Based on medical record review, observations, staff interviews, and policy review, the facility failed to ensure resident's medications were administered as ordered resulting in three medication errors out of 29 opportunities or a 10.3 percent (%) medication error rate. This affected one (#37) out of the two residents observed for medication administration. The facility census was 37. Findings include: Review of the medical record for Resident #37 revealed an admission date of 01/02/25 with medical diagnoses of left femur fracture, arthritis, hyperlipidemia, cerebrovascular disease, and dysphagia. Review of the medical record for Resident #37 revealed an admission Minimum Data Set (MDS) assessment, dated 01/08/25, which indicated Resident #37 had moderate cognitive impairment and was dependent for toilet hygiene, bathing, bed mobility, and transfers. Review of the medical record for Resident #37 revealed physician orders dated 01/03/25 for tamsulosin (Flomax) 0.4 milligram (mg) one tablet by mouth daily, aspirin-dipyridamole (Aggrenox- an antiplatelet) 12 hour 25-100 mg one tablet by mouth two times per day, and Colace 100 mg one tablet by mouth daily. Review of the physician orders revealed no documentation to support an order for aspirin 81 mg one tablet daily. Review of the medical record for Resident #37 revealed an April 2025 Medication Administration Record (MAR) which indicated staff administered Colace, tamsulosin, and aspirin-dipyridamole as ordered from 04/01/25 through 04/07/25. Review of the medical record for Resident #37 revealed a pharmacy recommendation, dated 03/28/25, which recommended discontinuation of Colace and tamsulosin. The pharmacy recommendation revealed documentation to support the physician agreed with the pharmacy recommendation and an order to discontinue the medications was signed on 03/31/25. Observation on 04/08/25 at 8:05 A.M. revealed Registered Nurse (RN) #114 prepared Resident #37's medications for administration. The observation revealed RN #114 prepared one Colace 100 mg tablet, one aspirin 81 mg tablet, and one tamsulosin 0.4 mg tablet for administration. The observation revealed RN #114 administered the Colace, aspirin, and tamsulosin tablets to Resident #37. Interview on 04/08/25 at 8:26 A.M. with RN #114 confirmed she administered aspirin 81 mg tablet to Resident #37 and not the aspirin-dipyridamole 25-100 mg tablet as ordered by physician. RN #114 also confirmed she also administered Colace and tamsulosin to Resident #37. Interview on 04/09/25 at 1:00 P.M. with Chief Clinical Officer (CCO) #112 confirmed Resident #37's pharmacy recommendation dated 03/28/25 indicated a recommendation to discontinue Colace and tamsulosin medications. The pharmacy recommendation revealed documentation the physician discontinued the orders for Colace and tamsulosin on 03/31/25. Interview with CCO #112 confirmed the medications were not discontinued and staff administered medications from 04/01/25 through 04/08/25. Review of the facility policy titled, Administering Oral Medications, revised October 2010 stated staff are to verify there is a physician's medication order, check label of the medication, and confirmed the medication name and dose with Medication Administration Record (MAR), check medication dose, and re-check to confirm proper dose. The deficiency was based on incidental findings discovered during the course of this complaint investigation.

Based on medical record reviews, observations, staff interviews, review of medication information from Medscape, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (#37) out of two residents reviewed for medication administration. The facility census was 37. Findings include: Review of the medical record for Resident #37 revealed an admission date of 01/02/25 with medical diagnoses of left femur fracture, arthritis, hyperlipidemia, cerebrovascular disease, and dysphagia. Review of the medical record for Resident #37 revealed an admission Minimum Data Set (MDS) assessment, dated 01/08/25, which indicated Resident #37 had moderate cognitive impairment and was dependent for toilet hygiene, bathing, bed mobility, and transfers. Review of the medical record for Resident #37 revealed a physician order dated 01/03/25 aspirin-dipyridamole (Aggrenox- an antiplatelet medication) 12 hour 25-100 milligram (mg) one tablet by mouth two times per day. Review of the physician orders revealed no documentation to support an order for aspirin 81 mg one tablet daily. Observation on 04/08/25 at 8:05 A.M. revealed Registered Nurse (RN) #114 prepared Resident #37's medications for administration. The observation revealed RN #114 prepared one aspirin 81 mg for administration and administered the aspirin tablet to Resident #37. Interview on 04/08/25 at 8:26 A.M. with RN #114 confirmed she administered aspirin 81 mg tablet to Resident #37 and not the aspirin-dipyridamole 25-100 mg tablet as ordered by physician. Review of the facility policy titled, Administering Oral Medications, revised October 2010 stated staff are to verify there is a physician's medication order, check label of the medication, and confirmed the medication name and dose with Medication Administration Record (MAR), check medication dose, and re-check to confirm proper dose. Review of medication information from Medscape at https://reference.medscape.com/drug/aggrenox-aspirin-dipyridamole-342148?_gl=1*19qd2zd*_gcl_au*MTEwNzM0NDc3OS4xNzQ0MjA5MDk3 revealed aspirin/dipyridamole is a antiplatelet medication used to treat stroke secondary prophylaxis of transient ischemic attack (TIA) or cerebrovascular accident (CVA). The deficiency was based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure resident code status was updated and correct in the medical electronic medical record. This affected one (Resident #26) of 15 sampled residents. The facility census was 39 residents. Findings include: Review of the medical record for Resident #26 revealed an admission date of 07/23/23 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and multiple myeloma. Review of physician's orders for Resident #26 revealed an order dated 08/28/23 for the resident's code status to be Do Not Resuscitate Comfort Care Arrest (DNRCCA). Review of the care plan for Resident #26 dated 07/17/24 revealed the resident wished her code status to be DNRCCA and wanted her advanced directives wishes to be known to staff. Review of the progress note for Resident #26 dated 12/18/24 and timed at 9:40 A.M. revealed the resident's oxygen levels were low and the physician had recommended the resident be sent to the hospital for an evaluation. Resident #26 did not want to go the hospital because she feared being put on a ventilator. The physician recommended the facility talk to resident about changing her code status to DRNRCC and consulting with hospice. Review of the progress note for Resident #26 dated 12/18/24 and timed at 2:15 P.M. revealed the certified nurse practitioner was notified of resident condition and signed for the resident's code status to be changed to Do Not Resuscitate Comfort Care (DNRCC.) Review of the hard chart medical record for Resident #26 revealed it included a code status form for the resident to be a DNRCC dated 12/19/24 and signed by Family Nurse Practitioner (FNP) #63. Review of the Minimum Data Set (MDS) assessment for Resident #26 dated 12/29/24 revealed the resident was cognitively intact and required staff assistance with activities of daily living (ADLs.) Interview on 01/28/25 at 2:27 P.M. with Resident #26 confirmed she wished to continue as a DNRCC due to her diagnosis of multiple myeloma. Resident #26 was concerned if chest compressions were done, her bones would break. Interview on 01/28/25 at 3:07 P.M. with the Director of Nursing (DON) confirmed Resident #26's code status was changed to DNRCC on 12/19/24, and that the resident's code status order had not been updated from DNRCCA. Review of the facility policy titled Communication of Code Status dated October 2022 revealed the nurse who notates the physician's order for an advanced directive/code status is responsible for ensuring the code status is updated correctly in all sections of the resident's medical record including the hard chart, the electronic medical record, and the physician's orders.

