fungal infection of the nails), mild hammertoe, and peripheral vascular disease. Podiatry consults dated 1/3/24 and 6/24/24 both recorded Resident #63 received follow-up podiatry services for routine footcare due to chronic onychomycosis. Both consults documented that conservative footcare was recommended due to marked limitation and pain from the thickening and dystrophy (tissue degeneration) of the affected nails. Both consults documented a care plan to maintain regular footcare visits as scheduled to decrease pressure and reduce pain and infection risk to his feet and toes. A review of the list of residents who received podiatry services in the facility in August 2024 revealed Resident #63 was not included in the list of residents who received podiatry services. A 9/3/24 podiatry consult recorded Resident #63 did not receive podiatry services because he was currently at the hospital. A review of the list of residents who received podiatry services in the facility in September 2024 revealed Resident #63 was not included in the list of residents who received podiatry services due to a hospitalization. A care plan revised 9/5/24 identified Resident #63 was dependent on staff for activities of daily living (ADL), at risk for a decline in skin integrity, and refused care at times. Interventions included staff would provide personal hygiene, inspect skin and notify nurse of any abnormal changes. Additionally, staff were to inform Resident #63 of ADL care to be provided ahead of time, give options of times care would be done to allow for flexibility and accommodate his mood, and if refused, reattempt at another time. A 9/13/24 significant change MDS recorded Resident #63 had adequate hearing and vision, clear speech, able to be understood by others and able to understand, and his cognition was intact. Review of Resident #63's Shower, Tub, Bath Sheets revealed the following: - 10/3/24, documented Resident #63 refused a shower, received a bath instead, but it did not indicate if nails were cleaned or clipped or if there was a need for podiatry services. The form was not signed by staff. - 10/7/24, documented Resident #63 refused a shower, it did not indicate if nails were cleaned or clipped or if there was a need for podiatry services. The form was not signed by staff. - 10/10/24, documented Resident #63 refused a shower, received a bath instead, but it did not indicate if nails were cleaned or clipped or if there was a need for podiatry services. The form was not signed by staff. - 10/17/24, documented Resident #63 refused a shower because that day was not his assigned shower day and that he wanted a shower on the next day. The document did not indicate if his nails were cleaned or clipped or if there was a need for podiatry services. - 10/21/24 documented Resident #63 refused a shower, but did not indicate if his nails were cleaned or clipped or if there was a need for podiatry services. Resident #63 was observed in bed and interviewed on 10/21/24 at 11:31 AM. He stated, Look at my toenails, how long they are, they need to be trimmed. Each toenail on each foot was observed extended over the skin and curled towards his skin. He stated that he was taken to the shower room on Monday, 10/21/24, for a shower, but that the shower room was full, he was cold, so he asked staff to bring him back to his room and to give him a shower on Friday, 10/25/24. He said no when asked if he was offered a bed bath, or to have his toenails trimmed. Resident #63 was observed in bed on 10/23/24 at 9:21 AM. The length of each toenail extended over the skin on each foot. During a 10/23/24 9:23 AM observation with Medication Aide (MA) #1 of Resident #63 in bed, his feet were observed. MA #1 stated each of his toenails were long and asked Resident #63 if he wanted them trimmed, Resident #63 stated yes. During a 10/23/24 9:25 AM interview with Nurse Aide (NA) #6, he stated he was a regular NA for Resident #63 and offered him a shower on Monday, 10/21/24, but he refused and did not want to be bothered. NA #6 stated he reported the refusal to the nurse, but did not report that his toenails were long, because Resident #63 said he did not want to be bothered. Nurse #7 observed the toenails of Resident #63 on 10/23/24 at 9:29 AM at the request of the surveyor. Nurse #7 stated during the observation that the toenails of Resident #63 were long and asked him if he wanted to have his nails trimmed, he replied Yes, they are too long. An interview with the Social Worker on 10/23/24 at 9:36 AM revealed nurses were responsible to give her a referral for a podiatry consult for each resident and then she forwarded the resident information to the consulting podiatrist who would schedule a podiatrist consult on the next visit to the facility. The SW confirmed the podiatrist was expected to be at the facility monthly. The SW reviewed the list of residents seen by the podiatrist in the facility in August 2024 and confirmed Resident #63 was not on the list, but stated she did not know why. The SW reviewed the list of residents seen by the podiatrist in September 2024, and confirmed Resident #1 was not included, because he was in the hospital. The SW stated that Resident #63 would have to wait for the next podiatry visit because the provider would not come back for one resident. The SW stated the next podiatry visit was scheduled for 11/12/24 and that Resident #63 would be added to the list to be seen. During a 10/23/24 1:20 PM interview with Unit Manager #2 (UM #2), she stated that only licensed nurses were to provide any nail care to residents. UM #2 revealed that the nurse should check the resident's toenails during weekly skin checks and notify the SW if a resident needed a podiatrist consult. A 10/23/24 12:30 PM interview with the physician revealed he was not aware that Resident #63 needed podiatry care, but that the facility did have standing orders for residents to have podiatry consults. A 10/23/24 4:42 PM interview with the Interim Director of Nursing (DON), she stated the nurse was responsible to notify the SW if podiatry care was needed. The DON expected nursing staff to include toenail assessments on weekly skin check audits and make referrals for toenail care as indicated. The DON stated she could not find any record that Resident #63 received podiatry services since June 2024.

