**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, Medical Director (MD), and Physician Assistant (PA) interviews, the facility failed to notify the provider of significant weight gain greater than 5-pound discrepancy from the last weight for a resident with Congestive Heart Failure (CHF) and on diuretic medication (a medication that helps the body remove excess fluid) when the resident's weight indicated a 27 pound weight gain in one week. This deficient practice occurred for 1 of 1 sampled resident reviewed for notification of change. (Resident #108) Findings included: Resident #108 was admitted on [DATE]. His medical diagnoses included Congestive Heart Failure (CHF), coronary artery disease (CAD), and pulmonary hypertension. An admission physician order written to start on 04/18/25 revealed weekly weight times four weeks than monthly, and Demadex (used to reduce swelling). Review of Resident #108's weekly weights revealed: 04/18/24 hospital weight was 148.6 pounds (lbs.) 04/18/25 was 126.6 lbs. 04/19/25 was 126 lbs. 04/26/25 was 153.2 lbs., a weight gain of 27.2 lbs. in 7 days 04/28/25 was 156 lbs. Further review of Resident #108's medical record revealed there were no additional weights. Further review of the medical record for Resident #108 revealed there was no evidence the physician was notified of weight changes. An interview was conducted on 04/30/25 at 10:05 AM with Nurse #1. He stated he helped the NA on 04/26/25 to weigh Resident #108 since two nursing staff were needed to do resident's weight using a mechanical lift. He said he noticed the resident's weight was more than 20 lbs. greater than his last weight, but since there was not a specific physician order telling him to notify the MD if resident's weight was greater or less than 5 lbs., he did not need to, even if the resident had a history of CHF. He said he just went by what he saw on the physician orders, and since it did not say to contact the MD with significant weight change, he did not need to. An interview on 04/30/25 at 10:15 AM with the Director of Nursing (DON) revealed it was her expectation that Resident #108's physician should have been notified by his nurse of the resident's greater than 5-lb. weight gain in a week, given the residents' history of CHF, even if there was no physician order. An interview was conducted on 04/30/25 at 10:25 AM with the Physician Assistant (PA). The PA stated this was the first time he heard of Resident #108's one week weight gain of 27 pounds since admission on [DATE]. He stated no staff had reported to him any weight concerns. The PA expected he or the MD to be notified if Resident #108's weekly weights were greater than 5-lbs. from the previous weight, especially if the resident had a diagnosis of CHF. The PA said he expected the MD to have been notified, in order to treat the weight gain and to determine if related to CHF, and if additional medication was to be ordered or a change in treatment needed. An interview was conducted on 05/01/25 at 9:45 AM with the Medical Director (MD). The MD stated this was the first time she had heard of Resident #108's weight gain of 27 pounds from 04/26/25. The MD said she expected to be notified if residents' weights were greater than 5 pounds after a re-weight, which would include any resident having a diagnosis of CHF. The MD said she was not made aware or notified by nursing staff of resident's weight gain and should have. The MD said Resident #108's weight gains had no health outcome, and she expected the PA, MD, or on-call physician to have been notified, so they could treat the weight gain, and determine if it was related to CHF.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, Medical Director (MD), and Physician Assistant (PA) interviews, the facility failed to determine the accuracy of a weekly weight for a resident with Congestive Heart Failure (CHF) and on diuretic medication (a medication that helps the body remove excess fluid) when the resident's weight indicated a 27 pound weight gain in one week for 1 of 4 residents reviewed for nutrition. (Resident #108) Findings included: Resident #108 was admitted on [DATE]. His medical diagnoses included Congestive Heart Failure (CHF), coronary artery disease (CAD), and pulmonary hypertension. An admission physician order written to start on 04/18/25 revealed weekly weight times four weeks then monthly, and Demadex (used to reduce swelling). Resident #108's admission Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired, had CHF, CAD, and needed total assistance with activities for daily living (ADLs). Review of Resident #108's weekly weights revealed: 04/18/24 hospital weight was 148.6 pounds (lbs.) 04/18/25 was 126.6 lbs. 04/19/25 was 126 lbs. 04/26/25 was 153.2 lbs., a weight gain of 27.2 lbs. in 7 days. 04/28/25 was 156 lbs. Further review of Resident #108's medical record revealed there were no additional weights. An interview was conducted on 04/29/25 at 1:15 PM with Resident #108. The resident was alert, resting in bed, with feet elevated. He stated he was breathing fine, was not on any oxygen, had swollen ankles and feet, ate very little breakfast, but ate a normal lunch. He said he did not know if he had any weight gain or loss since his admission. An interview was conducted on 04/30/25 at 10:05 AM with Nurse #1. He stated he helped the NA on 04/26/25 to weigh Resident #108 since two nursing staff were needed to do resident's weight using a mechanical lift. He said he noticed the resident's weight was 27 lbs. greater than his last weight, but since there was no order do a re-weight for weights greater or less than 5 pounds, he did not need to do a re-weight. Nurse #1 could not recall the NA that weighed Resident #108. An interview on 04/30/25 at 10:15 AM with the Director of Nursing (DON) revealed it was her expectation that Resident #108 should have been reweighed immediately after noting a possible 27 lb. weight gain on 04/26/25. The DON stated any weights with a 5-pound discrepancy from the last weight should be re-weighed, especially since the resident had a history of CHF. She said she did not know why Nurse #1 did not get the NA to re-weigh Resident #108 but should have. An interview was conducted on 04/30/25 at 10:25 AM with the Physician Assistant (PA). The PA stated this was the first time he heard of Resident #108's one week weight gain of 27 pounds since admission on [DATE]. The PA stated if Resident #108's weekly weight was greater than 5-lbs. from the previous weight, and had a history of CHF, that a re-re-wight should have been done. The PA said Resident #108's weight 27 gain had no health outcome but could have. An interview was conducted on 05/01/25 at 9:45 AM with the Medical Director (MD). The MD stated this was the first time she had heard of Resident #108's weight gain of 27 pounds from 04/19/25 to 04/26/25. The MD stated it was expected that if any resident had a weight loss or gain greater than 5 pounds from the previous weight, to have a re-weight confirming the second weight, which was not done, and was important in this case due to the resident having a diagnosis of CHF. The MD said Resident #108's weight gain of 27 lbs. could not have been accurate, since the resident had no respiratory health outcome, and that the weight was not close to the hospital's discharge weight.

Based on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 1 of 419 days reviewed for staffing (08/11/24). Findings included: The PBJ (Payroll Based Journal) Staffing Data Report Fiscal Year - Quarter 4, 2024 (July 1 - September 30) documented the facility had no RN Coverage on 08/11/24. Review of the daily assignment sheets from 03/8/24 through 04/30/25 revealed the RN who was originally scheduled to work 7:00 PM - 7:00 AM beginning on 08/11/24 had called off. The staff member who replaced the RN on the schedule was a Medication Aide. In an interview with the Director of Nursing (DON) and the Administrator on 05/01/25 at 11:49 AM the DON stated she had been the nurse on call and had taken the call when the RN called off work on 08/11/24. She noted it was her responsibility to find RN coverage for the shift and she had not. The Administrator stated she expected the on call staff member who had the on call phone to find coverage for the assignment. The Administrator explained that the process when there was a call off was that the on call staff member or nurse who had the call off phone was responsible for filling the assignment on the schedule. On 8/11/24 the on call nurse was notified of the call off but she did not find a replacement and no RN coverage was in the building on 8/11/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, the Nurse Practitioner, and Physician interviews the facility failed to obtain an ordered Pro BNP (pro-B-type natriuretic peptide) a blood test that measures the levels of Pro BNP, a protein produced by the heart and used to help diagnose and monitor heart failure. This occurred for 1 of 1 resident (Resident #23) reviewed for laboratory services. Findings included. Resident #23 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease and Stage 5 chronic kidney disease with heart failure. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #23 was cognitively intact. A physician's order dated 4/3/25 for Resident #23 entered by Nurse #3 revealed to obtain a Pro BNP level. Review of Resident #23's electronic medical record from 4/3/25 through 5/1/25 revealed no documentation of the Pro BNP lab result. Review of the progress notes from 4/3/25 through 5/1/25 revealed no documentation that Resident #23 had experienced any acute symptoms of heart failure such as shortness of breath, swelling in the abdomen or lower extremities, chest pain, or fatigue. Her blood pressure was stable. During an interview on 4/30/25 at 12:00 PM the Nurse Practitioner stated the Pro BNP was ordered for Resident #23 to monitor heart failure. He stated he reviewed the electronic medical record and could not find the lab result. He indicated Resident #23 was not symptomatic, and the lab would be reordered. During an interview on 05/01/25 at 10:30 AM the Physician stated the Pro BNP lab was ordered for Resident #23 to evaluate her cardiovascular status due to heart failure and chronic kidney disease. She stated Resident #23 received hemodialysis three days a week which pulled fluid off to keep her at dry weight (the weight after excess fluid is removed) and therefore had no significant outcome from not obtaining the ordered lab and she had not been symptomatic of acute heart failure or fluid overload. She stated she expected labs to be obtained according to the physician orders. During an interview on 5/1/25 at 2:00 PM Resident #23 was observed sitting up in a bedside chair in her room. She was alert and oriented to person, place, and time. She was smiling and talkative and was not aware of the ordered lab. She stated she received hemodialysis three days a week, she felt fine, and stated she had no complaints at this facility. An attempt was made on 5/1/25 at 2:19 PM to contact Nurse #3 who entered the order for the Pro BNP on 4/3/25. There was no response. During an interview on 05/01/25 at 2:00 PM the Director of Nursing stated she completed a record review and could not find the Pro BNP lab result for Resident #23. She stated she determined that the Physician entered the order into the electronic medical record but then the nurse who completed the new order failed to edit the order so that it would trigger on the Medication Administration Record (MAR) which was why it continued to be missed. She stated the process included that the physician entered the orders into the residents electronic medical record, then the nurse would go in and edit the order so that it would flow to the Medication Administration Record (MAR). The nurse was supposed to print the residents face sheet (this provides the residents identifying information) and fill out the lab requisition form (informs the lab of what tests to perform) and then records the order in the lab book located at the nurses station. She stated Nurse #3 who was responsible for the error no longer worked at this facility. She stated labs were reviewed daily in clinical meetings to ensure they were done and to ensure that the physician had reviewed the results. She stated they missed the lab in clinical meetings because of the order not being edited and completed by Nurse #3 therefore it did not show on her lab reports. She stated she planned to review the process for ordered labs and education would be provided to staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to implement infection control policies and procedures when Nurse Aide #1 failed to apply all the required Personal Protective Equipment (PPE) before entering a room with a resident on special contact-droplet precautions. This occurred for 1 of 1 staff observed for infection control practices (Nurse Aide #1). The findings included: Review of the facility's contact precautions signage last revised 01/20/22 read in part: All healthcare personnel must: Clean hands before entering and when leaving room. Wear gloves when entering room and remove before leaving room. Wear a gown when entering room and remove before leaving. The facility's Infection Prevention and Control Program policy last revised on 08/2024 read in part: When a resident is infected or colonized with any Multidrug-Resistant Organism (MDRO) that has secretions or excretions that are unable to be covered or contained then contact precautions should be used. Review of Resident #111's April/2025 physician orders included: Admit to skilled level of care for Extended Spectrum Beta Lactamase (ESBL), Escherichia Coli (E. coli), Methicillin Resistant Staphylococcus Aureus (MRSA), and chronic kidney disease stage IV, Vancomycin, and contact precautions related to ESBL dated 04/29/25. An interview and observation were conducted on 04/30/25 at 8:05 AM with Nursing Assistant (NA#1). NA #1 was observed entering room [ROOM NUMBER] to deliver Resident #111's breakfast meal tray without first cleaning her hands or applying appropriate contact precaution personal protection equipment (PPE) of gown and gloves. She was observed leaning against the left side of resident's bed while setting up his meal tray. She then exited the resident's room without washing her hands. When NA #1 was asked in the hall why she did not clean hands, or apply PPE she said she did not have to if the resident was on enhanced barrier precautions. The NA then looked at the isolation sign hanging on the resident's door and realized the resident was on contact precautions and not on enhanced contact precautions. She said, after reading the sign, that she made a mistake, thinking the resident was on enhanced contact precautions and not contact precautions. She stated she should have washed her hands prior to entering and exciting resident's room and applied a gown and gloves while in the room. An interview was conducted on 04/30/25 at 8:10 AM with Nurse #2. Nurse #2 stated Resident #111 was on contact precautions for having multiple Multidrug-Resistant Organism (MDRO) with secretions or excretions so he was ordered by the Physcian to be on contact precautions, the only resident in the facility on contact precautions. Nurse #2 indicated staff were supposed to clean hands and put on the PPE prior to entering the room. An interview was conducted with NA #1 on 04/30/25 at 8:15 AM and she stated, it's confusing, I thought as long as I was not providing patient care it was ok since I was just taking the tray in the room. I did not realize there was a resident in the facility on contact precautions. She said she needed to pay closer attention to the isolation signs on residents' doors. An interview was conducted on 04/30/25 at 12:15 PM with the Physician Assistant (PA). The PA indicated he expected staff to read the contact isolation signage and put on the PPE prior to entering Resident #111's room. An interview was conducted on 04/30/25 at 12:20 PM with the Director of Nursing (DON). She stated, Sometimes her nursing staff were not reading the signs. The DON further stated, we haven't had a contact precaution isolation in a while. The DON indicated she expected NA #1 to have read the signage on the resident's door and put on the appropriate PPE that was listed on the signage, which the NA did not do. An interview was conducted on 05/01/25 at 10:45 AM with the Administrator. She indicated staff should read the isolation signs to understand the precautions before entering a room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and resident, staff and physician interviews, the facility failed to obtain an appointment with a retinol specialist for treatment of visual impairment for 1 of 1 residents (Resident #9) reviewed for vision. Findings included: Resident #9 was admitted to the facility on [DATE] with a diagnosis which included dry eye syndrome. Review of Resident #9's electronic health record revealed a 10/17/23 vision consult which indicated Resident #9 had gradual blurry vision with the left eye greater than the right. The plan of care indicated Resident #9 was to have a referral to a retinol specialist for treatment with an appointment to be scheduled within 2-3 weeks. Review of Resident #9's electronic health record revealed a 10/17/23 optometry order form indicated a referral to a retinol specialist was required for evaluation of left eye advanced macular degeneration, a disease that causes vision loss. Review of Resident #9's 2/13/24 quarterly Minimum Data Set assessment revealed resident had adequate vision, corrective lenses were not used, and was cognitively intact. Observation of Resident #9 on 3/4/24 at 3:25 PM revealed resident sitting on the side of the bed with mail in her hands, glasses on and her call bell was activated. An interview was conducted with Resident #9 on 3/4/24 at 3:28 PM. Resident #9 stated she needed to see a vision specialist and the appointment was supposed to have been scheduled months ago. Resident #9 revealed she had trouble with vision in her left eye and was unable to see. Resident #9 indicated she activated her call bell to request assistance with reading her mail. Review of Resident #9's progress notes as of 3/5/24 revealed no evidence that the appointment with the retinol specialist was scheduled or completed. Review of Resident #9's consult notes as of 3/5/24 revealed no evidence that the resident was evaluated by the retinol specialist. Interview on 3/6/24 at 12:10 PM with the Transporter/Appointment Scheduler revealed she was in the position since September 2023. The Transporter/Appointment Scheduler stated she was responsible for scheduling appointments for the resident after she received a referral from the nurses. The Transporter/Appointment Scheduler stated she scheduled the appointments and informed the resident and family of the date and time. The Transporter/Appointment Scheduler stated she thought she recalled the Nurse Practitioner said she was waiting for the resident to be seen by the vision clinic that visits the facility. The Transporter/Appointment Scheduler stated the vision clinic only visits the facility once per year. The Transporter/Appointment Scheduler stated she did not recall receiving a referral for an appointment with a retinol specialist. Interview on 3/6/24 at 1:15 PM with the Director of Nursing (DON) revealed Medical Records received the report from the optometry appointment in October and uploaded it to Resident #9's medical record. Medical Records had not provided the Nurse Practitioner (NP) with the report for review. The DON stated the NP or physician was not made aware of the results of Resident #9's optometry appointment in October or the recommendation for the referral to a retinol specialist. The DON stated she was not aware of the results of the appointment in October or the referral. The DON stated an appointment was made today with the retinol specialist for 4/9/24 at 12:40 PM. Interview on 3/7/24 at 10:50 AM with the physician revealed she was just made aware that the appointment with the retinal specialist had not been scheduled as ordered on the consult report. The physician stated it would not cause resident harm by not obtaining the appointment with the retinol specialist sooner, but it was a system process error.