Based on medical record review, resident interview, and staff interview, the facility failed to communicate the last covered day of skilled services to residents. This affected one (Resident #190) of three residents reviewed for beneficiary notices. The facility census was 39 residents. Findings include: Review of the medical record for Resident #190 revealed an admission date of 01/16/25 with diagnoses of aftercare following joint replacement surgery, hypertension, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #190 dated 01/17/25 revealed the resident had moderate cognitive impairment. Review of the progress note for Resident #190 dated 01/21/25 timed at 8:47 A.M. revealed the resident was alert, oriented, able to make her own decisions, and was a very social person. Review of the Notice of Medicare Non-Coverage (NOMNC) for Resident #190 dated 01/24/25 revealed the resident's last covered day (LCD) was 01/26/25. admission Nurse (AN) #263 documented notification of the LCD to the resident's daughter by telephone on 01/24/25 at 4:30 P.M. Interview on 01/27/25 at 11:01 A.M. with Resident #190 confirmed concerns the facility did not provide her with a NOMNC nor did the facility communicate with her regarding her LCD of skilled services. Interview on 01/27/25 at 11:19 A.M. with AN #263 confirmed she did not provide a NOMNC to Resident #190 nor did she verbally communicate with the resident regarding the resident's LCD of skilled services. AN #263 confirmed the resident was alert and oriented. Review of progress note for Resident #190 dated 01/27/25 timed at 12:27 P.M. per AN #263 revealed the nurse met with the resident and apologized for not providing a copy of the NOMNC and verbal notification of the LCD to the resident. AN #263 then provided the resident with a copy of the NOMNC with a LCD of 01/26/25 and obtained the resident's signature. Interview on 01/30/25 at 3:00 P.M. with Chief Clinical Officer (CCO) #64 confirmed the facility did not a policy for notification of NOMNCs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #11 revealed an admission dated of 05/24/24 with diagnoses including cerebral vascular disease, anxiety, and dementia. Review of the progress note for Resident #11 dated 08/06/24 revealed the resident was transferred to the hospital after a fall. Review of the MDS for Resident #11 dated 01/22/24 revealed the resident was severely cognitively impaired. Review of the medical record for Resident #11 revealed it did not include a bed hold notice for the resident's hospital transfer on 08/06/24. Based on medical record review, staff interview, and review of the facility policy, the facility failed to provide bed hold notices to residents or their representatives when residents were transferred to the hospital. This affected three (Residents #2, #11 and #26) of three residents reviewed for hospitalizations. The facility census was 39 residents. Findings include: 1.Review of the medical record for Resident #2 revealed an admission date of 08/13/20 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertension, chronic kidney disease, vascular dementia, and epilepsy. Review of the Minimum Data Set (MDS) assessment for Resident #2 dated 01/15/25 revealed the resident was moderately cognitively impaired and required staff assistance with activities of daily living (ADLs.) Review of a progress note for Resident #2 dated 12/28/24 revealed the resident was sent to the hospital for evaluation and treatment. Review of the medical record for Resident #2 revealed it did not include a bed hold notice for the resident's transfer to the hospital on [DATE]. 3. Review of the medical record for Resident #26 revealed an admission date of 07/23/23 with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and multiple myeloma. Review of the progress note for Resident #26 dated 12/18/24 revealed the resident was sent to the hospital for evaluation and treatment of respiratory distress. Review of the MDS for Resident #26 dated 12/29/24 the revealed the resident was cognitively intact and required staff assistance with ADLs. Review of the medical record for Resident #26 revealed it did not include a bed hold notice for the resident's transfer to the hospital on [DATE]. Interview on 01/29/25 at 4:53 P.M. with Chief Clinical Officer (CCO) #64 confirmed the facility had not provided bed hold notices to Residents #2, #11, and #26 nor to the residents' representatives upon resident transfer to the hospital. Review of the facility policy titled Bed Hold Notice Upon Transfer policy dated October 2024 revealed at the time of transfer for hospitalization the facility would provide to the resident and/or their representative written notice specifying the duration of the bed hold policy and information explaining the return to the next available bed. Review of the facility policy titled Transfer and discharge date d October 2024 revealed the facility would provide a notice of the facility's bed hold policy to the resident and the resident's representative upon resident transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to complete a resident discharge summary including a recapitalization of the stay, a final summary of status and a post discharge plan. This affected one (Resident #39) of one residents reviewed for discharge. The facility census was 39 residents. Findings include: Review of the medical record for Resident #39 revealed an admission date of 11/25/24 with diagnoses including chronic kidney disease, sick sinus syndrome, hypertension, osteoarthritis, and traumatic subdural hemorrhage with a discharge date of 12/03/24. Review of the Minimum Data Set (MDS) assessment for Resident #39 dated 12/01/24 revealed the resident was severely cognitively impaired and required staff assistance with activities of daily living (ADLs). Review of the discharge MDS assessment for Resident #39 dated 12/03/24 revealed the resident discharged home. Review of the medical record for Resident #39 revealed it did not include a discharge summary. Interview on 01/30/25 at 11:15 A.M. with Licensed Practical Nurse (LPN) #74) confirmed the facility had not completed a discharge summary for Resident #39 who had discharged to home on [DATE]. Review of the facility policy titled Transfer and discharge date d October 2024 revealed members of the interdisciplinary team (IDT) should complete relevant sections of the discharge summary that included a recapitulation of the resident's stay that included diagnoses, course of illness and treatment and therapy, pertinent labs and consultation results, as well as a final summary of the resident's status. The discharge summary should also include reconciliation of all pre-discharge medications with the resident's post-discharge medications and a post discharge plan of care.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure residents had adequate supervision and use of appropriate assistive devices to prevent falls. This affected three (Residents #4, #11, and #21) of five residents reviewed for falls. The facility also failed to thoroughly investigate resident falls and implement interventions to prevent further falls. This affected one (Resident #34) of five residents reviewed for falls. The facility census was 39 residents. Findings include: 1.Review of the medical record for Resident #4 revealed an admission date of 10/04/24 with diagnoses including Parkinson's disease, vascular dementia, psychosis and anxiety. Review of the fall assessment for Resident #4 dated 01/19/25 revealed the resident at high risk for falls. Review of the care plan for Resident #4 dated 01/19/25 revealed the resident was at risk for falls and interventions included to not leave the resident alone in common areas. Review of the Minimum Date Set (MDS) assessment for Resident #4 dated 01/22/25 revealed the resident was severely cognitively impaired and required maximum staff assistance with ambulation. Observation on 01/28/25 at 10:19 A.M. revealed Resident #4 was sitting in his wheelchair in the dining room with no staff present. Interview on 01/28/25 at 10:20 A.M. with Licensed Practical Nurse (LPN) #271 confirmed Resident #4 had been left alone without supervision in the dining room and the resident should not be left alone due to his frequent falls. 2. Review of the medical record for Resident #11 revealed an admission date of 05/24/24 with diagnoses including cerebral vascular disease, anxiety, and dementia. Review of the fall risk assessment for Resident #11 dated 11/12/24 revealed the resident was at high risk for falls. Review of the care plan for Resident #11 dated 11/14/24 revealed the resident was at risk for falls with an intervention to ensure the resident had on proper footwear, either shoes and socks or nonskid socks. Review of the MDS assessment for Resident #11 dated 01/22/25 revealed the resident was severely cognitively impaired and required maximum assistance with standing. Observations of Resident #11 throughout the morning of 01/29/25 revealed the resident was anxious and at times trying to stand without assistance. Resident #11 was wearing regular socks, instead of shoes and socks or non-skid socks as per the resident's care plan. Interview on 01/29/25 at 2:25 P.M. with LPN #27 confirmed Resident #11 was wearing regular socks but should be wearing shoes and socks or nonskid socks due to the resident's high risk for falls. 4. Review of the medical record for Resident #34 revealed an admission date of 07/27/23 with diagnoses including hemiplegia and hemiparesis following cerebral infarction, hypertension, metabolic encephalopathy, malignant neoplasm of bladder, anxiety disorder, major depressive disorder, and epilepsy. Review of the MDS assessment for Resident #34 dated 11/25/24 revealed the resident was moderately cognitively impaired and required staff assistance with activities of daily living (ADLs). Review of the care plan for Resident #34 dated 01/26/25 revealed the resident was at risk for falls due to impaired cognition and safety awareness, impaired mobility, and poor balance and weakness secondary to a recent stroke with left hemiplegia. Interventions included the following: fall mats, bed in low position, bolster mattress, frequent safety checks. Review of the progress note for Resident #34 dated 12/27/24 revealed the resident raised his bed to the high position. The nurse went in and put the bed lower to floor and repositioned the resident in bed. Five minutes later Resident #34 was yelling out he needed help. When the nurse entered the room the resident was found on the floor and it was noted the resident had raised his bed back up to the high position. Review of the fall investigation for Resident #34 dated 12/27/24 revealed the nurse observed the resident had raised his bed to the high position and she lowered it. A few minutes later Resident #34 called out, and he had raised the bed back up to a high position and had fallen out. The resident was sent to the hospital for an evaluation because he hit his head and was on a blood thinner, Eliquis. Resident #34 was admitted to the hospital after a scan of the resident's head showed a small right sided hematoma. The investigation did not include any interventions or measures to be implemented in order to prevent further falls. Interview on 01/30/25 at 12:21 P.M. with the DON confirmed a new intervention had not been implemented nor added to the care plan for Resident #34 following the resident's fall on 12/27/24. Review of the facility policy titled Incidents and Accidents revised October 2022 revealed the facility should assure appropriate and immediate interventions were implemented and corrective action taken to prevent further occurrences. 3.Review of the medical record for Resident #21 revealed an admission date of 03/17/23 with diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, and malignant neoplasm of the brain. Review of the MDS assessment for Resident #21 dated 12/21/24 revealed the resident was cognitively intact and required substantial staff assistance for bed mobility and transfers and was dependent on staff for wheel chair mobility. Review of the care plan for Resident #21 dated 03/18/23 revealed the resident was at risk for falls related to poor safety awareness and generalized weakness. Interventions included staff should assist the resident with ambulation and transfers using therapy recommendations. The resident's care plan was updated on 12/25/24 to include the intervention of use of a gait belt for all resident transfers. Review of the progress note for Resident #21 dated 12/25/24 timed at 8:16 A.M. revealed the aide reported lowering the resident down to the floor in front of the recliner in the resident room while assisting with transferring the resident. The aide stated Resident #21's knees got wobbly when assisting the resident to stand and pivot from the wheelchair to the recliner. Interview on 01/30/25 at 12:34 P.M. with the Director of Nursing (DON) confirmed the intervention added to Resident #21's care plan on 12/25/24 to ensure gait belt use with all transfers was not an appropriate intervention since that was supposed to be the standard practice for all residents who need assistance with transfers and ambulation. The facility policy was to use a gait belt with residents that could not independently ambulate or transfer. Interview confirmed the aide had not used a gait belt when assisting with the transfer for Resident #21 on 12/25/24 which resulted in a fall for the resident. Review of the facility policy titled Use of Gait Belt dated January 2018 revealed the facility staff should use gait belts with residents that could not independently ambulate or transfer for the purpose of safety.