Based on a breakfast meal test tray observation, minutes from Resident Council meetings, a Resident Council meeting, resident and staff interviews, the facility failed to provide food that was palatable and had an appetizing temperature for 8 of 8 residents reviewed for palatable foods (Resident #5, Resident #1, Resident #88, Resident # 77, Resident # 76, Resident #95, Resident #63, and Resident # 34). The findings included: Resident #95 was interviewed on 10/21/24 at 10:43 AM and he reported he was on a regular diet with ground meat. The resident was not happy with the breakfast meat and it had no taste. Resident #63 was interviewed on 10/21/24 at 11:28 AM and when asked about the food in general, he reported the food looks like [expletive] and tastes like it, too. Resident Council Meeting minutes for 12/6/23, 1/10/24, 2/8/24, 6/12/24, and 7/10/24 identified issues with food and coffee temperatures, food texture, and flavor. During the Resident Council meeting on 10/22/24 at 1:30 PM, 6 of 6 residents in attendance (Resident#1, #49, #88, #77, #5, and #76) identified ongoing issues with cold coffee and tough meat. The residents also noted the microwave was broken and they did not have coffee available at any time they wanted. A breakfast test tray was requested on 10/23/24 at 8:05 AM. The plate was placed on an insulating bottom and had an insulating cover. The tray left the kitchen at 8:17 AM on an open cart. The coffee had a plastic lid over the cup and was in a plastic cup. The cart arrived at the 400/500 halls at 8:19 AM. Staff delivered the breakfast meal to residents on the 400/500 halls from 8:20 AM until 8:30 AM. During the observation of staff delivering resident trays, a staff member lifted the insulated lid on the test tray and then replaced it askew. The DM noted the lid was not on the test tray plate correctly and she replaced it. The test tray was sampled with the Dietary Manager (DM) at 8:32 AM. When the DM removed the insulated cover from the plate of food, no steam was noted to rise off the food. No steam came from the cup of coffee and the temperature was tepid to taste. The fried eggs were cool to the touch and taste, the pancakes were cool to the touch and were not warm, and the sausage links were cool to the touch and were not warm. The DM agreed the food temperature was not warm and reported she thought it was because the insulated lid had not been placed on the plate of food correctly, which allowed the heat to escape. The DM reported she expected food to be delivered covered correctly with the insulated lid to prevent loss of temperature. Resident #5 was interviewed 10/23/24 after the breakfast tray sample, and she reported that her breakfast was not good; I don't like the eggs, the coffee was barely warm, and the pancakes were cold. Resident #34 10/23/24 was interviewed after the breakfast tray sample, and she reported her breakfast was awful. Resident #34 was noted to have eaten approximately 10% of her meal and she had replaced the cover over her plate. The DM was interviewed on 10/24/24 at 2:15 PM and she explained she was surprised by the results of the test tray and felt that breakfast was the best meal of the day with the residents feeling pleased with that meal. The DM reported the staff performed test trays for palatability and temperature, and she attended Resident Council meetings to talk about food preferences and food issues. The DM reported she ate at least one meal per day at the facility and they did test trays routinely but was unable to provide information for when the last test tray had been completed. The DM reported she had responded to the Resident Council concerns by changing the coffee vendor, offering flavored creamers for coffee, having more staff pass out the trays so the trays did not sit for a long time, and providing education to the kitchen staff for complaints of over-cooked foods. The Administrator was interviewed on 10/24/24 at 2:05 PM and he reported he expected the food to be served at the correct temperature and to be palatable.