Based on observations, record review, and staff interviews the facility failed to record an opened date on two insulin pens and on two opened bottles of eye drops that had shortened expiration dates. This was observed on 1 of 3 medication carts (300 hall medication cart) reviewed for medication storage. Findings included. Review of the manufacturer's instructions for Lantus insulin pens revealed to discard 28 days after opening. Review of the manufacturer's instructions for Brimonidine eye drops revealed to discard 4 weeks after opening. Review of the manufacturer's instructions for Latanoprost eye drops revealed to discard 6 weeks after opening. An observation of the 300-hall medication cart on 03/04/24 at 11:30 AM along with Nurse #3 revealed two Lantus insulin pens stored on the medication cart that were in use with no opened dates labeled on the insulin pens. A bottle of Brimonidine eye drops and a bottle of Latanoprost eye drops were opened with no opened dates labeled on the bottles. During an interview on 03/04/24 at 11:35 AM Nurse #3 stated she was not aware the insulin pens were not dated and indicated she did administer one of the two insulin pens to the resident it was prescribed for earlier today. She stated she was new to the facility and still getting used to procedures. She acknowledged the Lantus insulin pen was not dated and stated she failed to check for an opened date prior to administering the insulin. She indicated she had not administered either of the eye drops and had not checked the bottles for opened dates. During an interview on 03/07/24 at 12:24 PM the Director of Nursing stated insulin pens and eye drops should be labeled with opened dates when they were opened. She stated the nurse should have checked the date prior to administering the insulin. She stated education would be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews the facility failed to administer medications on time as prescribed by the physician for 1 of 1 residents reviewed. (Resident #7) Findings included: Resident #7 was admitted to the facility on [DATE]. Diagnoses included, in part, schizophrenia, anxiety, dementia with behavioral disturbance, and constipation. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #7 was cognitively intact and received antipsychotics and antianxiety medications. An interview was conducted with Resident #7 on 03/04/24 at 1:00 PM. Resident #7 reported she did not receive her medications on time and at times the nursing staff would wake her up after 10:00 PM to administer her medications that were due at 8:00 PM. Resident #7 stated she had told the nursing staff she wanted her medications at 8:00 PM so she could go to bed and not be woken up. Resident #7 stated she had received her 8:00 PM medications as late as 2:00 in the morning. Resident #7 stated she did not have any increased anxiety, delayed bowel movements or increased behaviors as a result of receiving the medications late, but added, she wanted them when they were scheduled. Review of the physicians' orders revealed an order written on 10/03/20 for Senna Plus 8.6-50 milligrams (mg) give 2 tablets one time a day for constipation, an order written on 10/14/21 for Risperidone (an antipsychotic) tablet 0.5 mg give one tablet at bedtime, and an order written on 07/31/23 for Klonopin (an antianxiety) 0.5 mg give one tablet two times a day for anxiety. Review of the Medication Administration Record for February 2024 revealed the medications (Senna Plus, Risperidone, and Klonopin) were all scheduled to be given at 8:00 PM. Review of the Medication Administration Audit Report for February 1 through February 29, 2024, revealed the bowel medication, the antipsychotic medication, and the antianxiety medication were administered later than 8:00 PM. The audit report indicated the scheduled time which was 8:00 PM and the administration time. The following included the dates the medications were administered late per the actual administration time: 02/01/24 medications administered at 11:41 PM by Medication Aide (MA) #5 02/03/24 medications administered at 10:30 PM by MA #1 02/04/24 medications administered at 10:04 PM by MA #1 02/06/24 medications administered at 10:04 PM by MA #1 02/07/24 medications administered at 10:15 PM by MA #5 02/09/24 medications administered at 12:30 AM by MA #1 02/13/24 medications administered at 10:40 PM by MA #1 02/14/24 medications administered at 12:56 AM by MA #5 02/15/24 medications administered at 1:39 AM by Nurse #4 02/17/24 medications administered at 1:46 AM by MA #1 02/19/24 medications administered at 10:27 PM by MA #1 02/20/24 medications administered at 10:50 PM by MA #1 02/22/24 medications administered at 10:58 PM by MA #1 02/24/24 medications administered at 10:32 PM by MA #1 02/27/24 medications administered at 10:49 PM by MA #1 Review of the Medication Administration Record for March 2024 revealed the medications (Senna Plus, Risperidone, and Klonopin) were all scheduled to be given at 8:00 PM. Review of the Medication Administration Audit Report for March 1 through March 6, 2024, revealed the bowel medication, the antipsychotic medication, and the antianxiety medication were administered later than 8:00 PM. The audit report indicated the scheduled time which was 8:00 PM and the administration time. The following included the dates the medications were administered late per the actual administration time: 03/03/24 medications administered at 10:20 PM by MA #1 03/04/24 medications administered at 10:15 PM by MA #1 An interview was conducted with MA #1 via phone on 03/06/24 at 3:15 PM. MA#1 revealed she worked on the 500 hall where Resident #7 resided and the 300 hall from 7:00 PM to 7:00 AM. She stated she could not remember why she was late administering the medications to Resident #7. MA #1 added, things happen and she would fall behind. She stated she did not ask her nurse to help her when she was getting behind because she did not want to bother the nurse. MA #1 stated the medication time was 8:00 PM and the nursing staff had the flexibility to give the medications one hour before or one hour after the medications were due. MA #1 confirmed the times she gave the medications were much later than the prescribed allowable time. MA #1 stated she did not recall Resident #7 expressing to her that she wanted her medications at 8:00 PM. An interview was conducted with MA #5 via phone on 03/07/24 at 3:00 PM. MA #5 reported her routine when she came on shift was to read through the progress notes and she would start her medication pass about 8:00 - 8:30 PM. She stated she started on the 500 hall were Resident #7 resided and would usually finish about 10:00 - 10:30 PM. MA #5 stated she did not know why the medications were passed so late to Resident #7 on 02/01, 02/07 and 02/14/24. MA #5 stated Resident #7 had expressed to her to that she wanted her medications before she went to bed and not at 1:00 AM. MA #5 stated she did not reach out to the nurse on those nights to let her know she was behind on passing medications and she should have. An interview was attempted with Nurse #4 via phone on 03/07/24 at 11:00 AM. There was no response. An interview was conducted with the Physician on 03/07/24 at 12:10 PM. The Physician stated she would expect the nursing staff to administer the medications when they were due or within the hour before the medication was due or the hour after. An interview was conducted with the Director of Nursing (DON) on 03/07/24 at 2:30 PM. The DON reported she felt the medications aides needed to work on their time management and that the medication pass had been significantly decreased when the new physician had done an audit and discontinued several medications for several residents to decrease the medication pass time and unnecessary medications. The DON stated the medication aides were expected to start on the 500 hall and then finish on the 300 hall. She stated there were about 29 residents between the two halls and the medications aides should have been able to administer the medications at the prescribed time or no later than an hour after the prescribed time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, and Physician interviews the facility failed to clarify a medication order prescribed for hypotension (low blood pressure) to include hold parameters if the systolic blood pressure was greater than 120 mm/hg ( millimeters of mercury). This resulted in a resident (Resident #61) receiving 59 additional doses of the medication. There was no significant outcome from receiving the medication. This occurred for 1 of 3 residents reviewed for medication administration. Findings included. Resident #61 was admitted to the facility on [DATE] with diagnoses included in part; hypertensive chronic kidney disease with end stage renal disease, dependence on dialysis, and hypotension. A physicians order dated 05/03/23 for Resident #61 revealed Midodrine 10 milligrams (prescribed to treat hypotension which works by constricting the blood vessels causing increased blood pressure). Give 1 tablet by mouth three times a day for hypotension. Hold if systolic blood pressure is greater than 120 mm/hg. Review of the Medication Administration Record (MAR) for Resident #61 from 05/03/23 through 10/23/23 revealed Midodrine was administered as prescribed. Review of a hospital Discharge summary dated [DATE] for Resident #61 revealed Midodrine oral tablets 10 mg (milligrams). Give 1 tablet by mouth three times a day for hypotension if systolic blood pressure is greater than 120 mm/hg. There was no hold parameter. Review of the Medication Administration Record (MAR) for Resident #61 dated November 2023 revealed Midodrine oral tablets 10 mgs. Give 1 tablet by mouth three times a day for hypotension if systolic blood pressure is greater than 120 mm/hg. There was no hold parameter included on the MAR. Further review of the Medication Administration Record (MAR) for Resident #61 dated November 2023 revealed Midodrine 10 mg was signed as administered to Resident #61 for the following blood pressure readings: 11/01/23 a blood pressure recorded at 09:00 AM revealed 142/76 (systolic/diastolic). 11/01/23 a blood pressure recorded at 02:00 PM revealed 142/76. 11/02/23 a blood pressure recorded at 06:00 AM revealed 142/84. 11/03/23 a blood pressure recorded at 09:00 AM revealed 170/65. 11/03/23 a blood pressure recorded at 02:00 PM revealed 176/89. 11/03/23 a blood pressure recorded at 09:00 PM revealed 176/89. 11/07/23 a blood pressure recorded at 09:00 AM revealed 133/72. 11/07/23 a blood pressure recorded at 02:00 PM revealed 122/64. 11/11/23 a blood pressure recorded at 06:00 AM revealed 122/58. 11/11/23 a blood pressure recorded at 02:00 PM revealed 122/58. 11/11/23 a blood pressure recorded at 09:00 PM revealed 130/79. 11/12/23 a blood pressure recorded at 02:00 PM revealed 172/95. 11/13/23 a blood pressure recorded at 06:00 AM revealed 152/97. 11/17/23 a blood pressure recorded at 02:00 PM revealed 139/66. 11/19/23 a blood pressure recorded at 02:00 PM revealed 167/105. 11/21/23 a blood pressure recorded at 02:00 PM revealed 152/78. 11/22/23 a blood pressure recorded at 06:00 AM revealed 144/72. 11/22/23 a blood pressure recorded at 04:00 PM revealed 148/78. 11/22/23 a blood pressure recorded at 09:00 PM revealed 148/78. 11/24/23 a blood pressure recorded at 04:00 PM revealed 128/70. 11/27/23 a blood pressure recorded at 06:00 AM revealed 147/84. 11/27/23 a blood pressure recorded at 04:00 PM revealed 129/78. 11/27/23 a blood pressure recorded at 09:00 PM revealed 132/86. 11/29/23 a blood pressure recorded at 06:00 AM revealed 138/78. Review of the Medication Administration Record (MAR) for Resident #61 dated December 2023 revealed Midodrine 10 mg was signed as administered to Resident #61 for the following blood pressure readings: 12/04/23 a blood pressure recorded at 04:00 PM revealed 141/76. 12/04/23 a blood pressure recorded at 09:00 PM revealed 141/76. 12/06/23 a blood pressure recorded at 06:00 AM revealed 141/76. 12/06/23 a blood pressure recorded at 04:00 PM revealed 128/98. 12/08/23 a blood pressure recorded at 06:00 AM revealed 132/64. 12/08/23 a blood pressure recorded at 04:00 PM revealed 130/68. 12/11/23 a blood pressure recorded at 06:00 AM revealed 142/60. 12/13/23 a blood pressure recorded at 04:00 PM revealed 127/79. 12/13/23 a blood pressure recorded at 09:00 PM revealed 127/79. 12/15/23 a blood pressure recorded at 06:00 AM revealed 130/70. 12/20/23 a blood pressure recorded at 06:00 AM revealed 122/64. 12/20/23 a blood pressure recorded at 04:00 PM revealed 122/64. 12/27/23 a blood pressure recorded at 04:00 PM revealed 126/79. Review of the Medication Administration Record (MAR) for Resident #61 dated January 2024 revealed Midodrine 10 mg was signed as administered to Resident #61 for the following blood pressure readings: 01/01/24 a blood pressure recorded at 09:00 PM revealed 167/87. 01/03/24 a blood pressure recorded at 06:00 AM revealed 167/87. 01/05/24 a blood pressure recorded at 04:00 PM revealed 136/72. 01/08/24 a blood pressure recorded at 06:00 AM revealed 157/79. 01/08/24 a blood pressure recorded at 04:00 PM revealed 158/80. 01/10/24 a blood pressure recorded at 09:00 PM revealed 131/74. 01/12/24 a blood pressure recorded at 04:00 PM revealed 140/85. 01/15/24 a blood pressure recorded at 04:00 PM revealed 165/84. 01/15/24 a blood pressure recorded at 09:00 PM revealed 165/84. 01/17/24 a blood pressure recorded at 06:00 AM revealed 165/84. 01/19/24 a blood pressure recorded at 06:00 AM revealed 123/68. 01/24/24 a blood pressure recorded at 06:00 AM revealed 134/73. 01/29/24 a blood pressure recorded at 04:00 PM revealed 148/89. 01/29/24 a blood pressure recorded at 09:00 PM revealed 148/89. Review of the Medication Administration Record (MAR) for Resident #61 dated February 2024 revealed Midodrine 10 mg was signed as administered to Resident #61 for the following blood pressure readings: 02/02/24 a blood pressure recorded at 06:00 AM revealed 141/82. 02/02/24 a blood pressure recorded at 09:00 PM revealed 147/77. 02/18/24 a blood pressure recorded at 06:00 AM revealed 140/80. 02/21/24 a blood pressure recorded at 06:00 AM revealed 152/95. 02/21/24 a blood pressure recorded at 09:00 PM revealed 146/68. 02/23/24 a blood pressure recorded at 09:00 PM revealed 155/77. 02/26/24 a blood pressure recorded at 06:00 AM revealed 155/77. Review of the Medication Administration Record (MAR) for Resident #61 dated March 2024 revealed Midodrine 10 mg was signed as administered to Resident #61 for the following blood pressure readings: 03/01/24 a blood pressure recorded at 4:00 PM revealed 146/87. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #61 was cognitively intact. She received Hemodialysis. During an interview with Resident #61 on 03/06/24 at 2:30 PM she indicated she was not aware of what times or dates the medication for low blood pressure was administered to her. She stated dialysis treatments took a lot out of her and she didn't feel well most days. She indicated she was not certain if receiving the Midodrine when it wasn't needed had any affect at all on her. During a phone interview on 03/06/24 at 02:53 PM Medication Aide #1 stated she routinely provided care to Resident #61. She stated she knew Midodrine was prescribed for low blood pressure. She stated she thought she held the medication if her blood pressure was over 120 but couldn't indicate what dates the medication was held. She stated she could have held the medication although documented she gave it. She indicated if it was signed that the medication was given, then she gave the medication in error. During an interview on 03/07/24 at 09:46 AM the Registered Nurse Supervisor stated Resident #61's order for Midodrine should have been clarified when it was transcribed from the hospital discharge summary on 10/27/23. She stated Resident #61 received dialysis and her medication times varied according to her dialysis schedule. She stated although her name was on the order entry following Resident #61's readmission she believed she only revised the order and was not the staff that entered the order. She could not determine who entered the initial order. She stated the Midodrine should have been clarified and hold parameters put in place but that was not done. During a phone interview on 03/07/24 at 12:00 PM Medication Aide #2 stated she routinely provided care to Resident #61. She stated she thought she held the medication at times. She indicated if the medication was administered when it wasn't needed then it was done in error. During a phone interview on 03/07/24 12:13 PM Medication Aide #8 stated she gave Midodrine to Resident #61 when her blood pressure was over 120 (mm/hg). She indicated that was how the order was written on the MAR. Attempts were made to contact Nurse #1 during the investigation. Nurse #1 was an agency nurse and was on duty during the dates and times the Midodrine was administered to Resident #61. There was no response. Attempts were made to contact agency Medication Aides #5 and #7 during the investigation. The Medication Aides were on duty during the dates and times the Midodrine was administered to Resident #61. There was no response. Medication Aide #6 who was on duty during the dates and times the Midodrine was administered to Resident #61 was no longer employed and no phone number was available. During an interview on 03/07/24 at 10:18 AM the Physician stated she was made aware of the Midodrine error this morning. She wrote a new order with hold parameters for blood pressures greater than 160/90. She indicated the medication was not needed if Resident #61's blood pressure was elevated. She stated the order should have been clarified and hold parameters accurate. She stated Resident #61 receiving Midodrine when it wasn't needed would have no significant effect on her and there had been no change in her condition. During an interview on 03/07/24 at 12:24 PM the Director of Nursing stated medications were reviewed in their morning meetings. She indicated she was not aware that hold parameters were not clarified on the order for Resident #61. She stated the order was corrected today. She stated the order should have been clarified on readmission and administered per order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, Nurse Practitioner, and Physician interviews the facility failed to follow the physicians order and provide sliding scale insulin at bedtime to a resident (Resident #18) when the blood glucose reading was greater than 200 mg/dl (milligrams per deciliter). This resulted in the resident not receiving a total of 74 units of insulin from 01/12/24 through 03/04/24. There was no significant outcome. This occurred for 1 of 3 residents reviewed for medication administration. Findings included. Resident #18 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus. A care plan dated 08/23/23 revealed Resident #18 had diabetes with the risk for complications. The goal of care was to adequately manage her diabetes in order to minimize the risk for complications. Interventions included in part; to administer sliding scale insulin as ordered. The Minimum Data Set annual assessment dated [DATE] revealed Resident #18 was cognitively intact. She required limited assistance with activities of daily living. She received insulin. A physicians order dated 01/11/24 for Resident #18 revealed Novolog Injection Solution 100 units per milliliter: Inject as per sliding scale subcutaneously before meals for diabetes for blood glucose readings as follows: 000 - 199 administer 0 units; 200 - 250 administer 2 units; 251 - 300 administer 4 units; 301 - 350 administer 6 units; 351 - 400 administer 8 units; 401 - 450 administer 10 units; 451 - 1000 administer 10 units - recheck and notify the physician. A progress note dated 01/11/24 documented by the Nurse Practitioner revealed in part; plan to stabilize Resident #18's blood sugars which have been more elevated lately. Adding sliding scale insulin now four times a day in addition to her Lantus (long-acting insulin). A physicians order dated 01/12/24 revealed blood glucose checks before meals and at bedtime for diabetes please see sliding scale instructions. Review of the Medication Administration Record (MAR) for Resident #18 dated January 2024 revealed Novolog sliding scale insulin was administered as needed before meals. Novolog sliding scale insulin was not administered at bedtime as needed for blood glucose greater than 200 mg/dl for the following: 01/12/24 at 10:29 PM the blood glucose reading was 305 mg/dl no insulin administered. 01/13/24 at 08:41 PM the blood glucose reading was 253 mg/dl no insulin administered. 01/18/24 at 08:48 PM the blood glucose reading was 234 mg/dl no insulin administered. 01/19/24 at 09:03 PM the blood glucose reading was 259 mg/dl no insulin administered. Review of the Medication Administration Record (MAR) for Resident #18 dated February 2024 revealed Novolog sliding scale insulin was administered as needed before meals. Novolog sliding scale insulin was not administered at bedtime as needed for blood glucose greater than 200 mg/dl for the following: 02/03/24 at 10:42 PM the blood glucose reading was 248 mg/dl no insulin administered. 02/04/24 at 10:11 PM the blood glucose reading was 235 mg/dl no insulin administered. 02/06/24 at 10:11 PM the blood glucose reading was 215 mg/dl no insulin administered. 02/07/24 at 09:18 PM the blood glucose reading was 348 mg/dl no insulin administered. 02/08/24 at 08:34 PM the blood glucose reading was 274 mg/dl no insulin administered. 02/11/24 at 09:29 PM the blood glucose reading was 203 mg/dl no insulin administered. 02/12/24 at 09:20 PM the blood glucose reading was 204 mg/dl no insulin administered. 02/13/24 at 10:48 PM the blood glucose reading was 341 mg/dl no insulin administered. 02/15/24 at 08:44 PM the blood glucose reading was 207 mg/dl no insulin administered. 02/18/24 at 08:56 PM the blood glucose reading was 253 mg/dl no insulin administered. 02/19/24 at 10:18 PM the blood glucose reading was 204 mg/dl no insulin administered. 02/20/24 at 10:41 PM the blood glucose reading was 204 mg/dl no insulin administered. 02/25/24 at 10:51 PM the blood glucose reading was 225 mg/dl no insulin administered. 02/26/24 at 09:55 PM the blood glucose reading was 284 mg/dl no insulin administered. Review of the Medication Administration Record (MAR) for Resident #18 dated March 2024 revealed Novolog sliding scale insulin was administered as needed before meals. Novolog sliding scale insulin was not administered at bedtime as needed for blood glucose greater than 200 mg/dl for the following: 03/03/24 at 10:26 PM the blood glucose reading was 283 mg/dl no insulin administered. 03/04/24 at 10:32 PM the blood glucose reading was 220 mg/dl no insulin administered. During a phone interview on 03/06/24 at 02:53 PM Medication Aide #1 stated she worked night shift from 7:00 PM through 7:00 AM and routinely provided care to Resident #18. She stated she checked Resident #18's blood sugars two times during her shift, which were at bedtime and in the morning. She stated Resident #18 did not have orders for sliding scale coverage at bedtime and she only received insulin coverage before meals. She indicated Resident #18 was only given sliding scale insulin to cover her blood sugars when she checked her in the mornings. She stated she was not aware that sliding scale insulin was ordered at bedtime and indicated there was no space on the electronic medical record to document that insulin was to be administered at bedtime. She indicated she was not clear on the order if insulin was to be administered at bedtime. She stated as a Medication Aide she would not administer the insulin but would report it to the charge nurse anytime sliding scale insulin was ordered and the nurse would administer it. She reported that Resident #18 was not symptomatic at bedtime when her blood sugar levels were over 200 mg/dl. During a phone interview on 03/07/24 at 12:00 PM Medication Aide #2 stated she worked night shift from 7:00 PM through 7:00 AM and routinely provided care to Resident #18. She stated she checked blood sugars two times during her shift for Resident #18 which were at bedtime and in the morning. She stated Resident #18 did not have orders for sliding scale coverage at bedtime. She stated she would have reported blood sugar readings to the nurse in charge if insulin was scheduled and the nurse would administer the insulin, but no insulin was ordered at bedtime. She indicated she was not clear on the order if Resident #18 was supposed to be given insulin at bedtime. Attempts were made to contact Nurse #1 during the investigation. Nurse #1 was an agency nurse and was on duty during the dates and times the sliding scale insulin was not administered to Resident #18. There was no response. Attempts were made to contact Nurse #2 during the investigation. Nurse #2 was on duty during the dates and times the sliding scale insulin was not administered to Resident #18. Nurse #2 was no longer employed by the facility. There was no response. Attempts were made to contact agency Medication Aides #3, #4, and #5 during the investigation. The Medication Aides were on duty during the dates and times the sliding scale insulin was not administered to Resident #18. There was no response. During an interview on 03/07/24 at 10:18 AM the Physician indicated she was not aware Resident #18 was not getting sliding scale coverage at bedtime. She reported the Nurse Practitioner wrote the order for sliding scale insulin at bedtime. She stated she didn't typically like to prescribe nighttime insulin to residents due to the risk of hypoglycemia. She stated there would not be any significant outcome for Resident #18 not receiving insulin at bedtime and it was probably best that she didn't get the insulin at bedtime. During an interview on 03/07/24 at 11:12 AM the Nurse Practitioner stated she wrote the order for sliding scale insulin in January 2024 and had planned to discontinue the bedtime sliding scale insulin order after a few weeks which would be in February 2024, but she overlooked discontinuing the order. She stated it was fine that Resident #18 wasn't getting sliding scale insulin coverage for the bedtime blood sugar checks even though some of the blood sugar readings were greater than 200 mg/dl because of the risk of hypoglycemia. She stated she planned to change the order today and order blood sugar checks with sliding scale insulin three times a day before meals. During an interview on 03/07/24 at 11: 15 AM the Registered Nurse Supervisor stated that Novolog sliding scale was ordered before meals on 01/11/24, then on 01/12/24 an order was entered for blood sugar checks before meals and at bedtime and to see sliding scale instructions for coverage. She indicated what should have occurred when the order for blood sugars before meals and at bedtime was added the entire order for Novolog sliding scale before meals should have been discontinued and Novolog sliding scale four times a day before meals and at bedtime should have been entered and that was not how it was entered. She indicated this was likely the cause of the bedtime sliding scale insulin order not being followed. During an interview on 03/07/24 at 12:24 PM the Director of Nursing stated medications were reviewed daily in the morning meetings. She indicated she was not aware of the insulin order not being followed for Resident #18. She stated her expectation was for staff to follow the physicians orders and indicated the sliding scale insulin was an active order and should have been followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint survey of [DATE] and the recertification and complaint survey of [DATE]. This was for one deficiency that was originally cited in [DATE] in the area of significant medication errors and for two deficiencies originally cited in [DATE] for medication storage and unnecessary medications. These deficiencies were subsequently recited on the current recertification survey of [DATE]. The continued failure during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F757: Based on observations, record review, staff, and Physician interviews the facility failed to clarify a medication order prescribed for hypotension (low blood pressure) to include hold parameters if the systolic blood pressure was greater than 120 mm/hg (millimeters of mercury). This resulted in a resident (Resident #61) receiving 59 additional doses of the medication. There was no significant outcome from receiving the medication. This occurred for 1 of 3 residents reviewed for medication administration. During the recertification and complaint survey of [DATE] the facility administered a medication to a resident that was not medically justified. An interview was conducted with the Administrator on [DATE] at 3:30 PM. The Administrator stated she believed the QA process needed to be more focused on clarifying orders and reviewing all medications daily for accuracy and following the parameters. F760: Based on observation, record review, staff, Nurse Practitioner, and Physician interviews the facility failed to follow the physicians order and provide sliding scale insulin at bedtime to a resident (Resident #18) when the blood glucose reading was greater than 200 mg/dl (milligrams per deciliter). This resulted in the resident not receiving a total of 74 units of insulin from [DATE] through [DATE]. There was no significant outcome. This occurred for 1 of 3 residents reviewed for medication administration. During the recertification and complain survey of [DATE], the facility failed to administer intravenous (IV) medication as ordered by the physician. An interview was conducted with the Administrator on [DATE] at 3:30 PM. The Administrator stated she believed the QA process needed to be more focused on clarifying orders and reviewing all medications daily for accuracy and following the parameters. F761: Based on observations, record review, and staff interviews the facility failed to record an opened date on two insulin pens and on two opened bottles of eye drops that had shortened expiration dates. This was observed on 1 of 3 medication carts (300 hall medication cart) reviewed for medication storage. During a recertification and complaint survey of [DATE] the facility failed to: accurately label and record an opened date on a bottle of tuberculin solution and a bottle of Influenza vaccine; accurately record an opened date on a bottle of eye drops and insulin pens; dispose of expired bottles of nitroglycerin, insulin pens, and bottle of nasal spray; lock and secure a medication cart in an unattended resident care area; and to securely store medication on a medication cart. An interview was conducted with the Administrator on [DATE] at 3:30 PM. The Administrator revealed the facility including the pharmacist and the Director Nursing believed that the problems with medication storage were related to the inconsistency of the staff on the 300 and 500 halls. The Administrator stated two new nurses were hired to be consistent floor nurses for the two halls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, physician interview, pharmacist interview, and staff interviews, the facility failed to notify the physician that a resident who had a urinary tract infection (UTI) was prescribed a medication that was reported by the laboratory as resistant for 1 of 4 residents reviewed for UTIs (Resident #66). Findings included: Resident #66 was admitted to the facility on [DATE]. She had diagnoses that included a urinary tract infection and a neurogenic bladder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #66 had intact cognition. She had an indwelling urinary catheter. Review of the physician orders for October 2022 revealed Resident #66 was ordered the antibiotic medication Bactrim DS (Sulfamethox/Trimethoprim) tablet 800-160 MG (Milligrams) every 12 hours for a UTI for 7 days on 10/16/22. Review of the electronic Medication Administration Record (eMAR) for Resident #66 for October 2022 documented she was administered the antibiotic Bactrim DS 800-160 MG every 12 hours for 7 days (14 doses) between 10/16/22 and 10/23/22. Review of a final laboratory report dated 10/16/22 for a urine culture and sensitivity documented Resident #66 had a urinary infection of >100,000 Escherichia coli, an organism that was resistant to the antibiotic Bactrim DS. This information was documented on page 2 of the laboratory report. On page 1 of the laboratory report Nurse #8 hand wrote a verbal order from the physician to administer Bactrim DS twice daily for seven days then recheck another urinalysis. In an interview with the physician on 11/18/22 at 1:38 PM he stated he was familiar with Resident #66. He reported the nurse had not told him the antibiotic Bactrim DS was documented as resistant on the 10/16/22 laboratory results. He stated had he known he would have ordered a different medication the organism was susceptible to. He commented it had not hurt Resident #66 to receive the antibiotic the organism was resistant to, but it was an unnecessary medication because it wouldn ' t kill the organism. He reported no problems were encountered because of it. In an interview with Nurse #8 on 11/18/22 at 5:41 PM she stated it was the responsibility of the floor nurse to report to the physician any laboratory results that were received. She reported she had taken the order for the antibiotic Bactrim DS for Resident #66 on 10/16/22. She noted she usually sent a copy of the laboratory report via fax to the physician. She could not recall this laboratory report or situation. She could not remember calling the results to the physician or taking the verbal order from the physician that she had handwritten on page one of the report. She did not know if the report had a second page. In an interview with Support Nurse #1 on 11/21/22 at 9:22 AM she stated she reviewed physician orders daily. She reviewed records to ensure labs were collected and sent, reviewed laboratory reports that were received and reviewed physician orders for appropriateness. Typically, the floor nurse would contact the physician and obtain an order. She stated she was not aware of the report results of 10/16/22 because it was a Sunday when the report came in and she only worked Monday through Friday. Normally on Mondays she would look at the Order Listing Report to view new orders and would then know to look for a follow up culture and sensitivity. She noted this situation happened a month ago and she could not recall what happened a month ago. In an interview with Pharmacist #1 on 11/21/22 at 12:12 PM she stated she reviewed the orders for Resident #66 on 10/22/22 and confirmed she had documented: Antibiotics: Reviewed and following. She commented she had not realized the laboratory report had a second page and missed that the organism was resistant to the medication the resident was receiving, Bactrim DS. She noted had she seen the second page of the report she would have alerted the facility that the resident was on the wrong medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and esident and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of vision and hearing (Resident #32), nutrition (Resident #67), falls (Resident #75), and medications (Resident #84) for 4 of 29 residents reviewed for MDS assessments. Findings included. 