Based on record review, observations, staff interviews, review of guidelines from Centers for Disease Control and Prevention (CDC) and policy review, the facility failed to implement infection control policies and guidelines to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 37 residents residing in the facility. Facility census was 37. Findings include: 1. Observation on 12/06/23 at 9:54 A.M. revealed State Tested Nursing Assistant (STNA) #10 was outside of Resident #34's room. Resident #34's door was noted to have a sign taped to it for droplet precautions and a three-drawer cart just outside the door. STNA #10 was observed wearing a surgical mask and no eye protection. STNA #10 was observed donning a gown and gloves prior to entering Resident #34's room. Interview on 12/06/23 at 9:56 A.M. with STNA #10 revealed she did not know where the eye protection was prior to entering Resident #34's room. STNA #10 checked the four carts on the hall and none contained eye protection. Interview on 12/06/23 at 10:12 A.M. with Registered Nurse (RN) #12 revealed she was unable to find eye protection during her shift. RN #12 shared she did not have an issue finding other Personal Protective Equipment (PPE) but added there were yellow gowns hanging on the inside of isolation room doors for staff to re-use. Interview on 12/06/23 at 10:14 A.M. with STNA #13 revealed she had purchased her own eye protection. STNA #13 acknowledged isolation rooms did have yellow isolation gowns hanging on the inside of the doors for staff to re-use. STNA #13 shared she did not use them as they were left from previous shift. Observation of Resident #44's room, revealed a sign taped on the front for droplet isolation and a three-drawer cart to the left of it, revealed two yellow isolation gowns were hanging on hooks on the back of the door. During the interview, STNA #13 was observed to be wearing a KN-95 mask. STNA #35 verified she wore that style of mask because it was more comfortable and stated it was available in the top drawer of the cart outside of Resident #44's room. Observation was made of one additional KN-95 mask in the drawer indicated. STNA #13 verified those were the style of masks she used for her shifts, including for the care of COVID-19 residents. Interview on 12/06/23 at 10:16 A.M. with STNA #14 revealed there was no eye protection available on her hall and she was trying to find some to care for COVID-19 positive residents. Interview on 12/06/23 at 10:28 with STNA #15 verified she did wear a surgical mask and no eye protection while providing care for Resident #34, who was positive for COVID-19. STNA #15 stated she looked for eye protection, but was unable to find any. Observation and interview on 12/06/23 at 10:48 A.M. with Chief Clinic Officer (CCO) revealed two yellow isolation gowns hanging on the inside of Resident #15's room. The CCO acknowledged it was an isolation room and there should not be gowns hanging on the inside of the door. The CCO verified proper procedure was for one time use and gowns would either be disposed of or laundered. Observation was also made of a box of KN-95 masks in the top drawer of a three-drawer isolation cart in front of Resident #20's room, which the CCO verified as an isolation room which required an N-95 mask. CCO confirmed the facility had N-95 masks available. Observation on 12/06/23 at 10:54 A.M. was made of Maintenance Assistant (MA) #17 stocking isolation carts on hall #2. Interview with MA #17 revealed he was stocking the COVID-19 isolation carts with N-95 masks, surgical masks and face shields. MA #17 stated he was unsure whose responsibility it was to stock the carts, but he was asked today by the manager to do so. Observation on 12/06/23 at 10:54 A.M. was made of Maintenance Manager (MM) #9 stocking isolation carts on hall #2. Interview at 10:59 A.M. with MM #9 revealed the carts had KN-95's and he was stocking them with N-95's as well as other needed PPE. Observation and interview on 12/07/23 at 8:32 A.M. with STNA #14 revealed the staff was exiting Resident #22's room. Resident #22 had a droplet isolation sign taped to an isolation cart outside the door. STNA #14 was observed wearing a KN-95 mask. STNA #14 verified she did not remove the mask after providing care to Resident #22 who is a COVID-positive resident. STNA #14 also confirmed she was wearing a KN-95 and not a N-95 in Resident #22's room. Review of CDC guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed health care providers (HCP) who enter the room of a patient with suspected or confirmed COVID-19 or SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N-95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Doffing (taking off) of PPE revealed HCP should remove gloves, gown prior to exiting the room, perform hand hygiene, remove face shield and remove and discard respirator. 2. Interview on 12/07/23 at 8:31 A.M. with Housekeeper #19 revealed she worked full time at the facility. Housekeeper #19 shared she was informed by her manager housekeepers were not responsible for cleaning the COVID-19 isolation rooms, and the STNA's would clean them. Interview on 12/07/23 at 10:04 A.M. with Housekeeper #20 revealed she worked full time at the facility. Housekeeper #20 shared she was informed by her manager housekeepers were not responsible for cleaning the COVID-19 isolation rooms, and the STNA's would clean them. Interview on 12/07/23 at 10:09 A.M. with STNA #21 revealed it was the responsibility of housekeepers to clean the COVID-19 rooms, she denied knowledge the STNA's were cleaning those rooms. Interview on 12/07/23 at 12:25 P.M. with STNA #22 revealed it was the responsibility of housekeepers to clean the COVID-19 rooms, she denied knowledge the STNA's were cleaning those rooms. Interview on 12/07/23 at 12:29 P.M. with the CCO revealed it was the responsibility of housekeepers to clean the COVID-19 rooms. Interview on 12/07/23 at 1:56 P.M. with the Environmental Services Manager (ESM) #9 revealed they had done room documentation cleaning sheets in the past but did not have any recent documentation available. ESM #9 denied knowledge housekeepers had not been cleaning COVID-19 rooms. A second interview at 2:04 P.M. with ESM #9 revealed he had spoken to the Housekeeping Manager (HM) #24 regarding the cleaning of COVID-19 positive rooms. ESM #9 further stated the HM #24 informed him that she had stayed until 4:00 P.M. to 4:30 P.M. after day shift had left, and cleaned the COVID-19 rooms. Interview on 12/07/23 at 2:08 P.M. with HM #24 alleged she cleaned the COVID-19 rooms daily herself. HM #24 shared that she worked Monday through Friday and admitted she did not clean the rooms on the weekends. HM #24 shared she had informed the STNA's her housekeepers would not clean the COVID-19 rooms, and it would be their responsibility. HM #24 acknowledged she was not directed by anyone at the facility, and she made the decision herself, and added she did not want her staff exposed to COVID-19. HM #24 also acknowledged any agency staff working on the weekend would not be aware housekeeping had become their responsibility. HM #24 stated the STNA's were aware where the cleaning supplies were located but did not provide any further instruction for them for properly disinfecting the COVID-19 rooms. Review of the facility policy Routine Cleaning and Disinfection last revised 05/2020 revealed to clean prior to disinfection as recommended by the manufacturer; the disinfection solution would be prepared fresh daily; manufacturer's recommendation for proper contact time to ensure adequate disinfection. 3. Review of medical record for Resident #23 revealed admission date of 09/08/23. Diagnoses included but were not limited to duodenal ulcer hemorrhage, cystitis, and Alzheimer's Disease. Resident#23 tested positive for COVID on 11/29/23. Review of physician orders revealed an 11/30/23 order for droplet isolation order for COVID-19 for 10 days. Review of medical record for Resident #36 revealed admission date of 08/11/22. Diagnoses included but were not limited to ataxia following stroke and anxiety. Resident #36 had no documented positive COVID-19 result. Further record review revealed Resident #23 and #36 shared a room at the time of the survey. Review of medical record for Resident #34 revealed admission date of 11/1/22. Diagnoses included but were not limited to type two diabetes mellitus, and depression. Resident #34 tested positive for COVID-19 on 11/30/23. Review of physician orders revealed an 11/30/23 order for droplet isolation order for COVID-19 for 10 days. Review of medical record for Resident #27 revealed admission date of 09/10/22. Diagnoses included but were not limited to stroke, and congestive heart failure. Resident #27 had no documented positive COVID-19 result. Further record review revealed Resident #34 and #27 shared a room at the time of the survey. Review of medical record for Resident #40 revealed admission date of 04/26/23. Diagnoses included but were not limited to stroke and depression. Resident #40 tested positive for COVID-19 on 12/02/23. Review of physician orders revealed an 12/02/23 order for droplet isolation order for COVID-19 for 10 days. Review of medical record for Resident #15 revealed admission date of 05/06/22. Diagnoses included but were not limited to hypertensive heart disease. Resident #15 had no documented positive COVID-19 result. Further record review revealed Resident #40 and #15 shared a room at the time of the survey. Review of medical record for Resident #22 revealed admission date of 08/11/23. Diagnoses included but were not limited to hemiparesis due to stroke and diabetes mellitus type two. Resident #22 tested positive for COVID-19 on 12/03/23. Review of medical record for Resident #18 revealed admission date of 01/15/21. Diagnoses included but were not limited to muscular dystrophy. Resident #18 had no positive COVID-19 result. Further record review revealed Resident #22 and #18 shared a room at the time of the survey. Review of medical record for Resident #20 revealed admission date of 07/27/23. Diagnoses included but were not limited to COPD and anxiety. Resident #20 tested positive for COVID-19 on 12/04/23. Review of progress notes dated 12/04/23 revealed the physician was notified of positive COVID-19 result and an order was received for droplet isolation. Review of medical record for Resident #33 revealed admission date of 12/30/22. Diagnoses included but were not limited to Parkinson's disease and dementia. Resident #33 had no positive COVID-19 result. Further record review revealed Resident #20 and #33 shared a room at the time of the survey. Record review of the facility provided positive COVID-19 residents and facility census revealed room changes had not been implemented after a positive COVID-19 result. On 12/06/23 at 12:12 P.M. the CCO and Director of Nursing (DON) were asked if they had COVID positive and negative residents in the same room. The CCO answered, we might. At 2:02 P.M. the CCO confirmed there had been COVID positive residents in with negative residents. The residents were separated, and the CCO was unable to provide a reason for the cohabitation and stated, they should have been moved. On 12/06/23 at 4:11 P.M. the DON reported all residents were tested for COVID-19 and there were no positive results. Review of CDC guidelines titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed it is recommended for a patient with suspected or confirmed COVID-19 infection to be in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only residents with the same respiratory pathogen should be housed in the same room. This deficiency represents non-compliance investigated under Complaint Number OH00148835.