Based on observations and staff interviews, the facility failed to dry metal pans before being stacked, clean 1 of 3 ice machines in 1 of 3 nourishment rooms (medical unit), and store dry goods off the floor. These failures had the potential to affect food served to residents. The findings included: a. The kitchen was toured on 10/21/24 at 9:28 AM with the Dietary Manager (DM). During the observation, the storage rack for metal pans was observed and 3 metal pans were noted to be stacked wet. Water was noted to drip down the sides of the pain when the pans were separated, and the interior of the pans felt wet. When asked, the DM reported the metal pans should have been air dried completely before stacking. The DM asked [NAME] #1 who stacked the pans and [NAME] #1 reported she did not know who stacked the pans while they were still wet. b. The medical unit nourishment room was observed on 10/24/24 at 9:50 AM with the DM. The ice machine was observed to have wet, slimy, black material along the seal of the ice machine door. The DM explained the Maintenance Director was responsible for cleaning the ice machines. The ice machine was observed with the Maintenance Director on 10/24/24 at 10:06 AM. The Maintenance Director explained he cleaned all ice machines once per month and he had cleaned the ice machine on the medical unit on 9/28/24. The Maintenance Director was able to rub the wet, slimy, black material off the seal and he stated it was mildew. c. The storage shed was observed on 10/24/24 with the DM at 9:56 AM. The storage shed was cluttered with boxed medical records, decorations, resident possessions, and dry food goods. There was not a clear path to the stored dry goods and the DM had to move things out of the way to get back to the stored dry goods. The DM reported the facility used the shed to store extra water and dry goods, and the emergency supplies of food were kept in the shed. Gallon jugs of water were noted to sit directly on the floor of the shed, and several were noted to be tipped over on their sides and appeared to be partially filled with water. A back support pillow was observed on top of the gallon jugs of water. The pillow was noted to have some yellow stains and was slightly dusty. A pallet of rolled oats was noted to be tipped over on its side and laying on the floor of the shed. The DM reported she had not been in the storage shed for a while, and the water and rolled oats should not have been directly on the floor. The DM reported the shed got very hot in the summer and this caused the water jugs to expand, which might cause the jugs to leak. The DM was interviewed on 10/24/24 at 2:15 PM and she reported she explained she had interviewed [NAME] #1 after the kitchen observation on 10/21/24 and [NAME] #1 reported she had stacked the metal pans with wet hands, and that's why the pans were stacked wet. The DM explained it had been a while since she had been in the storage shed to look at the food storage and she was not aware that it was cluttered with resident possessions, medical records, and decorations. The DM reported she expected all dry goods to be stored off the floor and the food storage area to be tidy and organized. The Administrator was interviewed on 10/24/24 at 2:05 PM. He reported the metal pans should be allowed to dry completely before they were stacked. The Administrator reported the ice machine had the potential to grow mildew because it was used often, and it was in a warm room and all ice machines should be checked for mildew growth. The Administrator reported the storage shed should be organized and the food stored off the floor of the shed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, Physician interview, and Family interviews the facility failed to communicate and provide information in a language the resident could understand for 1 of 1 resident whose primary language was Spanish (Resident #29). The findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses that included pain in the right knee, arthritis, and infection related to an artificial joint. A quarterly Minimum Data Set (MDS) for Resident #29 dated 4/23/23 revealed Resident #29 had moderate cognitive impairment with no behaviors. The care plan for Resident #29 revealed Resident #29 had an inability to express emotion, listen and share information related to a hearing deficit and language barrier. The interventions included use the google app translator, Resident #29 was Spanish speaking only. Get the resident's attention before speaking and observe for and report any change in cognition. An observation was made of Resident #29 on 5/1/23 at 5:20 PM. Resident #29 was sitting on the side of her bed looking through bags of clothing. Resident #29 spoke to me in Spanish while motioning her hands. Her roommate said she only spoke Spanish. An interview was conducted on 5/1/23 at 5:25 PM with Nurse Aide (NA) #5. NA #5 revealed Resident #29 spoke Spanish only. She had not used google translate with the resident. Resident #29 usually gestured her needs. During an interview on 5/1/23 at 5:30 PM Nurse #3 revealed it was difficult communicating with Resident #29 because she did not speak English, so she called the family if needed and they would help translate. Nurse #3 further revealed she has never used an interpreter for Resident #29. During an interview on 5/3/23 at 2:50 PM