1. Resident #32 was admitted to the facility on [DATE] with medical diagnoses which included in part dementia and hearing loss. Review of Resident #32's 8/13/22 care plan revealed a focus of communication problem related to hearing and vision deficits with interventions which included : Use communication techniques which enhance interaction: Allow adequate time to respond, Repeat as necessary, Do not rush, Request feedback, clarification from the resident, to ensure understanding, Face when speaking and make eye contact, Turn off TV/radio as needed to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication, Ensure hearing aids are in place. Resident #32's 10/13/22 significant change MDS assessment indicated resident's hearing was adequate, hearing aids were not used and had adequate vision with glasses. Resident was cognitively intact. Interview on 11/15/22 at 11:30 AM with Resident #32 revealed resident had trouble with her vision despite having had eye surgery and wearing glasses. Resident #32 stated she had hearing loss and required hearing aids. A sign was posted in her room regarding applying her hearing aids daily. Interview on 11/21/22 at 11:10 AM with MDS Coordinator revealed that Resident #32's 10/13/22 significant change MDS should have been coded as impaired vision and hearing and wears hearing aids. 2. Resident #67 was admitted to the facility on [DATE] with diagnoses which included in part End Stage Renal Disease and dialysis dependent. Review of Resident #67's 9/4/22 care plan revealed a nutrition problem related to obesity and therapeutic diet with a goal of will not develop complications related to obesity and interventions included maintain diet as ordered. Review of Resident #67's weights recorded in the medical record revealed a weight of 398.15 pounds on 9/6/22. Review of resident's 9/8/22 quarterly minimum data set (MDS) assessment revealed resident was cognitively intact, independent with eating, had a weight of 184 pounds with no weight loss or gain and received a therapeutic diet. Interview on 11/21/22 11:16 AM with MDS Coordinator revealed that the weight that was recorded on the 9/8/22 Quarterly MDS assessment was incorrect. The MDS Coordinator further stated that the weight automatically populated from the weight that was recorded in Resident #67's medical record and that weight was later struck out as incorrect. She stated that the MDS was to have an accurate weight and should be checked for accuracy prior to finalization and transmission. 3. Resident #75 was admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia, neuropathy (weakness, numbness, and pain resulting from nerve damage), mood disorder, and atrial fibrillation (irregular heart rhythm). The MDS admission assessment dated [DATE] revealed Resident #75 had falls prior to admission. Review of Resident #75's progress notes from 07/07/22 through 10/04/22 revealed Resident #75 had falls without injury on 07/09/22, 07/11/22, 07/15/22, and 08/02/22. Review of the MDS quarterly assessment dated [DATE] for Resident #75 indicated she had no falls since the prior MDS assessment. An interview was conducted on 11/18/22 at 10:30 AM with the MDS Coordinator. She reviewed Resident 75's quarterly MDS assessment dated [DATE] and indicated it was inaccurate regarding her falls. She stated the information had been missed in error. An interview was conducted on 11/18/22 at 2:30 PM with the Director of Nursing. She stated the MDS nurse was expected to review the residents' medical records and include accurate information. 4. Resident #84 was admitted to the facility on [DATE] and discharged with return not anticipated on 08/25/22. A review of the physician orders written on 07/30/22 revealed Furosemide (diuretic) 40 milligrams (mg) one tablet daily in the morning. The Medication Administration Record (MAR) revealed Resident #84 received Furosemide 40 mg, one tablet by mouth in the morning on 07/30/22 and 07/31/22 during this look back assessment period. The MDS 5-day assessment dated [DATE] revealed Resident #84 was moderately cognitively intact and was coded as not receiving diuretic medication during this assessment period. An interview with the MDS Nurse on 11/21/22 at 1:25 PM revealed she did not accurately code Resident #84 for receiving a diuretic medication. The MDS Nurse reviewed the MAR and stated Resident #84 was on Furosemide and should have been coded as receiving a diuretic. She added, when completing the MDS assessments, she reviewed the physician orders, progress notes and the MARs and it was a complete oversite that she missed this. An interview with the Administrator on 11/21/22 at 4:40 PM revealed she expected the MDS assessments to be accurate because it was a reference point for the providers to have a clear picture of how to take care of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews the facility failed to apply a left-hand splint for contracture management according to occupational therapy recommendations for 1 of 1 resident (Resident #24) reviewed for limited range of motion. Findings included. Resident #24 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. A care plan dated 01/12/22 revealed Resident #24 had an Activities of Daily Living (ADL) self-care performance deficit related to hemiplegia and limited mobility related to history of stroke. The goal of care included to receive staff assistance with all aspects of daily care to ensure that all needs were met. Interventions included in part; to encourage resident to participate to the fullest extent possible with each interaction, offer choices in daily care, and monitor, document, and report to nurse as needed any changes in ADL ability, any potential for improvement, and reasons for inability to perform ADLs. A review of the Occupational Therapy discharge summary for dates of service: 12/23/21 through 01/28/22 revealed Resident #24 can tolerate left hand and wrist orthosis for 6 hours (daily) with no complaints of pain, redness, or altered skin integrity to maximize positioning of left hand and wrist and to decrease risk for contractures. Skilled treatment interventions focused on education and training resident and caregivers in compensatory strategies, safety precautions and splinting/orthotic schedule in order to complete self-care skills and functional mobility. A review of the Occupational Therapy discharge summary for dates of service: 04/01/22 through 05/12/22 revealed Resident #24 can tolerate left hand and wrist orthosis for 6-8 hours (daily) with no complaints of pain or altered skin integrity to decrease risk of worsening contractures in left hand/wrist. Discharge recommendations revealed Resident #24 had a splinting program in place. A review of the physician orders from 01/28/22 through 11/21/22 revealed no splint device orders were in place for Resident #24. A review of the Treatment Administration Record from 01/28/22 through 11/21/22 revealed no documentation that Resident #24 had a left-hand splint applied daily. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #24 had mildly impaired cognition. She had no rejection of care and required extensive assistance with ADLs. She had impaired range of motion on one side. An observation conducted on 11/15/22 at 2:22 PM revealed Resident #24 was observed lying in bed, she was alert and oriented to person, place, and time. There was a sign above her bed showing how to apply splints and it read to apply splint to left hand 4-6 hours per day. There was no splint in place to her left hand. Resident #24 stated she should be wearing the splint every day and staff had not been applying the splint and stated she did not know where the splint was. She stated she had not worn the splint in a while and she wanted to wear it to help keep her hand stretched. There was no hand splint observed in the room. An observation conducted on 11/16/22 at 1:30 PM of Resident #24 revealed she was not wearing the left-hand splint. Resident #24 stated staff had not applied the left-hand splint and it had been a while since she last wore the splint. During an interview conducted on 11/16/22 at 4:01 PM Nurse Aide #8 stated she routinely provided care to Resident #24 over the last three weeks after being reassigned to the 200 hall. She stated Resident #24 was supposed to wear the splint to her left hand daily. She stated she had not applied the splint because she had not been trained on applying splints. An observation conducted on 11/16/22 at 6:00 PM of Resident #24 revealed she was not wearing the left-hand splint. During an interview conducted on 11/17/22 at 10:44 AM Nurse #6 stated Resident #24 was alert and oriented to person, place, and time and could voice her needs. She stated Resident #24 had a left-hand splint to be applied daily. She stated she saw the Occupational Therapist in with the resident this morning. An observation conducted on 11/17/22 at 10:50 AM revealed Resident #24 was wearing a left-hand splint. Resident #24 stated the splint was put on her this morning. During an interview on 11/17/22 at 1:01 PM the Occupational Therapist stated Resident #24 received therapy services initially from December 2021 through January 2022. He stated therapy ended in January 2022 and the discharge summary revealed to apply splint to left hand and wrist for 6 hours a day to decrease the risk of worsening contractures. He stated the splint should be applied to the resident's left hand daily for 4-6 hours and stated nursing staff were responsible for ensuring the splint was applied daily. He stated Resident #24 was picked up for therapy services again from 04/01/22 through 05/12/22 for additional support to reach maximum potential. He stated today he went to check Resident #24 for splints and could not find the left arm splint in her room, but eventually found it in the laundry room up on a shelf. He stated he retrieved the splint and placed it on the resident this morning. He stated there were backup splints in the therapy department to use when splints were being laundered. He stated nursing staff were educated by the therapy department in January and May 2022 on applying the splint to Resident #24 and stated there was a sign in sheet documenting the training. He stated new staff may not have been trained but therapy could provide training at anytime when notified. He stated he could not find the physician order for the splint for Resident #24 in the electronic medical record. He stated therapy recommended ongoing use of the left-hand splint to prevent worsening of contractures but at this time he stated Resident #24's contracture had not worsened. He indicated he would see that the order was entered into Resident #24's electronic medical record. An interview was conducted on 11/18/22 at 2:30 PM with the Director of Nursing. She stated therapy usually obtained the orders for splint placement and was not aware the order was not put in Resident #24's electronic medical record. She indicated she expected the nursing staff to apply the splint daily to Resident #24 for contracture management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to obtain a weight upon admission and physician ordered weekly weights on 1 of 2 residents (Resident #82) reviewed for nutrition. Findings included: Resident #82 was originally admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted back to the facility on [DATE] with admitting diagnoses included, in part, gastrointestinal bleed, anemia, Parkinson's Disease, and diabetes. A review of the hospital Discharge summary dated [DATE] revealed Resident #82's weight was 259 lbs. A review of Resident #82's facility weight record revealed on 10/07/22 his weight was 259 lbs. There were no other weights recorded in the log. The Minimum Data Set (MDS) discharge assessment dated [DATE] revealed Resident #82's weight was recorded as 259 lbs. A review of the hospital Discharge summary dated [DATE] did not indicate Resident #82's weight. A review of the MDS entry assessment on 10/24/22 revealed there was no recorded weight. A physician order written on 10/25/22 revealed weekly weights every 7 days for 28 days. The MDS admission assessment dated [DATE] revealed Resident #82 was moderately cognitively impaired. Resident #82 was independent with set up with meals and the weight was recorded as 259 lbs. A review of the medical record revealed there was no care plan for nutrition. A review of the Medication Administration Record (MAR) on 11/15/22 revealed weights were due during the evening shift on 10/25, 11/02, 11/08 and 11/15. On 10/25, the MAR indicated a #9 (which meant see nurse's note), on 11/02/22 the MAR indicated a #2 (which meant resident refused), on 11/08/22 no weight was recorded, and the weight on 11/15/22 was recorded as 259 lbs. A review of the nurse's notes on 10/25/22 revealed there was no documentation regarding Resident #82's weight. An interview was conducted with Nurse Aide (NA) #8 on 11/17/22 at 4:40 PM. NA #8 stated she worked on the 700 hall where Resident #82 resided on the evening of 11/15/22, but no one had asked her to get his weight. An interview with Nurse #3 on 11/20/22 at 7:48 PM who worked the evening shift on 11/15/22 revealed if a weight was due for a resident it would populate in the MAR so the nurse would know to obtain and document the weight. She stated she does not remember getting a weight on Resident #82 that evening and did not know why 259 lbs. was documented in the MAR. She stated it was an error that she documented that weight. She stated she did not recall asking NA #8 to get a weight for the resident. Nurse #3 stated she would need to be more careful in the future because it was confusing since the weight obtained on 11/17/22 was 205 lbs. and that showed a great weight loss. Nurse #3 stated she did not know why she did not obtain the weight as ordered, and added, it must not have populated for her to get a weight. An observation of Resident #82 on 11/15/22 at 12:20 PM revealed the resident was lying in bed and sleeping. The lunch tray had been provided and was at the resident's bedside. A nutritional supplement was noted to be on the tray. An interview with a family member on 11/15/22 at 12:20 PM revealed Resident #82 had lost a lot of weight in the last couple of months, and he had not been eating well, but was willing to try many different foods they brought in. The family member stated