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and review of facility policy, the facility failed to ensure staff assessed a resident's wound in a timely manner, delaying treatment. This affected one (Resident #35) of three residents reviewed for wound assessments. The facility census was 34. Findings included: Review of the discharged medical record for Resident #35 revealed an admission date of 05/19/23. Diagnoses included difficulty with walking and muscle weakness. The resident was discharged to home on [DATE]. Review of the Minimum Data Set (MDS) assessment date 05/26/23 revealed Resident #35 was cognitively impaired. Resident #35 required extensive two person assistance with bed mobility and transfers. The resident was at risk for pressure ulcers, however the assessment indicated the resident did not have an active pressure ulcer. Review of Resident #35's most recent care plan revealed the resident had actual skin impairment to his bilateral buttock related to a Deep Tissue Injury (DTI). Interventions included: encourage good nutrition, follow protocols for treatment of injury and resident needs, and pressure reduction cushion to protect skin while up in chair. Review of shower sheets from 05/26/23 to 05/30/23 revealed nurse aides noted Resident #35 had reddened area to bottom with an open area. Review of the skin sweep completed on 05/29/23 revealed Resident #35 had intact skin. Review of the progress note dated 05/31/23 revealed Resident #35 had a pressure area to the coccyx. The wound nurse would see the resident during next rounds. An order was placed for turning and repositioning every shift and an air mattress was ordered. The resident was incontinent of stool multiple times per day due to lactulose use for increased ammonia. The lactulose was decreased. Review of the wound assessment dated [DATE] revealed Resident #35 had an unstageable DTI to the coccyx measuring 10.8 centimeters (cm) by 11 cm. Nursing staff reported the wound developed quickly due to the resident's poor nutritional intake. The following treatment was initiated: clean, pat dry, apply Medi honey alignate and foam dressing every day and as needed. On 06/05/23, the wound measured 8 cm by 9 cm. The wound was healing and no changes to the treatment were made. Review of the falsification of documentation investigation revealed on 05/29/23, Registered Nurse (RN) #400 completed a skin sweep document for Resident #30, stating the resident's skin was intact. RN #400 admitted to the Director of Nursing (DON) she did not complete an actual skin assessment for Resident #30. Further investigation verified nurse aides reported the resident's wound on shower sheets on 05/26/23 and 05/30/23 and verbally notified RN #400. Interview on 07/19/23 at 2:30 P.M. with the Administrator revealed RN #400 admitted she did not perform a skin assessment for Resident #35 on 05/29/23, as indicated on the skin sweep document. Interviews with nurse aides revealed they informed RN #400 Resident #35 had a reddened area and open wound. The Administrator further verified the resident's treatment was delayed due to RN #400 not properly assessing the resident. Interview on 08/01/23 at 9:30 A.M. with State Tested Nurse Aide (STNA) #202 verified she initially noticed Resident #35's buttocks were red and notified RN #400, who did not look at the resident, but advised STNA #202 to start applying zinc. A few days later when STNA #202 showered Resident #35 again, she noticed the resident's buttock was bloody and choppy looking, which was reported to a nurse. STNA #202 further reported Resident #35 was having frequent loose stools during this time and was resistive to care needs. Resident #35 did not turn himself in bed, but did scoot up and down in the bed. Resident #35 rarely let staff turn and reposition him, or use pillows and just wanted to return home with his son. Once the resident developed the wound, he was more willing to allow staff to reposition him. Interview on 08/01/23 at 10:43 A.M. with the Medical Director (MD) revealed Resident #35's pressure area was unavoidable due to many comorbidities such as diabetes, Urinary Tract Infection (UTI) with Methicillin-resistant Staphylococcus aureus (MRSA), pneumonia with antibiotic use, and use of lactulose, which increased chances of diarrhea. The MD further reported Resident #35 had decreased mobility and required two staff assistance with transfers using a Hoyer life. Prior to the development of the pressure ulcer, the facility was unable to get an air mattress. Review of the policy titled, Pressure Ulcer Injury Risk Assessment, dated 03/20 revealed staff would complete a comprehensive skin assessment and document findings on a facility approved skin assessment tool. This deficiency represents non-compliance investigated under Complaint Number OH00143584.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of a personnel file, and review of facility policy, the facility failed to ensure staff did not falsify medical records. This affected one (Resident #35) of three residents reviewed for falsifying medical records. The facility census was 34. Findings included: Review of the discharged medical record for Resident #35 revealed an admission date of 05/19/23. Diagnoses included difficulty with walking and muscle weakness. The resident was discharged to home on [DATE]. Review of the Minimum Data Set (MDS) assessment date 05/26/23 revealed Resident #35 was cognitively impaired. Resident #35 required extensive two person assistance with bed mobility and transfers. The resident was at risk for pressure ulcers, however the assessment indicated the resident did not have an active pressure ulcer. Review of Resident #35's most recent care plan revealed the resident had actual skin impairment to his bilateral buttock related to a Deep Tissue Injury (DTI). Interventions included: encourage good nutrition, follow protocols for treatment of injury and resident needs, and pressure reduction cushion to protect skin while up in chair. Review of shower sheets from 05/26/23 to 05/30/23 revealed nurse aides noted Resident #35 had reddened area to bottom with an open area. Review of the skin sweep completed on 05/29/23 revealed Resident #35 had intact skin. Review of the progress note dated 05/31/23 revealed Resident #35 had a pressure area to the coccyx. Review of the wound assessment dated [DATE] revealed Resident #35 had an unstageable DTI to the coccyx. Review of the falsification of documentation investigation revealed on 05/29/23, Registered Nurse (RN) #400 completed a skin sweep document for Resident #30, stating the resident's skin was intact. RN #400 admitted to the Director of Nursing (DON) she did not complete an actual skin assessment for Resident #30. Interview on 07/19/23 at 2:30 P.M. with the Administrator revealed RN #400 admitted she did not perform a skin assessment for Resident #35 on 05/29/23, as indicated on the skin sweep document. Interviews with nurse aides revealed they informed RN #400 Resident #35 had a reddened area and open wound. The Administrator further verified the resident's treatment was delayed due to RN #400 not properly assessing the resident. Interview on 08/01/23 at 9:30 A.M. with State Tested Nurse Aide (STNA) #202 verified she initially noticed Resident #35's buttocks were red and notified RN #400, who did not look at the resident, but advised STNA #202 to start applying zinc. Review of RN #400's personnel file revealed discipline on file related to falsifying records. RN #400 was terminated on 06/01/23 due to falsifying records. Review of the policy, Charting and Documentation, dated 07/17 revealed all services provided to the resident, or any changes in the resident's medical condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective, completed, and accurate. This deficiency represents non-compliance investigated under Complaint Number OH00143584.

Based on record reviews, staff interviews and policy review, the facility failed to ensure resident funds were maintained in an interest-bearing account. This affected two (#6 and #27) of two resident reviewed for resident funds. Facility census was 32. Findings include Review of Resident #6's personal fund account revealed a current balance of $37.16. Review of Resident #27's personal fund account revealed a current balance of 164.03. Review of the Resident #6 and #27's personal fund statements revealed no interest has been given since prior to January 2021. Interview on 03/29/22 at 2:15 P.M., with Human Resource (HR) Manager #109 revealed the facility has one Medicaid resident with a fund account. HR Manager #109 revealed Resident #6 has not received interest in several years likely due to having so little in her account (typically $30-$60 dollars). HR Manager #109 revealed the bank has not been giving interest for any accounts, so no interest money has been dispersed to any of the residents. HR Manager #109 revealed she had never asked the bank about the interest or lack of interest. Interview on 03/29/22 at 4:55 P.M., with HR Manager #109 revealed she contacted the bank on 03/29/22 and was informed the bank sent a letter on 12/31/20 stating the bank was making changes to the account and only accounts with balances over $5000 would be given interest at a rate of 0.03%. HR Manager #109 revealed she was unaware of this change but revealed, this would make sense why the resident has not obtained any interest in 2021 or 2022. Review of the policy titled Personal Needs Allowance Account Policy, dated 2020, revealed the facility residents will receive credit for all earned interest.

Based on resident record review and staff interview, the facility failed to ensure a resident's code status documented in the electronic health record (EHR) matched the hard paper chart. This affected one (#11) of 16 resident reviewed for accuracy of the code status. The census was 32. Findings include: Review of Resident #11's medical record revealed an admission date of 04/12/21, with diagnoses including: hypertension, muscle weakness, and chronic obstructive pulmonary disease. Review of the paper document titled DNR Order Form signature date 10/18/21, revealed Resident #11's code status was do not resuscitate (DNR) comfort care (CC). Review of the electronic health record (EHR) for Resident #11 revealed the resident's code status was documented as full code. Interview on 03/29/22 at 2:07 P.M., with the Director of Nursing (DON) verified the EHR code status for Resident #11 was full code and the hard chart was DNRCC. The DON verified the code status documented in the EHR and hard chart did no match.