the Physician revealed that it was difficult to communicate with resident #29 because her primary language was Spanish, and she did not speak English. He indicated he had not used an interpreter with this resident, and he thought she understood some basic phrases. The Physician revealed the resident was sent to the hospital in February 2023 and he thought she understood the word hospital meant she was being transferred to the hospital. On 5/2/23 at 3:57 PM an interview was conducted with NA #4. She revealed Resident #29 only spoke Spanish and it was hard to communicate with her. She reported she was not usually assigned to care for Resident #29 but there was an NA that spoke that was usually assigned to Resident #29. She stated she had tried google translate with Resident #29 in the past, but the app could not capture what the resident said. She was unsure if the resident did not speak clearly or slowly enough for the app to work. NA #4 explained she could ask a question to the resident through the google translate app, but the app would not capture the resident's response. She tried to use yes or no questions with Resident #29. She further explained she relied on the resident's gesturing to identify her needs. During an interview on 5/4/23 at 8:41 AM the MDS Coordinator revealed when completing Resident #29's MDS assessments they utilized the NA that spoke Spanish to help translate so they could complete the assessment. She stated there had been times when they obtained assistance from the family, but they mostly used the NA who spoke Spanish. During a telephone interview on 5/4/23 at 10:17 AM Resident #29's family revealed there was a staff member that spoke Spanish at the facility that could communicate with Resident #29, but it was not on a consistent basis. They thought it was only a couple times a week. On the other days the family felt Resident #29 had trouble communicating her needs due to the language barrier. She tells me sometimes they don't understand her when she needs to go to the bathroom. The Family stated Resident #29 called her last week and kept saying COVID, COVID. The Family was told by Resident #29 that the staff put her in a different room and kept saying COVID, but she did not understand what was going on. The Family stated shortly after the call from Resident #29, a Nurse called and told them that the resident tested positive for Covid and had been moved to another room for isolation. A few days later the resident called the family again and told them she needed some clothes from her old room, but the staff did not understand what she was saying. The family revealed she went to the facility to gather things from Resident #29's old room and asked staff to give it to her. The Family stated they visit around 3 times a week, and they try to meet as many of the residents needs as possible while visiting. They did not think Resident #29 could effectively communicate with staff. Staff rarely called the family to translate for Resident #29, they only called if there was a dire need. They further stated the resident had never used an interpreter to their knowledge. During an interview on 5/4/23 at 11:34 AM Nurse #4 revealed she uses the google translate app to ask Resident #29 yes or no questions. She stated she could also ask the NA that spoke Spanish to translate Resident #29's needs and stated that NA work 3 days per week. An interview was conducted with the Director of Rehab on 5/4/23 at 3:05 PM. The Director of Rehab revealed Resident #29 was Spanish speaking and was provided a communication board to express her needs. She stated that with the communication board Resident #29 could only express her basic needs such as eat, drink, pain, and bathroom. She further stated there was a Spanish speaking staff member that helped with translation. During an interview on 5/4/23 at 3:37 PM Nurse #5 revealed it was difficult to communicate with Resident #29, she did a lot of pointing to express her needs. She stated she never used any type of interpreter services for Resident #29, and she has never seen her communication board. An interview was conducted with the Unit Manager (UM) on 5/4/23 at 3:44 PM. The UM revealed she used gesturing to communicate with Resident #29. Staff could also use google translate, her communication board or call her family. The UM stated she had never used any interpreter services with Resident #29. An interview was conducted with the Director of Nursing (DON) and the Facility Consultant on 5/4/23 at 4:41 PM. The DON revealed Resident #29 used gesturing and her communication board to express her needs. They also utilized an NA that spoke Spanish. The DON stated she had not used an interpreter to communicate with the resident. The Facility Consultant explained she was not sure exactly when, but she implemented an interpreter line for Resident #29. She was not aware that it was not being used and did not know where the phone was. The Facility Consultant stated she was not sure if Resident #29 had ever used the interpreter line or if she had been care planned for it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interviews and staff interviews the facility failed to provide nail care for 2 of 6 sampled residents (#5 and #48) reviewed for activities of daily living (ADL). 