the weight loss was mostly from his hospital stay and she had not seen a great weight loss since he was admitted to the facility. She stated he enjoyed milk shakes which they brought in a couple of times a day for him. The family member stated Resident #82 had not been weighed since he came to the facility, and she was curious what his weight was. On 11/17/22 at 2:10 PM the family member stated she had requested Resident #82 be weighed on the scale as they were passing by it with the Wound Treatment Nurse. The family member reported the weight was 208 lbs. On 11/17/22 at 4:30 PM a reweigh was requested on the scale, but the resident refused because he was tired and already in bed. A weight was instead obtained on the mechanical lift and was noted to be 205 lbs. An interview was conducted with Nurse #2 on 11/18/22 at 2:09 PM. Nurse #2 reported the resident was not eating much but he would drink his milk shakes the family brought in. She stated she was surprised to see the weight difference from 259 lbs. to 205 lbs. She stated the 259 lb. weight was recorded in the weight log on 10/07/22 and she did not see a new admission weight on 10/24/22 so she questioned how much he actually lost between 10/24/22 and 11/17/22. Nurse #2 stated she notified the physician regarding the new weight and an order was obtained to give nutritional supplements with meals. Nurse #2 stated there should have been an admission weight on 10/24/22 and the weekly weights should have been obtained as ordered on 10/25/22. An interview was attempted with the Registered Dietician (RD) on 11/18/22 and 11/21/22 via phone. The RD did not return the phone calls. An interview was conducted with the Director of Nursing (DON) on 11/18/22 at 3:15 PM. The DON stated the nurses should have obtained an admission weight upon entry because that was the facility protocol. The DON added if weekly weights were ordered, the nurses should have been getting the weights. She stated she questioned the accuracy of the 259 lb. weight obtained on 11/15/22 since that was the admitting weight on 10/07/22 and he was hospitalized for 2 weeks and definitely needed that readmission weight. The weight that was obtained on 11/18/22 of 205 lbs. is a 54 lb. discrepancy and she was not sure of the accuracy. The DON stated if an admission weight as well as weekly weights were getting done they would have a more accurate weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interviews, the facility failed to provide an agency Nurse Aide (NA #1) with education and to verify their competency to deliver catheter care for 1 of 3 residents (Resident #9) observed for catheter care. Findings included: Resident #9 was admitted to the facility on [DATE]. Diagnoses included Benign Prostate Hypertrophy (enlarged prostate gland BPH). The Minimum Data Set annual assessment dated [DATE] revealed Resident #9 was cognitively intact and was occasionally incontinent of bladder and frequently incontinent of bowel. A hospice progress note written on 10/28/22 revealed nurse made a visit with the physician to assist with inserting a catheter for Resident #9. The note indicated a #16 French, 10 milliliter (ml) catheter was inserted using sterile technique. An observation of Resident #9 on 11/15/22 at 11:45 AM revealed the resident was lying in bed. He was noted to have an indwelling urinary catheter which was hanging lower than the bladder, covered with dignity bag, and secured to his right leg. The catheter was noted to have dark yellow urine with about 400 ml in the urinary bag. An interview was conducted with Resident #9 on 11/15/22 at 11:45 AM. Resident #9 stated he had a catheter, and he believed the staff cleaned it but could not be sure. Resident #9 stated they usually secured the tubing to his leg. An observation of Nurse Aide (NA) #1 on 11/18/22 at 9:45 AM during catheter care was conducted. NA #1 washed her hands, applied gloves, obtained a wash basin with warm water and soap. She obtained wash clothes, personal wipes, and towels, and had Resident #9 check the water for temperature. NA #1 proceeded with Resident #9's catheter care as she unfastened and opened the brief. She was noted to use a single facility provided personal moistened cleansing wipe as she began to cleanse the Resident's penis. She pulled back the foreskin to cleanse the shaft of the penis and then moved upward toward the tip of the penis with the wipe. NA #1 proceeded to use the same cleansing wipe as she cleansed the catheter tubing starting at the tip of the penis down toward the connecting port of the catheter and then discarded the used wipe. NA #1 did not use a separate wash cloth to clean the tip of the penis or a separate wash cloth to cleanse the shaft of the penis or the catheter tubing. An interview was conducted with NA #1 on 11/18/22 at 10:15 AM. She stated she was a new agency nurse aide and had been working at the facility for a month. She stated she received training at her school on how to perform catheter care and she acknowledged she should have used soapy washcloths instead of using a single wipe and she should have washed the resident starting at the tip of the penis and working downward to avoid contamination. She stated she had only been a Nurse Aide for a month, and she did not receive any catheter care training by her Agency or the facility when she began working here a month ago. An interview was conducted with the Director of Nursing (DON) on 11/18/22 at 3:10 PM. The DON stated she would have expected the Nurse Aide to follow the procedures of doing catheter care the way she was taught. The DON stated the staff at the facility were not trained to use the cleansing wipes to do catheter care and their policy was to use warm soapy water to cleanse the perineal area and the catheter insertion site. The DON stated she would have expected the Nurse Aide to have had training with the agency she was working for prior to sending them to facilities and she would have expected the Support Nurses to make sure the agency NA was properly trained prior to starting her shift at this facility. The DON provided an Agency Nurse Aide Orientation outline that should have been used for NA #1's orientation. The outline had a signature line for the Agency Nurse Aide and date and a signature line for the Nurse providing training and date. The DON added, somehow the facility training slipped through the cracks. The DON was not able to provide any documentation from the facility that NA #1 had received orientation or training prior to starting at this facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, physician interview and Consultant Pharmacist #1 interview, the Consultant Pharmacist failed to identify that a resident (Resident #66) was prescribed and administered an antibiotic that was resistant to the organism based on laboratory test results for 1 of 4 residents reviewed for urinary tract infections. Findings included: Resident #66 was admitted to the facility on [DATE]. She had diagnoses that included a urinary tract infection (UTI) and a neurogenic bladder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #66 had intact cognition. She had an indwelling urinary catheter. Review of the physician orders revealed Resident #66 was ordered the antibiotic medication Bactrim DS (Sulfamethox/Trimethoprim) tablet 800-160 MG (Milligrams) every 12 hours for a UTI for 7 days on 10/16/22. Review of a final laboratory report dated 10/16/22 for a urine culture and sensitivity documented Resident #66 had a urinary infection of >100,000 Escherichia coli, an organism that was resistant to the antibiotic Bactrim DS. This information was documented on page 2 of the laboratory report. Review of the electronic Medication Administration Record (eMAR) for Resident #66 documented she was administered the antibiotic Bactrim DS 800-160 MG every 12 hours for 7 days (14 doses) between 10/16/22 and 10/23/22. In an interview with the physician on 11/18/22 at 1:38 PM he stated he was familiar with Resident #66. He reported the nurse had not told him the antibiotic Bactrim DS was documented as resistant on the 10/16/22 laboratory results. He stated had he known he would have ordered a different medication the organism was susceptible too. He commented it had not hurt Resident #66 to receive the antibiotic the organism was resistant to, but it was an unnecessary medication because it wouldn ' t kill the organism. In an interview with Consultant Pharmacist #1 on 11/21/22 at 12:12 PM she stated she reviewed the orders for Resident #66 on 10/22/22 and confirmed she had documented: Antibiotics: Reviewed and following. She commented she had not realized the laboratory report had a second page and missed that the organism was resistant to the medication the resident was receiving, Bactrim DS. She noted had she seen the second page of the report she would have alerted the facility that the resident was receiving the wrong medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, physician interview, staff interviews, and pharmacist interview, the facility administered a medication to a resident that was not medically justified for 1 of 5 residents reviewed for unnecessary medications, Resident #66. Findings included: Resident #66 was admitted to the facility on [DATE]. She had diagnoses that included a urinary tract infection and a neurogenic bladder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #66 had intact cognition. She had an indwelling urinary catheter. Review of the physician orders for October 2022 revealed Resident #66 was ordered the antibiotic medication Bactrim DS (Sulfamethox/Trimethoprim) tablet 800-160 MG (Milligrams) every 12 hours for a UTI for 7 days on 10/16/22. Review of the electronic Medication Administration Record (eMAR) for Resident #66 for October 2022 documented she was administered the antibiotic Bactrim DS 800-160 MG every 12 hours for 7 days (14 doses) between 10/16/22 and 10/23/22. Review of a final laboratory report dated 10/16/22 for a urine culture and sensitivity documented Resident #66 had a urinary infection of >100,000 Escherichia coli, an organism that was resistant to the antibiotic Bactrim DS. This information was documented on page 2 of the laboratory report. On page 1 of the laboratory report Nurse #8 hand wrote a verbal order from the physician to administer Bactrim DS twice daily for seven days then recheck another urinalysis. In an interview with the Director of Nursing (DON) on 11/18/22 at 10:30 AM she commented it was the responsibility of the floor nurse to contact the physician and report findings when laboratory reports were received. She stated she herself did not follow laboratory results, but it was the responsibility of the floor nurse and the unit Support Nurse to follow the laboratory reports daily and make sure the residents were on the correct antibiotics. In an interview with the physician on 11/18/22 at 1:38 PM he stated he was familiar with Resident #66. He reported the nurse had not told him the antibiotic Bactrim DS was documented as resistant on the 10/16/22 laboratory results. He stated had he known he would have ordered a different medication the organism was susceptible to. He commented it had not hurt Resident #66 to receive the antibiotic the organism was resistant to, but it was an unnecessary medication because it wouldn ' t kill the organism. He reported thankfully no problems were encountered because of it. In an interview with Nurse #8 on 11/18/22 at 5:41 PM she stated it was the responsibility of the floor nurse to report to the physician any laboratory results that were received. She reported she had taken the order for the antibiotic Bactrim DS for Resident #66 on 10/16/22. She noted she usually sent a copy of the laboratory report via fax to the physician. She could not recall this laboratory report or situation. She could not remember calling the results to the physician or taking the verbal order from the physician that she had handwritten on page one of the report. She did not know if the report had a second page. In an interview with Support Nurse #1 on 11/21/22 at 9:22 AM she stated she reviewed physician orders daily. She reviewed records to ensure labs were collected and sent, reviewed laboratory reports that were received and reviewed physician orders for appropriateness. Typically, the floor nurse would contact the physician and obtain an order. She stated she was not aware of the report results of 10/16/22 because it was a Sunday when the report came in and she only worked Monday through Friday. Normally on Mondays she would look at the Order Listing Report to view new orders and would then know to look for a follow up culture and sensitivity. She noted this situation happened a month ago and she could not recall what happened a month ago. In an interview with Pharmacist #1 on 11/21/22 at 12:12 PM she stated she reviewed the orders for Resident #66 on 10/22/22 and confirmed she had documented: Antibiotics: Reviewed and following. She commented she had not realized the laboratory report had a second page and missed that the organism was resistant to the medication the resident was receiving, Bactrim DS. She noted had she seen the second page of the report she would have alerted the facility that the resident was on the wrong medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #7 was admitted to the facility on [DATE] with diagnoses which included in part chronic obstructive pulmonary disease, diabetes, and history of bariatric surgery. Review of Resident #7's 10/12/22 quarterly minimum data set (MDS) assessment revealed resident was cognitively intact, was independent with eating and received a therapeutic diet. Resident #7's 10/18/22 care plan contained a nutritional problem or potential nutritional problem related to therapeutic diet and potential for fluctuations in weight. Interventions included to provide and serve the diet as ordered. Interview with Resident #7 on 11/15/22 at 10:49 AM revealed she frequently received foods she was not able to eat. Resident #7 stated she had gastric bypass surgery and she had things she couldn't eat. Resident #7 stated her family members brought in food for her frequently. Interview on 11/16/22 12:50 PM with Resident #7 revealed lunch was not something she was able to eat. Resident #7 was served a cheese sandwich and soup. Resident #7 stated they (the dietary department) knows I can't eat cheese. Then they brought me a crab cake, broccoli, and lima beans. Resident #7 stated she doesn't eat fish. Resident #7 stated she ate what she could of the vegetables and ate some snacks her family members brought in. Review of Resident #7's meal ticket revealed: Regular LCS (low concentrated sweets) diet. Allergies: grapefruit, oranges. Dislikes: cheese, fish, oranges. Interview on 11/18/22 at 12:30 PM with NA #4 revealed residents were asked before each meal which option they wanted and this information was brought to the kitchen. NA #4 stated that sometimes the residents did not receive the meal they wanted or received items they disliked. NA #4 further revealed that if a resident received something they did not like, they went to the kitchen and requested an alternate meal. A meal observation conducted on 11/18/22 at 1:10 PM revealed Resident #7 in bed with head of bed elevated feeding herself a hamburger. Observation of the meal tray revealed the hamburger, a cookie and the beverages were the only items on the meal tray. Review of the menu for lunch indicated macaroni and cheese and peas and carrots were to be served with the hamburger. Resident #7 did not know why she received only a hamburger for lunch with no side items. A phone interview conducted on 11/21/22 at 4:29 PM with the dietary manager revealed she had new staff in the kitchen who were not paying attention to the dislikes on the resident meal tickets. The dietary manager stated she needed to educate the staff about reading the meal tickets. She stated that after admission and periodically afterwards she went over likes and dislikes with residents to determine food preferences. During a phone interview on 11/21/22 at 6:30 PM the Director of Nursing stated she expected food preferences to be honored and residents be served meals according to their preferences. Based on observation, record review, resident and staff interviews the facility failed to honor food preferences for 2 of 29 residents (Resident #24, and #7) reviewed for meal preferences. Findings included. 