**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Nurse Practitioner, Physician, Responsible Party, and staff interviews, the facility failed to notify the responsible party of a change in medication for 1 of 1 residents (Resident #85). Findings included: Resident #85 was admitted to the facility on [DATE]. Diagnoses included, in part, fracture of left femur, presence of left artificial hip joint, fall, and epilepsy. The Minimum Data Set admission assessment dated [DATE] revealed Resident #85 was moderately cognitively impaired and was coded as receiving scheduled pain medication and as needed pain medication. Resident #85's pain was assessed and noted to be frequent with difficulty sleeping at night and limited day to day activities. Pain described at severe. Resident #85 was coded as having major surgery prior to admission and required active skilled nursing care due to recent surgery. Resident #85 received 2 days of opioid medication during this assessment period. A review of the physician orders revealed Keppra (medication to treat seizures) 500 milligrams (mg) twice daily written on 07/10/23, Tramadol (an opioid pain medication) 50 mg one tablet every 6 hours as needed for pain written on 07/10/25 and discontinued on 07/25/23, Acetaminophen (pain relieving medication) 325 mg give 2 tablets every 6 hours as needed for pain written on 7/10/23 and changed to every 6 hours scheduled on 07/25/23. A review of a nursing progress note written on 07/25/23 at 7:25 AM written by Nurse #1 revealed nurse spoke with resident's responsible party (RP) in facility. RP expressed some concerns regarding orders she was not aware about. Writer apologized that RP was not notified and explained that in the future she would be notified of any new orders. A review of a provider note written by the previous Nurse Practitioner (NP) on 07/25/23 at 8:58 AM revealed, in part, reviewed resident's medications. Resident had a past medical history of subarachnoid hemorrhage (bleeding in the brain) from 04/19/23 with hospitalization, history of seizures, Dementia, and frequent falls. Current medications included Keppra (antiseizure medication) 500 mg twice daily, Tramadol 50 mg every 6 hours as needed for pain, Acetaminophen 650 mg every 6 hours as needed for pain. Current rehabilitation for left hip fracture surgery on 07/06/23. Tramadol and Keppra together have risk of lowering seizure threshold, increasing dizziness, drowsiness, confusion and decreasing motor coordination. Will discontinue Tramadol for these risks. The following medication changes have been ordered: discontinue Tramadol, change Acetaminophen 650 mg from every 6 hours as needed to three times daily for pain, and consider Oxycodone 2.5 mg three times daily as needed for pain if needed. Discussed plan with physician. Review of new physician orders written on 08/02/23 revealed an order for Oxycodone (an opioid pain medication) 5 mg give 0.5 mg tablet 4 times a day for pain. This order was discontinued on 08/07/23. A review of the medication administration record (MAR) revealed Resident #85 received Oxycodone 2.5 mg from 08/03/23 through 08/06/23 at a total of 14 doses. The MAR revealed the order was discontinued on 08/07/23. A nursing progress note written on 08/07/2023 at 12:56 PM revealed, in part, Nurse #1 spoke with RP regarding her concerns. Nurse discussed pain medication and told the RP that she would look into her concerns. A late entry nursing note written by Nurse #2 on 08/18/23 at 3:23 PM revealed, in part, that this nurse and Nurse #1 spoke to RP on 08/18/23 as a follow up call. Nurse #2 explained that after following up on why changes to resident's medication of oxycodone had been changed the following occurred: 1) Resident was given Tramadol by NP #1. NP #1 reviewed medications for resident's pain with the physician. Discussed seizure threshold of medications. Resident currently on Keppra so Tramadol was discontinued due to lowering seizure threshold on 07/25/23. Oxycodone 2.5 mg 4 times daily scheduled was ordered and nursing was to notify RP of changes. 3) Resident received Oxycodone 2.5mg from 08/03/23 through 08/06/23 for a total of 14 doses. 4) Nurse #2 discussed education was given to staff on notification communication. A phone interview with the Responsible Party on 04/09/24 at 11:59 AM revealed she was not notified the facility had ordered the Tramadol for Resident #85 until it was discontinued nor was she made aware that Oxycodone was started as a new order. The RP stated she was visiting the resident on 08/06/24 and observed the nurse administering the Oxycodone and questioned when the resident started receiving that medication. Interview with Nurse #2 on 04/10/24 at 1:50 PM revealed she recalled Resident #85 and remembered writing the note regarding the Tramadol and the Oxycodone orders. Nurse #2 stated normally whenever the NP put a new order in place, the NP would notify the family. She stated she did not know what happened and why the NP did not notify the family, but that it then initiated the facility to do a complete in-service with all nursing staff to make sure any new changes or orders were being communicated to the family by the nurse. A phone interview with Nurse #1 on 04/10/24 at 2:10 PM revealed she recalled the day the RP was inquiring about the Oxycodone and she stated she did not notify the family regarding the change of medication with the Tramadol or the Oxycodone because she thought the NP was notifying the family. An interview with the Physician on 04/10/24 at 4:10 PM revealed she would have expected the nursing staff to notify the family of the medication changes. The