1. Resident #5 was admitted to the facility on [DATE] with diagnoses that included anemia, chronic kidney disease, dementia, and seizure disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene; total dependence on locomotion and bathing; supervision with eating. A revised care plan dated 12/23/22 revealed Resident #5 required assistance with ADLs to maintain or achieve the highest level of functioning by providing total care for personal hygiene/ grooming (face, skin, hands, nails, and perineum). A continuous observation and interview on 5/1/23 at 10:23 AM to 10:30 AM revealed Resident #5's fingernails on both hands were long with jagged edges. The observation further revealed his left arm/ hand was contracted and fingernails were long. Resident #5 reported he recently asked staff to cut his fingernails and was told they did not have nail clippers to cut his nails. A follow-up observation on 5/2/23 at 10 AM revealed Resident #5's fingernails on both hands remained long, jagged, and untrimmed. A review of bathing sheets and progress notes in the electronic medical record indicated Resident #5 had no refusals of nail care. During an interview on 5/3/23 at 12:17 PM, Nurse Aide (NA) #1 indicated she normally provided bed baths during the 7:00 pm- 7:00 am shift and that nail care was usually performed by the shower team, if they weren't pulled to work on the floor. She further indicated that she had been assigned to Resident #5 and did not notice that his nails were overgrown or needed care. During an interview on 5/2/23 at 4:03 PM, NA #2 revealed he started working at the facility on 4/28/23 and was assigned to Resident #5. He provided ADL care to Resident #5, noticed his nails needed to be trimmed and did not trim his nails because he did not have a nail clipper. He further revealed he asked a nurse (unable to recall the nurse's name) for clippers and was told they needed to check with the facility's corporate office. 2. Resident #48 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease and respiratory failure. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #48 had moderate cognitive impairment and required extensive assistance with bed mobility, toileting, and personal hygiene: total assistance with transfers, dressing and bathing; supervision with eating. A continuous observation and interview on 5/1/23 at 10:33 AM to 10:40 AM revealed Resident #48's fingernails on both hands were long, thick, and jagged with dark brown matter under his nails. Resident #48 further revealed he could not get staff to cut his fingernails, he wanted them cut and had not refused nail care especially since his left middle fingernail very thick, yellow in color and splitting. A follow-up observation and interview with the Unit Manager on 5/2/23 at 4:13 PM revealed Resident #5 and #48's fingernails on both hands remained long with jagged edges as they were observed on 5/1/23. The Unit Manager assessed the fingernails of both residents and determined their nails were overgrown and needed care. She further indicated she expected her staff to provide nail care during ADL care. During an interview with the Director of Nursing (DON) on 5/4/23 at 5:25 PM revealed she was not aware nail care was not provided during ADL care and expected this task to be routinely assessed and performed weekly on shower days by nursing staff.

Based on observations, staff interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions for Activities of Daily Living Care Provided for Dependent Residents, which were put into place during the complaint investigation survey of 2/21/22, and on the current recertification and complaint investigation survey of 5/5/23. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included: This tag is cross referenced to: F 677: Based on observations, record review, resident interviews and staff interviews the facility failed to provide nail care for 2 of 6 sampled residents (#5 and #48) reviewed for Activities of Daily Living (ADL). During the complaint investigation survey of 2/21/22 the facility failed to provide incontinence care to a resident causing the resident to soak through a brief, pad and onto bed linen for 1 of 3 residents reviewed for ADL care. During a phone interview on 5/4/23 at 1:14 PM, Administrator #1 stated she was unaware that the facility received a deficiency related to ADL care on a complaint investigation survey in March 2022. Administrator #1 stated that during the time she was the Administrator, she facilitated QAPI meetings which included all the department managers, the Nurse Consultant and Physician. She stated during these meetings the agenda included a discussion related to agency nursing staff not providing patient care and that agency nursing staff received re-education. Monitoring included room rounds and a checklist that included concerns related to patient care. Any concerns identified during the room rounds were addressed. The Administrator stated that she attributed continued concerns related to ADL care to agency nursing staff not providing patient care. An interview with the Nurse Consultant on 5/4/23 at 6:00 PM revealed she attributed continued concerns with ADL care to a lack of Director of Nursing (DON) oversight resulting from repeated DON turnover in the last year. The Nurse Consultant stated the lack of DON oversight attributed to a lack of management of nursing care and implementation of policies and procedures.