1.) Resident #24 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. A physician order dated 12/29/21 revealed Resident #24 was to receive a low concentrated sweets (LCS) diet, with soft and bite sized texture foods with thin consistency for nutritional needs. A care plan dated 09/19/22 revealed Resident #24 had a nutritional problem or potential nutritional problem related to receiving a therapeutic and mechanically altered diet and had the potential for fluctuation in weight. The goal of care included to maintain adequate nutritional status as evidenced by maintaining weight within 4 % of baseline with no signs or symptoms of malnutrition and consuming at least 50% of at least three meals daily. Interventions included in part to provide and serve diet as ordered. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #24 had mildly impaired cognition. She had no rejection of care and required extensive assistance with activities of daily living. She had impaired range of motion on one side and received a therapeutic diet. A meal observation conducted on 11/16/22 at 6:00 PM revealed Resident #24 sitting up in her wheelchair feeding herself. She was alert and oriented to person, place, and time. She had eaten all of her food on the dinner plate except for a serving of broccoli. When asked by the surveyor why she didn't eat her broccoli when she ate everything else, she stated I don't like broccoli. Resident #24 stated she had received broccoli on her meal tray before even though she didn't like it. Upon review of her meal ticket on the dinner tray it revealed her dislikes were: Broccoli. A phone interview was conducted on 11/21/22 at 4:29 PM with the Dietary Manager. She stated she had new staff in the kitchen who weren't paying attention to the dislikes on the resident's meal slip. She stated she would have to educate staff on reading the meal cards accurately and stated she would start getting on the food serving line with dietary staff to make sure they were reading the meal cards accurately. She stated after admission and then again periodically she would go over likes and dislikes with residents to determine food preferences. She stated if a resident's food preferences changed in between that time and the resident informed the nurse aide the nurse aide would in turn notify the kitchen to update the resident's food preferences. She stated about a month ago all residents were interviewed to update food preferences on their diet cards. She stated when plating food for meals the dietary aides on the opposite side of the serving line read the dislikes to the person plating the food, she stated it was missed on this incident and stated Resident #24 should not have been served broccoli when it was clearly on the meal ticket that Resident #24 did not like broccoli. During a phone interview conducted on 11/21/22 at 6:30 PM the Director of Nursing (DON) indicated she expected resident food preferences to be honored and stated Resident #24 should not have been served foods from her dislike list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and physician interview the facility failed to identify that a resident (Resident #66) was prescribed and administered an antibiotic that was resistant to the organism based on laboratory test results for 1 of 4 residents reviewed for urinary tract infections; failed to initiate physician orders for a continuous indwelling urinary catheter to include the size of the catheter and orders to maintain and care for the catheter; and failed to cleanse the perineal area and catheter site in a manner to prevent contamination for 1 of 3 residents (Resident #9) observed for urinary catheters. Findings included: 1. Resident #66 was admitted to the facility on [DATE]. She had diagnoses that included a urinary tract infection (UTI) and a neurogenic bladder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #66 had intact cognition. She had an indwelling urinary catheter. Review of the physician orders for October 2022 revealed Resident #66 was ordered the antibiotic medication Bactrim DS (Sulfamethox/Trimethoprim) tablet 800-160 MG (Milligrams) every 12 hours for a UTI for 7 days on 10/16/22. Review of a final laboratory report dated 10/16/22 for a urine culture and sensitivity documented Resident #66 had a urinary infection of >100,000 Escherichia coli, an organism that was resistant to the antibiotic Bactrim DS. This information was documented on page 2 of the laboratory report. On page 1 of the laboratory report Nurse #8 hand wrote a verbal order from the physician to administer Bactrim DS twice daily for seven days then recheck another urinalysis. Review of the electronic Medication Administration Record (eMAR) for Resident #66 documented she was administered the antibiotic Bactrim DS 800-160 MG every 12 hours for 7 days (14 doses) between 10/16/22 and 10/23/22. Review of the final laboratory report for the follow up urinalysis culture and sensitivity collected on 10/24/22 and reported to the facility on [DATE] documented the resident continued to have >100,000 Escherichia coli in her urine. In an interview with Resident #66 at 12:30 PM on 11/15/22 she stated she thought she was on the wrong medication for her UTI. She questioned if the medication she was currently receiving was strong enough because she did have chronic UTI ' s and stated she was afraid of becoming septic. She clarified during a second interview on 11/18/22 at 12:55 PM she had originally asked to go to the emergency room for evaluation on 11/13/22 because she felt short of breath, but after being evaluated at the hospital she found out she still had a UTI. In an interview with the Director of Nursing (DON) on 11/18/22 at 10:30 AM she commented it was the responsibility of the floor nurse to contact the physician and report findings when laboratory reports were received. She stated she herself did not follow laboratory results, but it was the responsibility of the floor nurse and the unit Support Nurse to follow the laboratory reports daily and make sure the residents were on the correct antibiotics. She did not review the results of the follow up urinalysis culture and sensitivity report. In an interview with the physician on 11/18/22 at 1:38 PM he stated he was familiar with Resident #66. He reported the nurse had not told him the antibiotic Bactrim DS was documented as resistant on the 10/16/22 laboratory results. He stated had he known he would have ordered a different medication the organism was susceptible to. He commented it had not hurt Resident #66 to receive the antibiotic the organism was resistant to, but it was an unnecessary medication because it wouldn ' t kill the organism. He reported no problems were encountered because of it. He stated he had not seen the follow up urinalysis culture and sensitivity report and it had not been reported to him. He noted had he been aware of the results on the follow up report he would have seen the antibiotic, Bactrim DS, had not been effective and he would have ordered a different medication to treat the infection. In an interview with Nurse #8 on 11/18/22 at 5:41 PM she stated it was the responsibility of the floor nurse to report to the physician any laboratory results that were received. She reported she had taken the order for the antibiotic Bactrim DS for Resident #66 on 10/16/22. She noted she usually sent a copy of the laboratory report via fax to the physician. She could not recall this laboratory report or situation. She could not remember calling the results to the physician or taking the verbal order from the physician that she had handwritten on page one of the report. She did not know if the report had a second page. In an interview with Support Nurse #1 on 11/21/22 at 9:22 AM she stated she reviewed physician orders daily. She reviewed records to ensure labs were collected and sent, reviewed laboratory reports that were received and reviewed physician orders for appropriateness. Typically, the floor nurse would contact the physician and obtain an order. She stated she was not aware of the report results of 10/16/22 because it was a Sunday when the report came in and she only worked Monday through Friday. Support Nurse # 1 added, normally on Mondays she would look at the Order Listing Report to view new orders and would then know to look for a follow up culture and sensitivity. She noted this situation happened a month ago and she could not recall what happened a month ago. In an interview with Nurse #5 on 11/21/22 at 10:27 AM she stated she had been the nurse on duty caring for Resident #66 on 10/26/22 when the second follow up urinalysis came back. She did not recall calling the results to the physician and had not seen the report until today. In an interview with Pharmacist #1 on 11/21/22 at 12:12 PM she stated she reviewed the orders for Resident #66 on 10/22/22 and confirmed she had documented: Antibiotics: Reviewed and following. She commented she had not realized the laboratory report had a second page and missed that the organism was resistant to the medication the resident was receiving, Bactrim DS. She noted had she seen the second page of the report she would have alerted the facility that the resident was receiving the wrong medication. In an interview with Pharmacist #2 on 11/21/22 at 12:51 PM she stated she reviewed the medications for Resident #66 in November 2022. She noted she normally began her review where the previous pharmacist left off the month prior, but in this instance, she did not review the follow up urinalysis that was reported to the facility after the October review by Pharmacist #1 because she noted Resident #66 had been to the emergency room on [DATE] and was prescribed a different antibiotic (Macrobid) than she was on in October. Review of the hospital report dated 11/13/22 for Resident #66 revealed she was diagnosed with a UTI and prescribed the antibiotic Macrobid 100 MG, one capsule orally every 12 hours for 7 days. Review of the electronic Medication Administration Record revealed Resident #66 received Macrobid 100 MG by mouth every 12 hours on 11/14/22, 11/15/22, 11/16/22 and one dose on 11/17/22. While the survey was in process, the facility received the final culture and sensitivity report for the urinalysis collected at the hospital on [DATE]. The organism was resistant to Macrobid. The resident was started on Imipenem Sodium Solution reconstituted 1 Gram intramuscularly every 24 hours for 3 days on 11/17/22. The laboratory report documented the infection was susceptible to the antibiotic Imipenem. 2. Resident #9 was admitted to the facility on [DATE]. Diagnoses included Benign Prostate Hypertrophy (enlarged prostate gland BPH). The Minimum Data Set annual assessment dated [DATE] revealed Resident #9 was cognitively intact and was occasionally incontinent of bladder and frequently incontinent of bowel and was coded as receiving hospice services. 2a. A physician note written on 10/28/22 revealed, in part, resident noted with episodic urinary retention. Recent ultrasound showed bladder distention with greater than 1000 milliliters (ml) of retained urine. Hospice Nurse assisted with inserting a catheter with great difficulty. Once the catheter was placed, an immediate return of 200 ml of clear urine followed by steady flow of some blood-tinged urine for a total of 300 ml. A hospice progress note written on 10/28/22 revealed nurse made a visit with the physician to assist with inserting a catheter for Resident #9. The note indicated a #16 French, 10 milliliter (ml) catheter was inserted using sterile technique. A review of the physician orders revealed there were no physician orders written for an indwelling urinary catheter on 10/28/22. A review of the Treatment Administration Record (TAR) revealed there were no orders to care or maintain an indwelling urinary catheter. A review of Resident #9's care plan revealed the last updated plan of care was 10/19/22. There was no care plan in place to include an indwelling urinary catheter. An observation of Resident #9 on 11/15/22 at 11:45 AM revealed the resident was lying in bed. He was noted to have an indwelling urinary catheter which was hanging lower than the bladder, covered with dignity bag, and secured to his right leg. The catheter was noted to have dark yellow urine with about 400 ml in the urinary bag. An interview was conducted with Resident #9 on 11/15/22 at 11:45 AM. Resident #9 stated he had a catheter, and he believed the staff cleaned it but could not be sure. Resident #9 stated they usually secured the tubing to his leg. An interview was conducted with Nurse #1 on 11/17/22 at 2:30 PM. Nurse #1 stated she was aware Resident #9 had an indwelling urinary catheter. Nurse #1 reviewed the physician orders and confirmed there were no orders to indicate the size of the catheter or any orders to maintain and care for the catheter or when the catheter should be changed. Nurse #1 stated she did not know how it got missed for two and half weeks and she would put the orders in the electronic medical record (eMAR) now. Nurse #1 stated that although the Hospice Nurse and the Physician inserted the catheter on 10/28/22, it would have been the facility nurse that would have been responsible for putting the orders in the eMAR and not the Hospice Nurse. Nurse #1 stated she knew the resident had a catheter but did not know how many millimeters the balloon was filled with. She stated since there were no orders put in the eMAR. Nurse #1 also stated thankfully, she was made aware the orders were not put in because, she added, the catheter was due to be changed in about a week and it may have gotten missed if we did not have the orders put in the eMAR. Nurse #1 stated whenever an order was put into the eMAR it would prompt the staff to initiate batch orders to include the type of catheter, the size and balloon amount, an order to change the catheter every 30 days or as needed for occlusion, secure the tubing with a stat lock (device to secure to leg), to do catheter care each shift, to change the urinary bag weekly, and to monitor urine output. An interview with the Nurse who was assigned to Resident #9 on 10/28/22 was not obtained. Nurse no longer worked at facility and there was no working forwarding number. An interview was conducted with the Director of Nursing (DON) on 11/18/22 at 3:10 PM. The DON stated she would have expected her nursing staff to put all the orders pertaining to the catheter and the care of the catheter into the eMAR on 10/28/22 so that it could be monitored and managed daily on each shift and to make the nurses aware of when it needed to be changed. The DON added it was important to ensure urinary catheters were being monitored daily to prevent increased chance of urinary tract infections. An interview was attempted with the Physician via phone on 11/21/22 at 2:34 PM. Physician returned call at 5:04 PM on 11/21/22 and left message to return his call. Called physician at 6:02 PM on 11/21/22 and left message for a returned call. 2b. An observation of Nurse Aide (NA) #1 on 11/18/22 at 9:45 AM during catheter care was conducted. NA #1 washed her hands, applied gloves, obtained a wash basin with warm water and soap. She obtained face clothes, personal wipes, and towels, and had Resident #9 check the water for temperature. NA #1 proceeded with Resident #9's catheter care as she unfastened and opened the brief. She was noted to use a single facility provided personal moistened cleansing wipe as she began to cleanse the Resident's penis. She pulled back the foreskin to cleanse the shaft of the penis and then moved upward toward the tip of the penis with the wipe. NA #1 proceeded to use the same cleansing wipe as she cleansed the catheter tubing starting at the tip of the penis down toward the connecting port of the catheter and then discarded the used wipe. NA #1 did not use a separate wash cloth to clean the tip of the penis or a separate wash cloth to cleanse the shaft of the penis or the catheter tubing. An interview was conducted with NA #1 on 11/18/22 at 10:15 AM. She stated she was a new agency nurse aide and had been working at the facility for a month. She stated she received training at her school on how to perform catheter care and she acknowledged she should have used soapy washcloths instead of using a single wipe and she should have washed the resident starting at the tip of the penis and working downward to avoid contamination. She stated she had only been a Nurse Aide for a month, and she did not receive any catheter care training by her Agency or the facility when she began working here a month ago. An interview was conducted with the Director of Nursing (DON) on 11/18/22 at 3:10 PM. The DON stated she would have expected the Nurse Aide to follow the procedures of doing catheter care the way she was taught. The DON stated the staff at the facility were not trained to use the cleansing wipes to do catheter care and their policy was to use warm soapy water to cleanse the perineal area and the catheter insertion site. The DON stated she would have expected the Nurse Aide to have had training with the agency she was working for prior to sending them to facilities and she would have expected the facility staff to ensure she was properly trained prior to starting her shift at this facility. The DON added, somehow the facility training slipped through the cracks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interviews, the facility failed to: accurately label and record an opened date for a bottle of tuberculin solution in the Station #1 medication room refrigerator and a bottle of Influenza vaccine in the 400 hall medication room. The facility failed to accurately record an opened dated for a bottle of eye drops, dispose of 2 expired bottles of nitroglycerin and an expired insulin pen on the 300 hall medication cart. The facility failed to dispose of an expired bottle of nasal spray, discard an expired Insulin pen, and accurately record an opened date for 2 Insulin pens on the 100/200 hall medication cart. The facility failed to lock and secure a medication cart (100/200 hall medication cart) in an unattended resident care area for 1 of 5 medication carts observed. The facility also failed to securely store medication on a medication cart for 2 of 5 (300 hall and 500 hall) carts observed. Findings included: 1.Observation on 11/15/22 at 4:15 PM of Nurses Station #1 medication room refrigerator revealed: 1 bottle of Tuberculin Solution labeled as opened on 8/22/22. Manufacturer's instructions indicated tuberculin solution was to be discarded 30 days after opened. 