Based on observations, record reviews, family member and staff interviews, review of policy, the facility failed to maintain a clean homelike environment. This affected two (#5 and #11) of two residents reviewed for homelike environment. Facility census was 32. Findings include 1. Review of Resident #5's medical record revealed an admission date of 07/07/19, with diagnoses including: fracture of left femur, dementia with behaviors, hip replacement, muscle weakness, heart failure, kidney disease, chronic pain, and depression. Observation on 03/28/22 at 9:57 A.M., revealed Resident #5's bathroom was dirty. The toilet seat was observed with a dark colored substance smeared on the toilet seat. The toilet bowl had a splattered black mold- like substance on it. Interview on 03/28/22 at 2:25 P.M., with Resident #5's family member revealed concerns about the cleanliness of resident's bathroom. Observations on 03/29/22 at 9:40 A.M. and 3:00 P.M., revealed the resident's toilet remained dirty with the mold-like splattering inside the toilet bowel and a smeared substance on the toilet seat. Observation 03/30/22 at 10:52 A.M., revealed the resident's toilet seat and toilet bowl were dirty with a smear on the seat and a mold-like substance in the bowl. Observation on 03/30/22 at 12:03 P.M., revealed the housekeeping staff and a trainee went into resident's room for cleaning. The staff had entered the bathroom and mopped the floor of the bedroom. Housekeeping staff finished cleaning at 12:09 P.M. Observation on 03/03/22 at 12:12 P.M., revealed the resident's bathroom was not thoroughly cleaned. Resident #5's toilet still had a dark substance smeared on the toilet seat and a mold-like substance in the toilet bowl. Interview on 03/03/22 at 12:20 P.M., with Housekeeper #96 stated he did not use the brush, only sprayed a cleaning solution into the bowl and the staff member working with her was in training. Housekeeper #96 confirmed the appearance of the toilet. 2. Review of Resident #11's medical record revealed an admission date of 04/12/21, with diagnoses including: encephalopathy, fracture of the left femur, fluid overload, generalized weakness, syncope, anxiety and depression. Observation 03/28/22 at 8:39 A.M., revealed Resident #11's room had food on the carpeting under and around bed. Observation 03/29/22 at 9:43 A.M. and 3:05 P.M., revealed Resident #11's room had large and small crumbs and chunks of food covering resident's carpet. Interview on 03/29/22 at 4:00 P.M., with the Director of Environmental Services (DES) #105 revealed housekeeping and laundry services are completed by four staff that typically work six to eight-hour shifts. Review of the housekeeping and laundry staff schedule revealed one of the four staff was not listed as having any shifts. The schedule contained several days with either a housekeeper or laundry staff and some days facility did not have both scheduled. Observation on 03/30/22 at 10:46 A.M., of housekeeping staff observed vacuuming the hallway outside of Resident #11's room. At 10:49 A.M., large crumbs of food were observed under resident's bed were observed. Interview on 03/30/22 at 11:10 A.M., with Housekeeper #96 revealed facility has been short staffed for laundry and housekeeping services. She revealed resident rooms should be cleaned daily including floors and bathrooms even for residents that do not use their bathrooms. Housekeeper #96 revealed they have finished cleaning all rooms in Resident #11's hallway. Interview on 03/30/22 at 11:16 A.M., with Register Nurse (RN) #73 revealed housekeeping staffing has been low lately. Interview on 03/03/22 at 12:20 P.M., with Housekeeper #96 confirmed the large crumbs under Resident #11's bed. She revealed she will need to get a hose vacuum to clean that area after confirming she had completed cleaning that entire hallway. Review of the policy titled Housekeeping Procedures, dated 02/19/07, revealed the resident rooms are to be swept and cleaned under furniture every two weeks, carpeted floor should be vacuumed every day. The policy also states resident bathroom floor are to be mopped daily and toilets should be cleaned daily from top to bottom and inside the bowl and also clean both sides of the toilet seat every day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to provide assistance with activities of daily living (ADL) care to dependent residents. This affected two (#5 and #10) of two residents reviewed for assistance with ADL care. Facility census was 32. Findings include 1. Review of Resident #5's medical record revealed an admission date of 07/07/19, with diagnoses including: fracture of left femur, dementia with behaviors, hip replacement, muscle weakness, heart failure, kidney disease, chronic pain, and depression. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 had significant cognitive impairment and required extensive assistance of one to two staff members for transfers and mobility and was totally dependent for transfers, and extensive assist of one staff for personal hygiene. Review of shower sheets for Resident #5 revealed showers were provided on 03/19/22, 03/26/22, and 03/29/22. No other shower sheets were available for the entirety of March 2022. Review of bathing documentation for Resident #5 from March 2022 revealed no baths were documented. All baths were marked as activity did not occur. Interview on 03/31/22 at 10:10 A.M., with Licensed Practical Nurse (LPN) #61 revealed the facility had two nurses and 3 State Tested Nurse Aide (STNA) 's scheduled. LPN #61 revealed the facility was trying to get a consistent shower aide as showers had been getting missed. LPN #61 revealed recently residents have been given bed baths instead of showers due to staffing. LPN #61 revealed facility staff complete paper shower sheets which are entered in a shower binder. LPN #61 confirmed several sheets were missing or unaccounted for but could not confirm if the showers had been given. Interview on 03/31/22 at 10:18 A.M., with STNA #58 revealed the section in the Activities of Daily Living (ADL) documentation labeled hygiene would include brushing teeth, brushing hair, and wiping their under arms and the bathing section includes tub baths and bed baths. Interview on 03/31/22 at 10:29 A.M., with STNA #132 revealed Resident #5 missed several showers earlier in the month of March and her and another STNA noticed Resident #5 looked dirty and unkempt and her hair was looking bad. So the STNA gave resident a bath on Saturday 03/19/22, which was not her shower day. Resident revealed the facility used to have a bath aide which helped get all the baths done timely, but they no longer have this position consistently filled. 2. Review of Resident #10's medical record revealed an admission date of 01/06/21, with diagnoses including: muscle weakness, hypo-osmolality, weakness, difficulty in walking, lack of coordination, syncope, dementia with behaviors, diabetes type two, and sepsis. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact and required limited assistance of one staff member for transfers and extensive assist of one staff for personal hygiene. Review of the plan of care revealed Resident #19 had an ADL self-care deficit with interventions to allow sufficient time for care, encourage resident to participate to the best of her abilities, and monitor for changes in grooming abilities. Review of ADL documentation for Resident #10 from March 2022 revealed hygiene was documented almost daily. Shaving and nail care were not specifically documented. Observation on 03/28/22 at 10:11 A.M., of Resident #10 revealed she had several inches long whiskers on her lip and chin. Interview on 03/28/22 at 10:11 A.M., with Resident #10 revealed staff help her with grooming including shaving and trimming of her nails. Observation on 03/29/22 at 12:10 P.M., of Resident #10 revealed she still had long whiskers on her lip and chin and her nails were long and had not been cut for some time. Interview on 03/29/22 at 12:10 P.M., with Resident #10 revealed she preferred her nails to be short. Resident #10 revealed she has asked staff to trim her nails and they say they will come back and never do. Resident #10 revealed the famous saying here was I forgot. Staff would tell her they will return and when she asked staff why they never returned for care they said, I forgot. Observation on 03/30/22 at 10:55 A.M., of Resident #10 revealed several long facial hairs and long fingernails. Interview at the observation revealed Resident #10 stated the facility staff are supposed to cut her nails and they are much longer than she likes. Interview on 03/30/22 at 11:16 A.M., with Registered Nurse (RN) #73 revealed facility staffing has improved in recent weeks and she feels that all care can get done but some days are better than others. RN #73 stated each hall today has one nurse and two STNA's scheduled which is very manageable. RN #73 revealed she has heard residents make complaints about staffing especially in the STNA role and revealed they had been behind on showers and ADL care. RN #73 revealed that shaving and nail care should be done on shower days. Observation on 03/31/22 at 9:40 A.M., revealed Resident #10 continued to have long facial hairs and long nails. Interview on 03/31/22 at 10:10 A.M., with LPN #61 revealed not previously noticing Resident #10's long nails but had noticed long hairs on her chin. LPN #61 revealed being unsure if aides had offered to assist Resident #10 with this care but denied he has offered to assist the resident with this care. Interview on 03/31/22 at 10:18 A.M., with STNA #58 revealed the section in the ADL documentation labeled hygiene would include brushing teeth, brushing hair, and wiping their under arms. STNA denied this would include shaving and nail care as those have their own sections for documentation. STNA #58 revealed she was not familiar with Resident #10's grooming needs as she had baths scheduled on third shift and staff are responsible to complete these tasks during bathing times. Interview on 03/31/22 at 10:29 A.M., with STNA #132 revealed she noticed Resident #10's long nails, but revealed it was third shifts responsibility to trim them. Review of the policy titled Promoting and Maintaining Resident Dignity, dated 12/2020, revealed the facility was responsible to protect and promote resident quality of life. The policy revealed all staff members are involved in providing care to promote and maintain resident dignity and when interacting with a resident, pay attention to the resident as an individual. Respond to requests in a timely manner. Groom and dress the resident according to their preferences. This deficiency substantiates Complaint Number OH00110940.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, Registered Dietician and staff interviews, and policy review, the facility failed to ensure a resident's weight was monitored. This affected one (#24) of two resident reviewed for nutrition. The census was 32. Findings include: Review of Resident #24's closed medical record revealed an admission date of 02/26/22, with diagnoses including: metabolic encephalopathy, hypertension, heart failure, and Alzheimer's disease. The resident was discharge home on [DATE]. Review of a dietary risk assessment dated [DATE], revealed Resident #24's dietary risk was moderate. Review of a dietary progress note dated 03/04/22, revealed Resident #24's weight was 147.1 pounds per the hospital record dated 02/21/22. The goal was for the resident's weight to remain stable with no significant weight changes related to current body mass index (BMI) of 23 (normal). Documentation revealed the goal included weight management, hydration management, and prevention of skin impairment. A recommendation was for magic cup twice a day in between meals. Further review of the medical record revealed no other weights being obtained at the facility for Resident #24. Review of a care plan dated 03/04/22, revealed Resident #24 had nutritional problems or potential nutritional problems related to metabolic encephalopathy, heart failure, hyperlipidemia, and Alzheimer's disease. Goals included weight will be stable with no significant weight changes in 30, 90, and 180 days. Interventions include magic cup two times a day and monitor and evaluate weights as needed and monthly. Interview on 03/29/22 at 11:45 A.M., with the Director of Nursing (DON) verified the medical record for Resident #24 contained no evidence of the resident's weight being obtained while the resident was at the facility. Interview on 03/29/22 at 2:26 P.M., with the Registered Dietician (RD) #100 revealed the dietician would expect a resident's weight to be obtained within the first 24 hours after admission. RD #100 further reported newly admitted residents were to be weighed weekly for four weeks and then monthly. RD #100 verified the medical record for Resident #24 had no evidence of the resident being weighed by the facility. RD #100 reported the only weight documented in the resident medical record was a weight obtained prior to admission, while the patient was at the hospital. Review of a policy titled, Weight Monitoring dated October 2020, revealed a weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. A weight monitoring schedule will be developed upon admission for all residents. Weights should be recorded at the time obtained. The policy revealed newly admitted residents - monitor weight weekly for four weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, interviews with staff and the Medical Director, the facility failed to provide evidence pharmacy recommendations were reviewed by the physician and acted upon in a timely manner. The affected one (#4) of five resident reviewed for medications. The facility census was 32. Findings include: Review of Resident #4's medical record revealed an admission date of 09/09/10, with diagnoses including weakness, osteoarthritis, dysphasia, orthopedic aftercare, anxiety, chest pain, cognitive impairment, major depressive disorder, arthropathy, back pain, hypertension, gout, and dementia with behaviors. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had moderate cognitive impairment and required extensive assistance of one to two staff members for transfers and ambulation. Review of the pharmacy recommendations revealed the pharmacist made two recommendations to the physician on 01/13/22 (to initiate Senna 8.6 milligrams (mg) 2 tablets, once daily at bedtime while resident was prescribed Morphine Sulfate, and to attempt a gradual dose reduction to Trazadone from 50 mg to 25 mg once daily). One recommendation to the physician on 02/10/22 (consider avoiding use of Morphine Sulfate 15 mg twice daily in combination with Clonazepam 0.5 mg, due to concern for this combination to have increased side effects). And one recommendations to the physician on 03/01/22 (a repeat recommendation from the 01/13/21 to start Senna 8.6 mg with Morphine Sulfate). Review of the Medication Administration Record (MAR) for January 2022, February 2022, and March 2022 revealed no changes to physician orders based on the pharmacy recommendations. Interview on 03/30/22 at at 9:50 A.M., with Director of Nursing (DON) revealed the pharmacy recommendations and physician responses could not be located and were requested to be sent over by the pharmacy. Interview on 03/31/22 at 11:21 A.M., with the facility Medical Director (MD) #130 revealed the facility typically places pharmacy recommendations on his desk for weekly review. He revealed after he reviews and signs the pharmacy recommendations, he is unsure of what happens to the paperwork and how it is filed. MD #130 verified facility does not have a record of him reviewing the recommendations and signing off on the forms. Review of the policy titled LTC Facility's Pharmacy Services and Procedure: Medical Regimen Review (MRR), dated November 2016, revealed the physician receiving the MRR should act upon the recommendations contained in the MRR. The policy revealed the facility shall maintain copies of the MRR's on file as part of the permanent health record.