Based on observation, staff interviews and record reviews, the facility failed to remove expired medications in accordance with manufacturer's guidelines and failed to date an opened eye medication for 4 of 6 medications carts observed during medication storage checks (200 hall, 400 hall, 600 hall, and 700 hall). The findings included: 1. Review of manufacturer's package insert for Latanoprost eye drops revealed unopened bottle should be stored under refrigeration between 36° to 46° F and protected from light. Once opened, Latanoprost could be stored at room temperature up to 77° F up to six weeks. a. A medication storage audit was conducted on 05/02/23 at 3:18 PM for the 600-hall medication cart in the presence of Nurse #1. One bottle of Latanoprost 0.005% eye drop opened on 01/20/23 was found in the medication cart and ready to be used. The eye drop was dispensed from the pharmacy on 01/11/23. During an interview conducted on 05/02/23 at 3:28 PM, Nurse #1 thought the eye drop would be expired a year from the dispensing date on 01/11/24. She did not know that opened Latanoprost eye drop stored in the room temperature would be expired in 6 weeks. b. During a medication storage check conducted on 05/02/23 at 3:47 PM for 400-hall in the presence of Medication Aide (MA) #1, one bottle of Latanoprost 0.005% eye drop without opening date was found in the medication cart and ready to be used. The label indicated the eye drop would be expired 6 weeks after it was opened. An interview was conducted on 05/02/23 at 3:54 PM. MA #1 explained she had not worked with 400-hall medication cart for long time. She acknowledged that the eye drop should be dated when it was opened and discarded after 6 weeks. She could not explain why the eye drop was not dated when it was opened. 2. Review of manufacturer's package insert for Novolog, Lantus, and Admelog indicated unopened vials should be stored in refrigerator at 36°F to 46°F until expiration and kept away from direct heat and light. Once these insulins were opened, it could be stored at room temperature (below 86°F) or refrigerated up to 28 days. a. A subsequent medication storage audit was conducted on 05/02/23 at 4:59 PM for the 200-hall medication cart in the presence of Nurse #2. One vial of Lantus 100 unit/milliliter (ml) insulin opened on 03/27/23 and one vial of Novolog 100 unit/ml insulin opened on 03/01/23 were found in the medication cart under room temperature and ready to be used. During an interview conducted on 05/02/23 at 5:08 PM, Nurse #2 explained one of the nurses worked before her might have opened another Novolog and forgotten to discard the expired one in the medication cart. She stated both insulins should be discarded after they were opened and stored under room temperature for 28 days. b. A medication storage check was conducted on 05/02/23 at 5:25 PM for the 700-hall medication cart in the presence of Nurse #3. One vial of Admelog 100 unit/ml insulin opened on 03/31/23 was found in the medication cart under room temperature and ready to be used. An interview was conducted on 05/02/23 at 5:28 PM. Nurse #3 stated she was not the only nurse who used this medication cart. It was hard for her to keep up with the expiration date of insulin if other nurses did not do their part. She acknowledged that the insulin should be discarded after it had been opened and stored in room temperature for 28 days. An interview was conducted with the Director of Nursing (DON) on 05/02/23 at 5:54 PM. She stated nurses and MAs were instructed to check their respective medication cart for expired medications at least once every night. It was her expectation for the facility to remain free of expired medication and store all medications according to manufacturer's guidelines. During an interview with the Administrator on 05/04/23 at 4:38 PM, he expected all the nursing staff to follow facility's policy and procedure for medication storage and store all medications according to manufacturer's guideline.