2. Observation on 11/15/22 at 4:20 PM of the 300 Hall Medication Cart revealed the following: Resident #30: bottle of Timolol 0.5% eye drops observed as opened with no opened date noted on bottle. Resident #47: bottle of nitroglycerin 0.4 mg. dispense date 10/14/21. Expiration Date on label 10/13/22. Resident #27: bottle of nitroglycerin 0.4 mg. dispense date on label 3/11/21. Expiration Date on label listed as 3/10/22. An opened Insulin Glargine Pen labeled with the name of a resident no longer in the facility with no opened date indicated. Interview on 11/15/22 at 4:30 PM with Nurse Aide (NA)#4 who was also a medication aide working on 300 Hall medication cart revealed that expired medications were to be discarded and medication for a discharged resident should be discarded. 3.Observation on 11/16/22 at 1:13 PM of 100/200 Hall medication cart with Nurse #4 in attendance revealed the following: Resident #60 Fluticasone nasal spray bottle with opened date recorded as 7/19/22 Resident #25's Lantus Pen labelled with an opened date of 10/10/22. Label stated expired 28 days after opening. Resident #11 with 2 Tresiba Flex Pens with the seals broken and opened date not recorded on either of the pens. The label indicated the medication expired 56 days/8 weeks after opening. Interview on 11/16/22 at 1:20 PM with Nurse #4 revealed she didn't know why the pens weren't dated when opened. Nurse #4 stated she only worked PRN or as needed and did not know who was supposed to be checking the medication cart for expired medications. Interview on 11/16/22 at 1:25 PM with the Director of Nursing (DON) revealed that the insulin pens should be discarded when expired and that medications were to be accurately labelled and dated. 4. Observation on 11/16/22 at 1:45 PM revealed 100/200 hall med cart was observed unlocked and not under direct supervision in a common area at the nurses station for approximately 15 minutes as multiple staff members and residents were observed walking past the cart. After approximately 15 minutes the DON came up to the medication cart and observed that it was unlocked. The DON stated that it should not be left unlocked. Nurse #4 who was assigned to the 100/200 hall medication cart returned to the cart. Nurse #4 stated she had gone to take care of something with a resident and the cart should not have been left unlocked. 5. Observation on 11/16/22 at 4:17 PM revealed a cup with crushed medications in liquid was left on top of the 100/200 hall medication cart unattended in an area where residents could access it while Nurse #4 went into a resident's room to perform a blood sugar check. The medication cart was not within direct observation of Nurse #4. Nurse #4 stated the medication was for a resident on another hall and it needed to be dissolved. The nurse further stated that it probably should not have been left unattended on top of the medication cart. 6. Observation on 11/16/22 at 4:30 PM of the 400 Hall medication prep room refrigerator revealed: 1 vial of Influenza vaccine solution with the cap removed from the vial with no opened date on the label. 7. Observation on 11/16/22 at 5:05 PM revealed Resident #43 entered her room, removed a bottle of Tums antacid tablets from the bedside table, removed 2 tablets from the bottle and ingested them. Resident #43 was admitted to the facility on [DATE] with medical diagnoses which included in part dementia and gastroesophageal reflux disorder. Record review revealed resident had not been assessed as appropriate for self-administration. Interview on 11/16/22 at 5:11 PM with Nurse #5 revealed Resident #43 was not alert and oriented and not able to self-administer medications. Nurse #5 further stated Resident #43 did not have an order for Tums and should not be taking them without an order. Nurse #5 stated that if a resident wanted to self-administer medication, they were to be assessed for this and if appropriate the doctor was informed and an order obtained. 8. Resident #47 was noted with a physician order dated 1/11/22 for self-administration of Fluticasone Propionate Suspension 50 micrograms/actuation. 1 spray in each nostril one time a day for allergies. unsupervised self-administration Shake before use. Blow nose before use. Initial Self Administration assessment was completed on 1/19/22 and resident was determined to be able to self-administer. Self-administration assessment was updated on 10/13/22 and resident was approved as able to self-administer medications. Resident #47's care plan revealed a Self-administration focus dated 1/19/22. Interview with Resident #47 on 11/17/22 at 2:00 PM regarding self-administration of nasal spray revealed resident had nasal spray on the table that she used once per day as needed. Observation revealed a bottle of nasal spray on the bedside table labelled Nasonex (memetasone furoate nasal spray 50 micrograms) label read 2 sprays into both nostrils once per day. Written on the bottle was a date 3/20/22. Also observed on the bedside table were 2 bottles of Pain Relief Cream 4 % Lidocaine topical analgesic. Resident #47 stated she used the pain relief cream every night for arthritis of her hands and shoulder. Interview was conducted on 11/17/22 at 2:15 pm with Nurse Aide #4 who was also the Med Aide on the 300 hall. NA#4 stated a self-administration evaluation was completed before a resident could self-administer medications. NA #4 stated she thought the medication was to be kept in a locked box, that she was unsure where Resident #47 kept her nasal spray and didn't check with her about when or how often she administered it. NA #4 was unaware that Resident #47 had other medication in her room. Interview on 11/17/22 at 2:55 PM with DON revealed that her expectation was that medications would not be kept at the bedside. The DON further stated that if a resident was assessed as able to self-administer, she expected a physician order and for medication to be stored in a drawer at the bedside or on the medication cart. The DON added that a physician order was required.

Based on observations, record review and staff interviews, the facility failed to: 1a) demonstrate how to clean and disinfect a glucometer device per manufacturer's instructions after use for 2 of 2 nurses (Nurse #4 and Nurse #5) observed during medication pass; 1b) perform hand hygiene prior to donning and after removal of gloves when performing a blood glucose check for 1 of 1 nurse (Nurse #4) observed; 2) perform hand hygiene after removing soiled gloves and prior to donning clean gloves during a wound care observation for 1 of 3 residents (Resident #34) reviewed for infection control practices; and 3) dispose soiled linens in a bag during catheter care for 1 of 3 residents (Resident #9) observed for catheters. Findings included: The facility's policy for glucometers updated January 2011 revealed, in part, anytime the glucometer is visibly soiled and as needed, it will be cleaned and disinfected per Manufacturer's guidelines. The Manufacturer's Guidelines for the antimicrobial wipes revealed the meter should be cleaned prior to disinfection. The cleaning process included: step 1: wear appropriate protective gear such as disposable gloves, step 2: remove one towelette, step 3: wipe the entire surface of the meter 3 times horizontally and 3 times vertically using 1 towelette to clean blood and other bodily fluids, step 4: discard towelette. The disinfecting process included: step 5: remove one towelette, step 6: wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood borne pathogens and allow exterior to remain wet for the appropriate contact time and then wipe the meter using a dry cloth, step 7: dispose of the used towelette in a trash bin, step 8: allow exteriors to remain wet for the appropriate contact time and then wipe the meter using a dry cloth, step 9: after disinfection, the user's gloves should be removed and thrown away. Wash hands before proceeding to the next patient. 1a. An observation of Nurse #4 was conducted on 11/16/22 at 4:17 PM as she obtained a blood sugar on Resident #69 using the resident's personal glucometer. Nurse #4 was observed as she donned gloves and removed a plastic box labeled with Resident #69's name from the bottom drawer of the medication cart. Nurse # 4 entered Resident #69's room carrying the plastic box which contained a glucometer, an alcohol prep pad, a lancet and a test strip. Nurse #4 obtained Resident #69's blood sugar. The glucometer read error. Nurse #4 with gloved hands went back to the medication cart, retrieved another lancet from a box, returned to the room, and obtained the blood sugar from Resident #69. After the blood sugar was successfully completed, Nurse #4 gathered the supplies, exited the room, and returned to the medication cart. Nurse #4 removed a bottle of blood glucose test strips from the box and placed it in the top drawer of the medication cart. Nurse #4 disposed of the used lancets, removed her gloves, signed into the laptop computer, and recorded the blood sugar reading. A continuous observation was made as Nurse #4 failed to wash her hands or use hand sanitizer before moving on to the next resident during medication administration pass observation. The personal glucometer was not cleaned or disinfected prior to or following use. An interview was conducted with Nurse #4 at 4:25 PM to discuss the cleaning and disinfectant procedure for the glucometer. Nurse #4 stated she wiped it all over with an alcohol prep pad as needed. Nurse # 4 took the glucometer out of the plastic box on the medication cart and quickly swiped an alcohol prep pad over the surface of the device. She then placed it back in the plastic box and put the box back on the medication cart. When asked when she typically washed or sanitized her hands during a medication pass Nurse #4 stated after removing gloves and between residents. Nurse #4 acknowledged she had not done so. 1b. The medication pass observation continued with Nurse #5 as she was observed exiting a resident room after completing a blood sugar check. An interview conducted with Nurse #5 on 11/16/22 at 4:25 PM revealed she typically cleaned the personal glucometer with an antimicrobial wipe. Nurse #5 had just completed a blood sugar check. Nurse #5 removed a towelette from a cannister of antimicrobial wipes, wiped it once across the surface, placed the glucometer back in a plastic bag, and put it in the drawer of the medication cart. An interview was conducted with the Director of Nursing (DON) on 11/21/22 at 9:05 AM via phone. The DON stated she expected the nursing staff to clean the personal glucometers with the antimicrobial wipes only and to follow the manufacturer's guide lines on how to clean them appropriately. The DON stated that antimicrobial wipes were provided and available for the staff to use. The DON further stated she expected the nursing staff to complete hand hygiene prior to donning and following removal of gloves. 2. A wound care observation was conducted on 11/17/22 at 10:30 AM with the Wound Treatment Nurse The nurse washed her hands and donned gloves when she entered the residents room. The soiled dressing was removed from the left hip wound. The dressing had a moderate amount of serosanguineous (containing blood and serum) drainage. She removed her soiled gloves and did not wash her hands before donning clean gloves and applying the clean dressing. The nurse cleaned the wound with wound cleanser, applied the treatment and covered with an oil emulsion dressing. She removed her gloves but did not wash her hands before donning clean gloves and removing the soiled dressing from wound site #2 a Stage IV coccyx wound, the dressing had a moderate amount of serosanguineous drainage, she removed the soiled dressing changed her gloves but did not wash her hands before donning clean gloves, packing the wound with gauze, and applying the clean protective dressing to the wound. After completion of the dressing change to the Stage IV coccyx wound, she removed her gloves and washed her hands. An interview was conducted with the Wound Treatment Nurse on 11/17/22 at 10:50 AM. She acknowledged that she did not wash her hands after removing the soiled gloves and donning clean gloves during the observation. She stated she thought she did everything right but with the State surveyor and the Federal surveyor in the room with her it made her nervous. She stated she always washed her hands after removing soiled gloves and prior to donning clean gloves and when moving between wound sites when performing wound care. An interview was conducted with the Director of Nursing who was also the Infection Control Preventionist on 11/18/22 at 2:30 PM. She indicated the facility policy required staff to wash hands after removing gloves. She stated the wound nurse should have washed her hands after removing soiled gloves and prior to donning clean gloves during wound care. 3. An observation of Nurse Aide (NA) #1 on 11/18/22 at 9:45 AM during catheter care was conducted. NA #1 washed her hands, applied gloves, and filled a basin with warm water and soap. She obtained wash clothes, personal wipes, and towels. NA #1 proceeded with Resident #9's catheter care. She was noted to use a single facility provided personal moistened cleansing wipe used for catheter care. NA #1 discarded the soiled wipe on the floor. At this time, Resident #9 stated he had a bowel movement. NA #1 cleansed his buttocks with a wash cloth and discarded the soiled wash cloth on the floor. NA #1 repositioned Resident #9 on his back and cleansed the perineal area with a washcloth, rinsed and dried the area with a towel and threw the used towel and washcloth on the floor. She then used 3 separate wash cloths to finish the catheter care and discarded the wash cloths on the floor. NA #1 used a towel to dry the area and discarded the towel on the floor. NA #1 removed her gloves, washed her hands, and exited the room stating she was getting a bag. Upon return she reapplied gloves and picked the soiled linens off the floor and placed them in a bag. An interview was conducted with NA #1 on 11/18/22 at 10:15 AM. She stated she was an agency nurse aide and had been working at the facility for a month. NA #1 acknowledged she discarded the soiled linens on the floor and stated she usually brought in trash bags to put the dirty linens in, but she forgot to bring them in the room with her prior to starting her care. An interview was conducted with the Director of Nursing (DON) on 11/18/22 at 3:40 PM. The DON reported she expected her nursing staff to put all soiled linens in a bag, secure the bag and place the bag in the dirty linen bin when finished. The DON added, disposing of soiled linens on the floor was an infection control concern.