Based on observation, medical record review and staff interview, the facility failed to ensure medication was administered as ordered by the physician, with a medication error rate less than five percent (%). There was four medications errors out of 32 opportunities to result in a medication error rate of 12.5 %. This affected one (#2) of three residents observed for medication administration. The census was 34. Findings include: Observation of medication administration on 03/29/22 at 8:06 A.M., with Registered Nurse (RN) #73 revealed RN #73 was preparing medication to be administered to Resident #2. RN #73 gathered the resident medication for administration: one bottle of artificial tears eye drops artificial tears, senna 8.6 milligram tablet, amiodarone 100 mg tablet, centrum silver tablet, eliquis 5 mg tablet, tamsulosin hydrochloride 0.4 mg tablet, lidocaine 4% topical patch, and alaway eye drop 0.025%. Continued observation revealed the RN #73 gathered the medication and brought the medication to the room of Resident #2. RN #73 washed hands, donned gloves and administered the artificial tears one drop in each eye. Then RN #73 administered the oral medication. RN #73 informed Resident #2 the alaway eye drops needed to be administered about 15 minutes after the artificial tears. RN #73 then asked Resident #2 to lean forward so the lidocaine patch could be placed on the residents back. The resident leaned forward the nurse removed a lidocaine patch from the resident back and placed the new lidocaine patch on the resident. Continued observation revealed RN #73 left the resident's room and returned in approximately 10 minutes. Further observation revealed RN #73 returned to the resident's room and administered the alaway eye drops one drop in each eye. Adequate infection control practices were maintained during the alaway eye drop administration. Review of Resident #2's active medication orders revealed the medication scheduled for administration at 7:30 A.M. was artificial tears (ophthalmic lubricant) two drops in each eye. The medication scheduled for administration at 8:00 A.M. was senna (laxative) tablet 8.6 mg. The medication scheduled for 9:00 A.M. was eliquis (anticoagulant) 5 mg tablet, centrum silver (supplement) one tablet, amiodarone (antidysrhythmic) 100 mg tablet, and alaway (antihistamine) 0.025% one drop each eye. Medication scheduled for administration at 10:00 A.M. were tamsulosin hydrochloride (alpha blocker) 0.4 mg tablet and lidocaine pain relief adhesive patch 4%. Review of the physician order for the lidocaine revealed the patch was to be removed at bedtime. Interview on 03/29/22 at 10:08 A.M., with RN #73 verified the artificial tears eye drop was ordered for two drops in each eye and RN #73 administered one drop in each eye. Continued interview with RN #73 verified the medication lidocaine patch and tamsulosin hydrochloride were scheduled to be administered at 10:00 A.M. but were administered early at 8:06 A.M. RN #73 further verified the lidocaine patch that was placed on Resident #2's back on 03/28/22 was removed by this nurse prior to placing the new lidocaine patch. The nurse verified the lidocaine patch was suppose to be removed on 03/28/22 at bedtime.

Based on observation, record review, resident and staff interviews, the facility failed to ensure a resident with a food allergy was not served food related to the allergy. This affected one (#331) of 32 residents observed for dining. Facility census was 32. Findings include Review of Resident #331's medical record revealed an admission date of 03/25/22, with diagnoses including: sepsis, muscle weakness, heart failure, type two diabetes, hypertension, chronic obstructive pulmonary disease, and chronic kidney disease. Review of Resident #331's medical chart, revealed onions were a listed allergy. Observation 03/28/22 at 12:12 P.M., revealed Resident #331's tray was returned to the kitchen. State Tested Nurse Aide (STNA) #58 informed kitchen staff working resident had an allergy to onions and was served onion rings. Interview on 03/28/22 at 12:15 P.M., with STNA #58 revealed resident did not want onions when she brought his tray so she went to get him an alternative. Interview on 03/28/22 at 12:42 P.M., with Resident #331 revealed STNA #58 brought his tray for lunch which contained a side of onion rings on it. He informed STNA #58 he is allergic to onion rings and she looked at his ticket which stated he is allergic to onion rings. Resident #331 reveled STNA #58 was apologetic and exchanged his tray for a different side dish. Interview on 03/29/22 at 10:15 A.M., with Dietary Manager #88 revealed when a resident admits, the nurse will inform the kitchen of the dietary orders and allergies. DM #88 revealed she meets with residents upon admission to discuss food preferences and dietary needs. DM #88 revealed there was an issue with Resident #331 getting food he was allergic to due to a new kitchen staff member failing to read the tickets when making up the trays. DM #88 revealed she first met with resident on 03/28/22 after the lunch meal.