Physician stated notifying the family was not the sole responsibility of the NP when she initiated an order, but she knew that the NP would notify family at times. The Physician stated communication of who notified the family should be documented at the time of the notification to avoid confusion. A phone interview was conducted with the previous Nurse Practitioner (NP #1) on 04/11/24 at 5:10 PM. NP #1 stated she was not responsible for notifying the families of any medication changes. She stated it was the nursing staff's responsibility. An interview with the Director of Nursing on 04/11/24 at 5:30 PM revealed the expectation was that the nursing staff was to notify the RP of any medication changes. He stated after this incident occurred he did a full in service with all nursing staff to ensure they understood it was their responsibility to notify the family and document the notification in a nursing note. He did not complete a full plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, Physician Assistant and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication (a medication that affects brain activities associated with mental processes and behavior) was limited to 14 days or document the continued use with a rationale and duration for 1 of 5 residents (Resident #10) reviewed for unnecessary medications. Findings included: Resident #10 was admitted to the facility on [DATE]. Diagnoses included, in part, fracture of left humerus, metabolic encephalopathy, Parkinson's, and anxiety. A review of the physician orders written on 03/12/24 revealed an order for Alprazolam 0.5 milligrams (mg) one tablet every 8 hours as needed for anxiety. There was no stop date indicated on this order. The Minimum Data Set admission assessment dated [DATE] revealed Resident #10 was cognitively impaired and exhibited hallucinations and refusal of care. Resident #10 received antianxiety, antidepressants, anticoagulant (blood thinner) and opioids during this assessment. Review of the Pharmacy Consultants medication regimen review dated 03/13/24 indicated, in part, PRN psychotropic medications are limited to 14 days. If you would like to extend Alprazolam 0.5 mg one tablet every 8 hours PRN for anxiety past 14 days, please document a rationale and indicate a duration. This was reviewed and signed by the Physician Assistant dated 03/14/24 with a rationale stating, working to wean off Alprazolam and hopefully will only need this one 14 dose package. Review of March 2024 Medication Administration Record revealed Resident #10 received Alprazolam 0.5 milligrams daily from 03/16/24 through 03/31/24. Review of the April 2024 Medication Administration Record revealed Resident #10 received Alprazolam 0.5 milligrams daily from 04/01/24 through 04/10/24. An interview with the Physician Assistant on 04/11/24 at 4:15 PM revealed when she reviewed this recommendation from the pharmacist, she did not include the end date along with her rationale and should have. The Physician Assistant added, when the nurse's put orders in for a PRN psychotropic medication, they should be putting an end date. She stated nursing did not make her aware that she was taking this regularly and she would reevaluate to see if the resident needed this medication scheduled instead of as needed. An interview was conducted with Nurse #3 on 04/11/24 at 4:20 PM. Nurse #3 reported anytime a resident was on a PRN psychotropic medication it should have a stop date at 14 days. She stated she entered the order as it was listed on the hospital discharge summary and she forgot to the put the 14 day stop date on the order. An interview with the Director of Nursing (DON) on 04/11/24 at 5:30 PM revealed he would have expected the PRN stop date to be applied. The DON stated the monthly Pharmacy medication recommendations regarding as needed orders with stop dates were given directly to the Physician or the Physician Assistant for review. Once the Physician reviewed and signed the recommendation, he would implement the order. The DON stated his nursing staff were aware of the regulation to have a stop date for as needed psychotropic medications and should have identified this when transcribing the order and during their medication pass.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and the Physician Assistant interviews the facility failed to administer an as needed antihypertensive medication as prescribed by the physician for blood pressure greater than 150/90 millimeters of mercury (mm Hg) resulting in 3 missed doses. This occurred for 1 of 1 resident (Resident # 7) reviewed for medication administration. Findings included. Resident #7 was admitted to the facility on [DATE] with diagnoses including hypertension. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #7 was cognitively intact. She had no rejection of care. A care plan dated 03/21/24 for Resident #7 revealed to administer antihypertensive medications as ordered. A physicians order dated 03/22/24 for Resident #7 revealed Clonidine (antihypertensive) oral tablet 0.1 milligram. Give 1 tablet by mouth every 24 hours as needed for hypertension. Give if systolic blood pressure is greater than 150 mm Hg and diastolic blood pressure is greater than 90 mm Hg. Review of the progress notes for Resident #7 from 03/21/24 through 03/31/24 revealed a blood pressure reading recorded on 03/23/24 at 9:33 AM of 168/98 mm Hg. The progress note revealed no documentation that Clonidine 0.1 mg as needed for blood pressure greater than 150/90 was administered to Resident #7. Review of the Medication Administration Record (MAR) dated March 2024 for Resident #7 revealed Clonidine 