Based on observations, record review, resident interview and staff interviews, the facility failed to follow the prepared menu for 3 out of 4 meals observed when food items were substituted or omitted, but not noted or updated on the menu in advance time. Findings included: 1. The menu provided titled Fall/Winter 2022-2023 Week 3 revealed the lunch on 11/16/22 was homemade vegetable soup, saltine crackers, grilled cheese sandwich, vegetable sticks, and chilled peaches. A review of a handwritten menu dated 11/16/22 at 9:30 AM which posted at the nurses' station on 11/16/22 revealed a pimento cheese sandwich instead of grilled cheese sandwich. Observation of the lunch meal on 11/16/22 at 12:30 PM revealed a cold pimento cheese sandwich was served instead of grilled cheese sandwich. An interview with Resident #26 on 11/16/22 at 12:30 PM who was described by staff as being alert and oriented revealed the menu that was provided was often different from what was served and added We never know what we are going to get. An interview was conducted with the Dietary Manager (DM) on 11/17/22 at 11:15 AM. The DM reported she served pimento cheese sandwiches on 11/16 because her flat griddle did not work. She stated she was not able to cook grilled cheese sandwiches for the whole facility, so she substituted with the pimento cheese sandwiches. She stated the flat griddle had been broken for a while and she told the previous Administrator about 2 months ago, but she had not informed the current Administrator. The DM stated she posted the revised menu on the morning of 11/16/22 at the nursing stations and felt that was enough notice to the residents about the revised menu. 2. The menu provided titled Fall/Winter 2022-2023 Week 3 revealed the lunch on 11/17/22 was turkey melt, tater tots, zucchini and tomatoes and sugar cookie. A review of a handwritten menu on 11/17/22 at 9:30 AM posted at the nurses' station on 11/17/22 revealed there were no tater tots written on the menu. Observation of the food service line starting at 11:30 AM on 11/17/22 revealed temperatures were taken on the turkey melt, zucchini and tomatoes and the alternate meal, but there were no tater tots on the food line. During the food service observation, the [NAME] prepared 10 trays with no tater tots and the Dietary Aide put the trays on the dietary cart for delivery. During this observation on 11/17/22, an interview was conducted with the Cook. The [NAME] was asked if she was going to be serving a starch and she reported she forgot to make the tater tots. The [NAME] continued to place food on the trays and did not ask for tater tots to be cooked. An interview with the DM on 11/17/22 at 11:40 AM was conducted. The DM was asked if tater tots were going to be served. The DM looked at the fall/winter menu and saw that tater tots were supposed to be served. The DM stated she did not know how the tater tots were missed to be served. The DM went to the freezer and brought out hash brown patties and stated we don't have tater tots and began cooking the hashbrowns. The first tray of hash brown patties were cooked by 11:55 AM and brought to the food line. The DM stated we could substitute the tater tots with the hash brown potatoes because they were comparable. The temperature was taken on the hash brown patties and the Dietary Aide removed the 10 trays from the dietary cart. The [NAME] placed a hash brown patty on the trays. 3. The menu provided titled Fall/Winter 2022-2023 Week 3 revealed the lunch on 11/18/22 was butter crumb tilapia, tartar sauce, macaroni and cheese, cucumber and onion slices salad, hush puppies and yellow cake with chocolate frosting. A review of a handwritten menu on 11/18/22 at 9:00 AM posted at the nurses' station on 11/18/22 revealed there were peas and carrots being served instead of cucumber and onion slices salad and dessert (no named dessert). Observation of the food service line starting at 11:30 AM on 11/18/22 revealed steamed peas and carrots were being served instead of cucumber and onion slices salad and a packaged cookie was served instead of yellow cake with chocolate frosting. During this observation on 11/18/22, the [NAME] reported, We did not have any cucumbers, so we are serving peas and carrots. The [NAME] also stated she was supposed to make a cake this morning and did not because we did not have any frosting, so we are serving a cookie. An interview was conducted with the DM on 11/18/22 at 11:50 AM. The DM reported, We were out of cucumbers, so we replaced the menu with peas and carrots. The DM also reported she did not know why the [NAME] did not make cake and was asked if she had frosting available. The DM stated, We did not have canned frosting, but the [NAME] could have used other ingredients we had on hand to make a frosting and should have made the cake. The DM stated she did not always look at the food service line to be sure what was on the menu was being served because she was busy doing other tasks. A follow up interview was conducted with the DM on 11/18/22 at 2:30 PM. The DM reported sometimes she had to substitute food with a similar food because the food distributer may not have what we need. She stated she was made aware of the fall/winter menu a few weeks before we would begin to use it and she ordered what she would need based on the menu. The DM could not say why she did not have tater tots, cucumbers, or frosting. She stated it had to do with the supply and demand of the food service company. An interview with the Administrator on 11/21/22 at 4:40 PM revealed she expected the Dietary Manager to follow the planned menu and to place her food order accordingly. The Administrator further stated that her expectation was that the menu was correct and that the residents were informed timely of changes or substitutions to the menu and that being notified hours before the meal was being served was not sufficient amount of time to inform the residents. The Administrator added that food was a major component of enjoyment to the residents, and she would be looking into all of these concerns.

Based on observations and staff interviews, the facility failed to discard leftover food stored ready for use past the use dates and failed to label, date, and seal a leftover food item stored in 1 of 1 walk-in refrigerator. These practices had the potential to affect food served to residents. Findings included: During the initial kitchen tour of the walk-in refrigerator on 11/15/22 at 10:05 AM the following concerns were observed: - a container labeled vanilla pudding with an opened date of 11/04/22 and a use by date by 11/08/22 - a container labeled franks and beans with an opened date of 11/07/22 and use by date by 11/13/22, and - a container labeled apple sauce had no opened date, and a use by date of 11/13/22 - a package of exposed ham which was unwrapped, and the expiration date was illegible. An interview with the Dietary Manager (DM) on 11/15/22 at 10:05 AM revealed she and any dietary staff who opened and stored the food items were responsible for checking the products to be sure it was dated when opened and they were responsible for discarding any products by their use by date. She stated she overlooked these products and discarded them at this time. The DM also revealed she and any dietary staff who opened food packages were responsible for checking the products to be sure it was dated when opened and all the items were to be sealed to prevent the items from spoilage. She stated she overlooked seeing the package unsealed with no open date and discarded the item. An interview with the Administrator on 11/18/22 at 4:40 PM revealed she expected the dietary staff to ensure all the items in the kitchen were dated when opened and discarded by the use date and that all items were sealed to prevent spoilage.

Based on observations, record review and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey on 07/30/21 and the recertification survey on 01/09/20. This was for two deficiencies that were originally cited in July 2021 in the areas of infection control and competent nursing staff and for one deficiency originally cited in January 2020 for food procurement, storage, and sanitation and were subsequently recited on the current recertification survey of 11/21/22. The continued failure during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included. This tag is cross referenced to: F880: Based on observations, record review, and staff interviews the facility failed to 1) demonstrate how to clean and disinfect a glucometer device per manufacturers instructions after use for 2 of 2 nurses (Nurse#4 and Nurse#5) observed during medication pass. The facility also failed to perform hand hygiene prior to donning and after removal of gloves when performing a blood glucose check for 1 of 1 nurses (Nurse#4) observed. 2) failed to perform hand hygiene after removing soiled gloves and prior to donning clean gloves during a wound care observation for 1 of 3 residents (Resident #34) reviewed for infection control practices. 3) During the recertification survey and the complaint investigation completed on 07/30/21 the facility failed to implement the Centers for Medicare and Medicaid Services (CMS) guidelines and the facility's COVID-19 program Infection Control Policy to ensure staff were screened upon entering the facility when a staff member was observed entering through a back door upon arriving for her shift and failed to be screened by a trained staff member before entering the resident care area (Nurse Aide#11), and two staff members were observed entering through the back door without screening and walked through the facility to the front entrance to be screened prior to starting their shift (Nurse Aide #4, #5). The facility failed to ensure staff were screened by a nurse or trained staff member prior to entering the facility when a staff member was observed screening herself upon entering the facility through a back door for 4 of 4 staff members observed. These failures occurred during the COVID-19 pandemic. F726: Based on observation, record review, resident and staff interviews the facility failed to provide an agency Nurse Aide (#1) with education and to verify their competency to deliver catheter care for 1 of 3 residents (Resident #9) observed for catheter care. During the recertification survey and the complaint investigation completed on 07/30/21 the facility failed to demonstrate a working knowledge of the IV (intravenous) pump equipment to enable antibiotic IV medications to be administered for 1 of 1 resident reviewed for IV medication administration (Resident #160). F812: Based on observations and staff interviews the facility failed to discard left over food stored ready for use past the use dates and failed to label, date, and seal a leftover food item stored in 1 of 1 walk-in refrigerators. These practices had the potential to affect food served to residents. During the recertification survey on 01/09/20 the facility failed to maintain a sanitary ice machine free from brown debris on the interior of the machine. A phone interview was conducted on 11/21/22 at 6:30 PM with the Administrator along with the Director of Nursing (DON). The Administrator stated the process put in place regarding the screening of staff members during the COVID-19 pandemic was successful. She indicated the QAPI meeting was held monthly, and QA activities and outcomes were on the agenda of every staff meeting. She indicated they prioritized opportunities for improvement and ongoing education and improvements would continue regarding infection control, competency training of staff, and food storage and sanitation.

Based on observations, record review and staff interviews, the facility failed to make repairs to the flat griddle for greater than 2 months which caused residents to not receive a planned meal since it was inoperable for 1 of 1 flat griddles. This affected all residents who expected grilled items according to the planned menu. Findings included: The menu provided titled Fall/Winter 2022-2023 Week 3 revealed the lunch on 11/16/22 was homemade vegetable soup, saltine crackers, grilled cheese sandwich, vegetable sticks, and chilled peaches. Review of a handwritten lunch menu posted at the nurses' station on 11/16/22 at 9:30 AM revealed a pimento cheese sandwich instead of grilled cheese sandwich. Observation of the lunch meal on 11/16/22 at 12:30 PM revealed a cold sandwich with pimento cheese was served instead of a grilled cheese sandwich. An interview was conducted with the Dietary Manager (DM) on 11/17/22 at 11:15 AM. The DM reported she served pimento cheese sandwiches on 11/16 because her flat griddle did not work. She stated she was not able to cook grilled cheese sandwiches for the whole facility, so she substituted with the pimento cheese sandwiches. She stated the flat griddle had been broken for a while and she told the previous Administrator about 2 months ago, but she had not informed the current Administrator who had been at the facility for about a month. An interview with the Administrator on 11/21/22 at 4:40 PM revealed that she was not made aware that the flat griddle was broken, and she would make sure to get it addressed. The Administrator added, she would have expected the Dietary Manager to inform her of any equipment that was not operable so that the menu could be served as planned.