Based on observations, staff interviews,and policy review, the facility failed to safely store food in the dry storage, refrigerator, freezer and failed to sanitize kitchen equipment. This affected 31 of 31 residents who receive food from the kitchen, excluding Resident #6 who does not eat food from the kitchen. The facility census was 32. Findings include Observation on 03/28/22 from 9:20 to 9:30 A.M., with Dietary Manager (DM) #88 revealed noodles in dry storage were tied but were undated. Four large cans of cream corn had large fist sized dents and had been placed on the shelf for use. A large bag of cauliflower had a baseball sized hole and was left open to air with piece falling out of the bag. A bag of frozen chicken was undated and had been freezer burnt. The refrigerator had a container of unsealed and undated cinnamon rolls and a second container that was unopened and undated. Interview on 03/28/22 from 9:20 to 9:30 A.M., with Dietary Manager (DM) #88 confirmed the observations listed above. DM #88 stated when the can comes from the supplied dented they will return it, but if it is dented by facility staff, it will be wiped off and stored on the shelf for use. Observation on 03/30/22 at 10:15 A.M., revealed no cans in the dry storage room had a date marked regarding the day of arrival to the facility. A small freezer in the dry storage room filled with bread revealed no dates were found on the bread either from delivery or from expiration date. An unopened box of muffins was in the fridge with no date on it and a second box of muffins was unopened with a date of 01/30/22. The cinnamon roll container seen on 03/28/22 in the refrigerator had been placed back in the fridge. Interview on 03/30/22 at 10:15 A.M., with Covering Kitchen Manager (CKM) #123 revealed the facility should be dating every item that arrives to the facility according to the policy. CKM #123 confirmed the findings from the 03/30/22 observations. CKM #123 revealed food can be kept in the freezer for up to one year and food should be kept in refrigerator for only 1 week after opening or until expiration for items such as milk. CKM #123 confirmed a box of muffins was in the fridge and had no date and another box of muffins was in the fridge with the date 01/30/22. CKM #123 pulled out the muffins to be thrown away. Observation on 03/29/22 at 11:55 A.M., of food temperatures revealed the facility did not sanitize the food thermometer when taking holding food temperatures between each item. Dietary Manager (DM) #88 took the temperature of the peas, then wiped the thermometer off with a dry paper towel. DM #88 then took temperature of the tomato soup and wiped the thermometer off with the same paper towel. DM #88 then took temperature of the grill cheese sandwich and attempted to wipe it off with the same paper towel. The cheese was not coming off, so DM #88 ran it under water and used a wet rag to clean the cheese off the thermometer. Interview on 03/29/22 at 12:02 P.M., revealed the kitchen did not currently have any sanitation wipes to clean the thermometer. DM revealed she puts the thermometer through the dishwasher after each meal. Review of the policy titled Food Temperature Requirements, dated 04/02/19, revealed the policy does not specify how the thermometer should be cleaned. Review of the policy titled Receiving and Storage, dated 04/02/19, revealed the policy revealed items will be properly stored to maintain food safety and quality. The policy revealed all items should be dated when received to ensure correct product rotation. The policy revealed swollen, rusted and dented cans will be returned to the provider for credit. The policy revealed all food items will be covered labeled and dated in storage after opening and using a portion, removing from the case and when transferring to another container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and family interview and policy review, the facility failed to ensure personal health information remained confidential. This affected one (#135) out of two closed records reviewed. Facility census was 38. Findings include: Review of former Resident #135's medical record reveal being admitted on [DATE] with diagnoses including cerebral vascular disease, mitral valve prolapse and flaccid hemiplegia. Review of Resident 135's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) of eight. Review of the MDS revealed the resident required extensive two-person assist for bed mobility, transfer, and toilet use. The resident required extensive one-person assist for dressing and personal hygiene. The resident required only supervision for eating. Review of Resident #135's plan of care dated 12/12/20 revealed the resident had a self-care deficit related to cerebral vascular disease process. Review of Resident #135's progress note dated 02/01/20 revealed the resident was discharged to home with Home Health services. Interview on 02/24/20 at 9:30 A.M. with Resident #129's daughter revealed her mother was admitted on [DATE]. Resident #129's daughter revealed she found another resident's medical records in the room when her mother was admitted . Resident #129's daughter provided Resident #135's medical records that were left in Resident #129's room. Review of the documents found in Resident #129's room included Resident #135's plan of care (three pages), nursing assessment checklist (one page), and physician orders (four pages). Interview on 02/24/20 at 6:00 P.M. with the Administrator and the Director of Nursing (DON) confirmed the records found in Resident #129's were original medical records for Resident #135 who was discharged to home on [DATE]. The Administrator and the DON were not able to provide an explanation as to why the records were in Resident #135's room. The DON and the Administrator confirmed Resident #135's personal health records were not maintained in a confidential manner. Review of the facility policy titled, Safeguarding of PHI, dated 12/04/19 revealed the facility will make reasonable efforts to have sufficient safeguards in place to protect personal health information (PHI).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of an incident report and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) Assessment for a resident. This affected one (#12) of thirteen residents reviewed during Phase II of the survey. Facility census was 38. Findings include: Review of the clinical record revealed Resident #12 was admitted [DATE]. Diagnoses include chronic obstructive pulmonary disorder, hypertension, hyperlipidemia, Stage III chronic kidney disease, and history of stroke with dysphagia. Resident #12 was admitted with hospice services and has received these services since admission. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was unable to participate in the Brief Interview for Mental Status (BIMS). Resident #12 received hospice services. Resident #12 also had a history of falls since the previous assessment. Resident had one fall without injury and one fall with injury (except major injury). Further review of the annual MDS assessment dated [DATE] revealed the resident required extensive assist with bed mobility, dressing, toileting, and personal hygiene. The resident required total assistance with transfers and bathing. Review of MDS Annual assessment dated [DATE] revealed section J100 revealed Resident #12 had a fall with major injury since prior assessment. Further review of the annual MDS revealed the resident was not coded for receiving hospice services. Review of progress note dated 11/22/19 at 11:19 A.M. revealed the resident continued on fall follow-up with no new or apparent injuries. Review of incident report dated 11/25/19 revealed the resident had a fall with major injury to the left knee. Interview 02/24/20 at 1:37 P.M., MDS Nurse #39 verified Resident #12 had received Hospice services since admission and the MDS assessments dated 01/07/20 was inaccurately coded. Interview 02/25/20 at 11:05 A.M., MDS Nurse #39 stated Resident #12 acquired a skin tear to his left knee after a fall 11/21/19. She confirmed the MDS assessment dated [DATE] was inaccurately coded due to a documentation error she failed to catch when it populated from the incident report to the MDS Assessment. MDS Nurse #39 confirmed Resident #12's fall was without major injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident, family and staff interview, the facility failed to timely identify and treat a resident's urinary tract infection (UTI). This affected one (#129) of three residents reviewed for urinary tract infections. Facility census was 38. Findings include: Review of Resident #129's medical record revealed an admission date of 02/19/20 with diagnoses including post femur fracture, hypertension and hyponatremia. Review of Resident #129's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) was not completed. The MDS revealed the resident required one-person physical assist for bed mobility, toilet use and personal hygiene. Review of Resident #129's Plan of Care dated 02/19/20 revealed resident had a self-care deficit related to history of open reduction of femur fracture. Review of Resident #129's nursing progress notes dated 02/21/20 revealed the resident complained of urinary frequency. Review of Resident #129's physician order dated 02/21/20 revealed an order to obtain urinalysis, culture and sensitivity. The order additionally documented the urinalysis may be obtained on 02/24/20. Review of Resident #129's Certified Nurse Practitioner Registered Nurse (RN) #200 progress note dated 02/24/20 revealed resident and daughter asking for results from urinalysis. The RN #200 revealed the results had not yet been received. Review of Resident #129's urinalysis report dated 02/24/20 at 1:48 P.M. revealed a partial report status which included abnormal clarity, blood noted in urine, leukocytes, white blood cells, epithelial cells and bacteria. The lab report identified the specimen was collected on 02/24/20 and received by the lab on 02/24/20. Interview on 02/24/20 at 11:30 A.M. with Resident #129 and Resident #129's daughter revealed the resident provided a urine sample on 02/21/20. Resident #129's daughter stated she spoke to the Certified Nurse Practitioner Registered Nurse (RN) #200 and asked about the results of a urinalysis. Resident #129's daughter revealed the RN #200 stated the results had not yet been received. Interview on 02/26/20 at 10:44 A.M. with Resident #129 and Resident #129's daughter revealed the resident continued to have urinary urgency. Resident #129 also complained of back pain. The resident confirmed the facility had not yet addressed the urinary symptoms. Interview on 02/26/20 at 12:30 P.M. with the Director of Nursing (DON) reviewed the order written on 02/21/20 and was not able to provide an explanation as to why the urine sample was not sent until 02/24/20. The DON called the laboratory and was told the pharmacy does not pick up specimens unless the order identified that it was a Stat or Immediate order. The DON revealed it was her expectation that the urine should be sent out right away for a resident who was symptomatic. Interview on 02/26/20 at 2:36 P.M. with RN #200 revealed she would not have written an order that would have waited three days to send a urine specimen on a resident who was having symptoms. The RN #200 stated the final lab report for the urinalysis had not yet been received by the facility. The RN #200 stated the urine sample should have been sent to lab on 02/21/20 when the resident first reported the symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to timely respond to pharmacy recommendations. This affected one (#2) of six residents reviewed. Facility census was 38. Findings include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include osteoarthritis, pain in joint, and hypertension. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is cognitively intact, had no hallucinations, delusions or behaviors coded. Resident is coded as requiring one person assist supervision for bed mobility, dressing, and personally hygiene, and is independent is toileting. Review of Resident #2's physician orders revealed the resident has the following orders: Calcium 600 plus Minerals (calcium Carbonate-Vitamin D3 minerals tablet 600 mg calcium- 400 units: Administer one tablet by mouth two times a day at 9:00 A.M. and 1:00 P.M. with an order date of 07/12/19; Iron (Feosol/Ferrous) tablet 325 milligrams (mg) (equal to 65 mg iron)-administer one tablet by mouth one time a day at 9:00 A.M. for supplement with an order date of 07/12/19. Review of medical record revealed the resident had a pharmacy recommendation written on 10/08/19 indicating the medication calcium with vitamin D mineral supplement and iron supplement are given concurrently. The recommendation was to consider minimizing this potential absorption-relate drug interaction by separating administration of these two products by at least two hours. Rationale for recommendation: concurrent administration of Calcium/Vitamin D/Mineral and iron products may reduce the absorption of either iron or the interacting medication. The recommendation is signed by Registered Nurse (RN) #45 indicating it was completed on 10/11/19. Further review of the medication administration record (MAR) revealed the resident currently has both medications administered at the same time of 9:00 A.M. Review of the physician orders revealed there was not order written indicating to change the administration time of either medications. During an interview with the Director of Nursing (DON) on 02/25/20 at 4:45 P.M. confirmed Resident #2's pharmacy recommendation from 10/08/19 was not acted upon and there was no evidence of change in the resident medication timing to indicate the facility had acted on the recommendation.