0.1 mg as needed for blood pressure greater than 150/90 mm Hg was not administered to Resident #7 on 03/23/24. Further review of the Medication Administration Record (MAR) dated March 2024 for Resident #7 revealed blood pressure readings less than 150/90 and the as needed Clonidine 0.1 mg was not needed and was not administered. Review of the Medication Administration Record (MAR) dated April 2024 for Resident #7 revealed blood pressure readings greater than 150/90 on the following dates: 04/01/24 the blood pressure reading was 179/98 mm Hg. 04/09/24 the blood pressure reading was 155/95 mm Hg. Review of the Medication Administration Record (MAR) dated April 2024 for Resident #7 revealed no documentation that Clonidine 0.1mg as needed for blood pressure greater than 150/90 mm Hg was administered to Resident #7 on 04/01/24 or 04/09/24. Review of the progress notes for Resident #7 from 04/01/24 through 04/09/24 revealed no documentation that Clonidine 0.1 mg was administered. During an interview on 04/11/24 at 6:10 PM the Physician Assistant stated Resident #7 had orders for scheduled Clonidine 0.1 mg daily and an as needed dose was ordered to be given once every 24 hours if her blood pressure was greater than 150/90 mm Hg. She indicated Resident #7 should have received the as needed dose on the days her blood pressure was elevated above 150/90 mm Hg. She stated she evaluated Resident #7 today and she was at her baseline and her vital signs were stable. She stated Resident #7 did not have any adverse effects by not receiving the 3 missed doses of the medication. During an interview on 04/11/24 at 6:35 PM Nurse #7 stated he was the assigned Nurse for Resident #7 on 04/01/24. He stated he did not give the as needed dose of Clonidine to Resident #7 because he gave the 9:00 AM scheduled dose and didn't want to give her 2 doses. He indicated he was uncertain of when exactly the blood pressure reading was taken on 04/01/24. He indicated with an elevated blood pressure of 179/98 he should have clarified the order with the physician. During an interview on 04/11/24 at 7:33 PM Nurse #4 stated the vital signs recorded on 04/09/24 for Resident #7 were taken by another staff member. She stated when she documented the blood pressure reading of 155/95 for Resident #7, she did not think to look at her medications to detrmine if any as needed medications for increased blood pressure should be given. She stated she did not administer as needed Clonidine to Resident #7 on 04/09/24. Nurse #8 who was assigned to Resident #7 on 03/23/24 when the blood pressure reading was 168/98 was not available for an interview. During an interview on 04/11/24 at 6:47 PM the Director of Nursing stated Resident #7 should have received the Clonidine 0.1 mg as needed for increased blood pressure when the blood pressure was greater than 150/90 mm Hg. He stated that did not occur and education would be provided.

Based on observations, manufacturer's instructions, staff interviews and Consultant Pharmacist interviews, the facility failed to store an unopened bottle of eye drops in the refrigerator specified by the manufacturer's instructions for 1 of 3 medication carts and failed to record an opened date on two opened bottles of eye drops for 1 of 3 medications carts observed for medication storage. Findings included: 1. During an observation with Nurse #1 on medication cart #1 on 12/20/22 at 9:30 AM an unopened bottle of Travoprost Solution 0.004% eye drops was not refrigerated as indicated on the manufacturer's instructions which stated, store unopened bottle in refrigerator, once opened store at room temperature and discard remaining amount not used after 6 weeks. An interview was conducted with Nurse #1 on 12/20/22 at 9:38 AM. Nurse #1 confirmed the label indicated the unopened eye drop solution should be refrigerated. Nurse #1 reported she did not know the eye drop solution was supposed to be refrigerated until it was opened. A phone interview was conducted with the Consultant Pharmacist on 12/22/22 at 10:55 AM. The Consultant Pharmacist stated the manufacturer's instructions should always be followed to ensure the medication maintains its efficacy. An interview was conducted with the Director of Nursing (DON) on 12/22/22 at 3:00 PM. The DON reported she expected her nursing staff to be following the manufacturer's instructions and labels as it pertained to medications. 2. During an observation with Nurse #1 on medication cart #1 on 12/20/22 at 9:30 AM revealed 2 bottles of Latanoprost Solution 0.005% eye drops were noted to be opened with no opened date indicated. Review of the manufacturer's instructions revealed store unopened bottle in refrigerator, once opened store at room temperature and discard remaining amount not used after 6 weeks. An interview with Nurse #1 revealed after opening the Latanoprost bottles, they should have been labeled with the date they were opened. Nurse #1 added, she did not know the eye drops were only good for 6 weeks after opening. A phone interview was conducted with the Consultant Pharmacist on 12/22/22 at 10:55 AM. The Consultant Pharmacist stated the manufacturer's instructions should always be followed to ensure the medication maintains its efficacy. The Pharmacist added, the medication should be discarded after 6 weeks from opening and without the date recorded when it was opened, staff would not know when to discard the medication. An interview was conducted with the Director of Nursing (DON) on 12/22/22 at 3:00 PM. The DON reported she expected her nursing staff to be following the manufacturer's instructions and labels as it pertained to medications.