Based on medical record review, observation, staff interview and review of an insulin pen manufacture recommendations, the facility failed to prime an insulin pen prior to administering insulin resulting in a significant medication error. This affected one (#133) of one observed for insulin administration. The facility identified one (#133) resident who receives insulin through via insulin pen administration on the North hallway. Facility census was 38. Findings include: Review of the medical record for resident #133 revealed an admission date of 2/14/20 with diagnosis that include but not limited to kidney failure, hypertension, diabetes, congestive heart failure, pain and hearing loss. Review of Resident #133's physician orders revealed the resident has an order for Admelog Solostar 100 units/ml sliding scale insulin that indicated if finger stick blood sugar (FSBS) is 240-289 administer three units of Admelog SoloStar 100u/ml. During an observation of the insulin administration for Resident #133 on 02/26/20 at 4:34 P.M. Licensed Practical Nurse (LPN) #60 was observed to perform Resident #133's FSBS as per standard/order with a reading of 273. LPN #60 was then dialed the resident dose of insulin via an Admelog insulin pen to three units and administered the insulin to the resident in the abdomen. The nurse was not observed to perform a safety test on the insulin pen prior to the administration of the insulin. During an interview with LPN #60 on 02/26/20 at 4:39 P.M. confirmed he/she administered three units of insulin to Resident #133 and prior to the administration did not perform any prior procedure to the insulin pen. LPN #60 stated to administer insulin with the pen you just dial the dose and administer the insulin. Review of the Admelog insulin manufacture recommendations revealed to always perform a safety test. The policy further instructed to always do a safety test before each injection to check your pen and the needle to make sure they are working properly. Make sure that you get the correct insulin dose. Select two units by turning the dose selector until the dose pointer is at the two mark. Press the injection button all the way in. When insulin comes out of the needle tip, your pen is working correctly. If no insulin appears: You may need to repeat this step up to three times before seeing insulin. If no insulin comes out after the third time the needle may be blocked. If this happens: Change the needle, then repeat the safety test. Do not use the pen if there is still no insulin coming out of the needle tip. Use a new pen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation in medication room [ROOM NUMBER]/26/20 at 10:05 A.M. revealed the Emergency Drug Kit for narcotics were stored in a canvas bag with a red lock tag attached to the zipper. The bag was freestanding and was not permanently affixed to the counter. Review of the Emergency Drug Kit contents revealed the following medications and quantities were being stored in the Emergency Drug Kit: Medication Quantity -Acetaminophen/codeine 300 milligrams (mg)/30 mg Six -Alprazolam 0.25 mg Six -Alprazolam 0.5 mg Six -Clonazepam 0.5 mg Six -Diazepam 5.0 mg Six -Diazepam 2.0 mg Six -Fentanyl 25 micrograms (mcg)/hour patch Three -Fentanyl 50 mcg/hour patch Three -Fentanyl 12 mcg/hour patch Three -Hydrocodone/acetaminophen 7.5/325 mg Six -Hydrocodone/acetaminophen 5/325 mg 12 -Hydrocodone/acetaminophen 10/325 mg Six -Hydromorphone 2.0 mg Six -Lorazepam 0.5 mg Six -Lorazepam 1.0 mg Six -Morphine Sulfate 15 mg Six -Morphine Sulfate 20 mg/1.0 solution Two -Morphine Sulfate ER 15 mg Six -Oxycodone HCL 5 mg Six -Oxycodone/acetaminophen 7.5/325 mg Six -Oxycodone/acetaminophen 10/325 mg Six -Oxycodone/acetaminophen 5/325 mg 12 -Oxycontin ER 12 Hour 10 mg Six -Pregabalin 50 mg Six -Temazepam 7.5 Six -Tramadol 50 mg Six -Zolpidem 5 mg Six Interview 02/26/20 at 10:06 A.M. with Registered Nurse (RN) #13 verified the narcotics with the Emergency Drug Kit was unopened indicating no medication had been removed since delivery from the pharmacy and the box was not permanently affixed in the medication room. Review of the information from DEA website (https://www.dea.gov/drug-scheduling) revealed Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. Some examples of Schedule II drugs are: combination products with less than 15 milligrams of Hydrocodone per dosage unit (Vicodin), cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), Fentanyl, Dexedrine, Adderall, and Ritalin. Based on medical record review, observation, staff interview, review of the Emergency Drug Kit content list and review of medication information from the Drug Enforcement Agency (DEA), the facility failed to observe a resident consume their medications. This affected one (#2) out of seven residents observed receiving medications at the facility. Additionally, the facility failed maintain a permanently-affixed Emergency Drug Kit containing Schedule II controlled substances that was being stored within the medication storage room. The facility census was 38. Findings include: 1. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include osteoarthritis, pain in joint, and hypertension. Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident is cognitively intact, had no hallucinations, delusions or behaviors coded. Resident is coded as requiring one person assist supervision for bed mobility, dressing, and personally hygiene, and is independent is toileting. Review of the resident physician orders for the resident revealed the resident has the following medications ordered at 9:00 A.M.: Ocular Vitamin tablet; Aspirin EC 81 milligrams (mg); Iron 325 mg; Calcium 600 vitamin D3 400 units; Cod liver oil 1,250-135 units administer two capsules; Glucosamine sulfate 500 mg; Lasix 40 mg give with Lasix 20 mg; Losartan 25 mg and Potassium Chloride 20 mg. Further review of the medical record revealed there was no physician order and/or no assessment permitting Resident #2 to self-administer medications. During an observation on 02/24/20 at 10:10 A.M. the medication cart was observed in the hallway between room [ROOM NUMBER] and 37 pushed up to the wall that on that side of the hallway. Registered Nurse (RN) #400 was observed exiting Resident #2's room and returned to the medication cart going to the far left side of the cart out of visual range of Resident #2 who remained in his/her room taking medication out of the medication cup and taking the medication. The resident was observed to take five medications during this time and still had medication in the cup to be administered. The nurse re-entered the resident room and proceeded to go into the bathroom remaining out of visual range of the resident who continued to take medication out of the pill cup and take the medications. The nurse exited the room again and moved her cart further down the hallway between room [ROOM NUMBER] and room [ROOM NUMBER], where the nurse could look into the room and keep the resident in visual sight if the nurse chose to do so. The nurse however proceeded to prepare medications for another resident, and not keep the resident in constant visual sight. During an interview with RN #400 on 02/24/20 at 10:55 A.M. confirmed the nurse gave Resident #2 her medication and then returned to her cart. RN #400 stated she did go back into the room and wash her hands in the bathroom. During an interview with the Resident #2 on 02/24/20 at 11:10 A.M. confirmed the nurse did not remain in the room this morning when his/her pills were given to him/her. Resident #2 stated some nurses stay in the room and some do not. Resident #2 stated the nurse gave me the pills and left the room while she took the medication and my potassium pills. Resident #2 stated they break the potassium pills in half to help them go down easier and she always takes them with milk to help. During an interview with the Director of Nursing on 02/26/20 at 12:25 P.M. confirmed the expectation of the facility nurses is to have the resident in visual sight while the residents take the medications to ensure all medications are consumed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, wound care observation, staff interview and policy review, the facility failed to perform hand hygiene during a dressing change for Resident #12. This affected one (#12) of three residents sampled for wound care. Facility census was 38. Findings include: Review of the clinical record revealed Resident #12 was admitted [DATE]. Diagnoses include chronic obstructive pulmonary disorder, hypertension, hyperlipidemia, Stage III chronic kidney disease, and history of stroke with dysphagia. The resident required extensive assist with bed mobility, dressing, toileting, and personal hygiene. The resident required total assistance with transfers and bathing and had moderate cognitive impairment. Observation of wound care 02/26/20 01:55 PM, revealed Hospice Registered Nurse (RN) #250 did not perform hand hygiene between glove changes after removing soiled dressing from Resident #12's left mid-back and applying a clean dressing. During an interview 02/26/20 at 1:55 P.M., Hospice RN #250 confirmed she did not was her hands between glove changes during the dressing change for Resident #12's left mid-back. Review of infection control policy for wound care revised February 2014 under section titled Steps in Procedure revealed: put on clean gloves; loosen tape and remove soiled dressing; pull glove over dressing and discard into plastic or biohazard bag and wash and dry hands thoroughly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to offer a resident the Pneumococcal 23 vaccine. This affected one (#10) our of five residents reviewed for immunizations. Facility census was 38. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with the diagnoses that include but are not limited to atrial fibrillation, acute kidney failure and congestive failure. Review of the immunization record revealed there was no immunization consent in the the medical record, however the facility provided historical record that indicated the resident had the Prevnar 13 immunization on 10/26/17, there was no indication of the pneumococcal 23 being offered and/or administered. On 02/26/20 at 1:43 P.M. interview with Infection Control Designee/Registered Nurse #64 confirmed Resident #10 received the Prevnar 13 immunization on 10/26/17; however, there is no documentation regarding if the resident was no offered and/or received the Pneumococcal 23 immunization. Review of facility policy titled Pneumococcal Vaccine revised December 2012 revealed under Policy Interpretation and Implementation: 1. Upon admission, residents will be assessed for eligibility to receive the Pneumovax (pneumococcal vaccine) and Prevnar 13, and when indicated, arrangements will be made for vaccine administration. 4. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given within the past year or refused) per our facility's physician-approved pneumococcal vaccination protocol, which is as follows: For resident's who received Pneumovax vaccine prior to age [AGE], have never received the Pneumovax vaccine or are unsure as to what date the received the Pneumovax vaccine and this information cannot be obtained from the PCP; Prevnar 13 will be administered then the Pneumovax vaccine administered twelve months later. 8. Administration of the pneumococcal vaccine or revaccinations will be made in accordance with the current Center for Disease Control and Prevention (CDC) recommendations at the time of vaccination.

Based on observation and staff interview, the facility failed to store food safely. This had the potential to affect 38 of 38 residents who receive food from the kitchen. Facility census was 38. Findings include: Observation 02/24/20 at 8:15 A.M. in dry storage revealed two boxes of Gold Medal Pancake Mix with an expiration date of 12/28/19 and three packages of Jet Puffed marshmallows with an expiration date of 01/18/19. Further observation revealed an opened, unlabeled container of chocolate fudge frosting. Interview 02/24/20 at 8:25 A.M. Dietary Manager verified items in dry storage were outdated and unlabeled. Observation 02/24/20 at 8:30 A.M. in walk-in refrigerator revealed one container of cottage cheese with an expiration date of 01/19/20, two containers of sour cream with an expiration date of 01/14/20, and unlabeled cheese slices wrapped in saran wrap. There was also an opened, undated bottle of water on its side on the shelf that leaked when set upright. Interview 02/24/20 at 8:40 A.M. Dietary Manager verified the outdated and unlabeled foods in the refrigerator. The facility confirmed the dietary concerns had the potential to affect all 38 residents who receive their meals and food from the kitchen.