Based on observations and staff interviews the facility failed to remove expired food items stored for use in the walk-in refrigerator. This practice had the potential to affect the foods served to the residents. The findings included: Initial observation of the kitchen walk-in refrigerator occurred on 12/19/2022 at 10:15 AM with the Director of Dining Services and revealed a plastic container of mandarin oranges with a discard date of 12/14/2022. A follow-up observation of the kitchen walk-in refrigerator on 12/21/2022 at 11:25 AM revealed a plastic container of yellow sliced cheese with a discard date of 12/19/2022 and a plastic container of chocolate mousse with a discard date of 12/19/2022. An interview with the Chef was completed on 12/21/2022 at 11:25 AM. The Chef stated that the expired food items observed on 12/19/22 and 12/21/2022 should have been discarded. He further stated that all the Dining Services staff were responsible for removing expired food items from the walk-in refrigerator. An interview with the Administrator occurred on 12/21/2022 at 3:45 AM. The Administrator stated that she expected the Dining Services staff to follow safe food handling practices when labeling and storing food items.

Based on observations 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 of 10/8/2021. This was for 1 deficiency cited in the area of Food and Nutrition Services (F812). The continued failure during two 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: F 812: Based on observations and staff interviews the facility failed to remove expired food items stored for use in the walk-in refrigerator. This practice had the potential to affect the foods served to the residents. During the recertification and complaint survey completed 10/8/2021 the facility failed to maintain safe food temperatures for potentially hazardous foods. Hot foods should be maintained at a temperature of 135 degrees or higher and cold foods should be maintained at a temperature of 41 degrees or lower. A telephone interview was completed with the Administrator on 12/22/2022 at 09:31 AM. The Administrator stated that she didn't think the facility's QA program for the kitchen had failed. She further stated that the facility was previously cited for failing to maintain safe food temperatures and that was not an issue during the current survey. The Administrator indicated that the facility would focus on developing a QA specific for safe food handling and storage practices.

Based on observations and staff interviews the facility failed to: 1) maintain broccoli at 135 degrees Fahrenheit (F.) or higher on the lunch meal tray line, and 2) maintain chicken salad, at 41 (F.) or below on the lunch meal tray line. Both of these items could be potentially hazardous if not served at the appropriate temperatures. The findings include: 1. An observation of the lunch meal tray line on 10/04/21 at 12:15 PM revealed a large stainless-steel serving tray of broccoli on the serving line (with the warming tray's switch off). Temperature monitoring, by the Chef on 10/04/21 at 12:30 PM revealed the following temperatures: broccoli - 80 degrees F. and chicken salad 53 degrees F. During an interview with the Chef on 10/04/21/21 at 12:35 PM, he stated that he expected dietary staff to serve hot foods 135 degrees F. or higher, and cold foods 41 degrees F. or below. and if temperatures of hot food were below 135-degree F. or cold foods were higher than 41-degree F., the food items should be discarded or re-heated prior to serving. He visually confirmed that the warming switch for the broccoli was not turned on, which resulted in the broccoli cooling down on the tray line to 80 degrees F. He also stated the chicken salad should have been kept cool below 41 degrees F. just prior to serving and was not. During an interview with the cook in the satellite kitchen on 10/04/21 at 12:45 PM she revealed when she took the temperatures of the food being served from the kitchens' tray line, they had to have hot food temperatures 135 degrees F. or higher, and the cold foods needed to be 35 degrees F. or colder. [NAME] said the kitchen staff should have checked both the broccoli and the chicken salad's temperatures to ensure all hot food items were above 135 degrees F. and that all cold foods were below 41 degrees F. before serving them on the lunch tray line. During an interview with the Director of Dietary Services on 10/07/21 at 8:52 AM, he revealed hot food temperatures were required to be at least 135 degrees F., and cold food temperatures were required to be below 41 degrees F. when served from the tray line. During an interview with the Administrator and Director of Nursing (DON) on 10/07/21 at 4:30 PM, they both reported it was their expectation the facility's kitchens follow all regulatory guidelines for food and kitchen sanitation safety