**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] Based on observation, record review, and interview, the facility failed to ensure a resident with MASD received necessary treatment and services that were consistent with the standards of practice for one (#256) of two residents reviewed for skin conditions. The DON identified 20 residents with MASD resided in the facility. Findings: The Non-Pressure Wounds: Moisture Associated Dermatitis Clinical Operations policy, dated July 2018, read in parts, .Review and investigate the type and frequency in which the areas managed for prevention and treatments .Briefs used and frequency of changing briefs .Review orders and treatments and gather supplies .Report abnormalities to supervisor . Resident #256 had diagnoses which included acute infarction of the spinal cord and neuromuscular dysfunction of the bladder. The care plan, dated 10/31/23, documented to inspect skin daily with care and bathing and report any changes to charge nurse. The late entry nurse note, dated 11/01/23, documented the resident had MASD and scarring to the sacrum and the skin was intact. The late entry nurse note, dated 11/06/23 at 2:15 p.m., documented the resident had a scabbed area to the sacrum that was currently intact. The note further documented the brief was soiled with stool and the nurse changed the residents brief and performed catheter care. On 11/07/23 at 1:40 p.m., LPN #1 was observed removing the resident's brief. The resident's brief was soiled with stool and the wound on the sacrum was observed to be open. The nurse contacted the physician and obtained wound care orders for the resident. On 11/07/23 at 2:15 p.m., CNA #2 stated they had performed incontinent care on the resident on 11/06/23 and they were unsure if the wound was open or not at that time. On 11/07/23 at 3:00 p.m., CNA #3 stated they had provided incontinent care for the resident around 10:30 a.m. on 11/07/23 and they noted the wound on the resident's sacrum was open. They stated they forgot to tell the nurse the wound had opened. On 11/08/23 at 2:00 p.m., Resident #246 stated they were unable to tell if they had been incontinent. They also stated that the aides do not check very often to see if the resident's brief is soiled. They stated this has been an ongoing issue and today they complained to the charge nurse. On 11/08/23 at 3:00 p.m., LPN #3 stated Resident #246 had spoken to him about the aides not providing care and he spoke to the CNA working that hall regarding the importance of providing care in a timely manner. On 11/08/23 at 4:45 p.m., the DON stated CNAs were required to report changes in a residents condition to the charge nurse and appropriate incontinent care is part of the treatment protocol for residents with MASD.

Based on record review, observation, and interview, the facility failed to ensure a Lovenox injection (an anticoagulant medication) was available for one (#158) of 12 residents observed during medication pass. The DON identified five residents who were prescribed Lovenox. Findings: A facility policy titled, Disposal of Medications, Syringes and Needles, dated December 2012, read in parts, .Discontinued medications and/or medications left in the nursing care center after a resident's discharge, which do not qualify for return to the pharmacy, are identified and removed from current medication supply in a timely manner for disposition . A facility policy titled, Medication Administration General Guidelines, dated September 2018, read in parts, .Medications supplied for one resident are never administered to another resident . Resident #158 had diagnoses which included fracture of the left femur. A Physician's Order, dated 08/16/22, documented to administer Lovenox 40 mg/0.4 mL subcutaneous one time a day for 24 days. A delivery manifest, dated 08/16/22, documented six Lovenox 40 mg/0.4 mL syringes were delivered to the facility. This provided the medication for six days. Resident #158 would not have a dose for 08/23/22, unless reordered. Resident #158's MAR, dated August 2022, documented the resident had received a Lovenox injection everyday from 08/17/22 to 08/23/22. A delivery manifest, dated 08/24/22, documented six Lovenox 40 mg/0.4 mL syringes were delivered to the facility. On 08/24/22 at 8:50 a.m., LPN #3 was observed to prepare/administer medications to Resident #158. The resident was scheduled to receive a Lovenox 40 mg injection. The nurse obtained a Lovenox 40 mg syringe from the medication cart and prepared supplies to administer the injection. The label of the injection's packaging identified a different resident's name. When this surveyor requested to review the label, the nurse stated, Oh that's not who is getting the medication. The nurse identified the name on the label was a discharged resident. LPN #3 was asked if Resident #158 had their own Lovenox on the cart. The LPN searched the cart and stated no and it appeared as the medication had not been reordered. The nurse was asked if the resident had received the Lovenox as ordered by the physician. The LPN stated Resident #158 had been at the facility since the 08/16/22 and had received Lovenox since 08/17/22. LPN #3 was asked what the protocol was for medications when a resident discharged from the facility. The nurse stated when a resident was discharged , medications should be put in the dispose box in the medication room. LPN #3 was asked why the discharged resident's Lovenox was not removed from the cart. They stated they did not know. The LPN was asked if other medications for the discharged resident were on the cart. They stated the one Lovenox injection was the only medication of the discharged resident on the cart. On 08/26/22 at 2:26 p.m., the DON was asked if it was acceptable to utilize a discharged resident's medication for a current resident. They stated no. They were asked why a discharged resident's medication was still available and on the medication cart. They stated they did not know and it may have been over looked. The DON was asked how Resident #158 had received the medication if it were not available in the facility on 08/23/22. They stated the resident may have received a different resident's medication or did not receive the Lovenox injection on that day.

Based on record review, observation, and interview, the facility failed to ensure medications and treatments were properly stored/secured for one (100 hall) of six medication carts observed and two of two treatment carts observed. The DON identified the facility had seven medication carts and two treatment carts. Findings: A facility policy titled, Medication Administration General Guidelines, dated September 2018, read in parts, .During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse .The cart must be clearly visible to the personnel administering medications when unlocked . On 08/23/22 at 10:30 a.m., a medication cart was observed to be unlocked/unsecured on the 100 hall. LPN #2 was sitting at the nurses desk with their back to the cart. On 08/23/22 at 10:32 a.m., LPN #2 approached the medication cart, obtained medication, and locked the cart. On 08/24/22 at 8:43 a.m., a medication cart was observed to be unlocked/unsecured on the 100 hall. On 08/24/22 at 8:46 a.m., LPN #1 was asked who the medication cart belonged to. They stated it was their cart. They were asked why the medication cart was not locked/secured. They stated they had been called into a room but the cart was supposed to be locked. On 08/26/22 at 9:44 a.m., two unlocked/unsecured treatment carts were observed in the wound nurse's office by the door. The door was open and staff were not observed in the office. On 08/26/22 at 9:52 a.m., CNA #1 was observed to enter the office for the wound nurse. CNA #1 was asked who the treatment carts belonged to. They stated the wound nurse. On 08/26/22 at 9:59 a.m., the wound nurse approached the office and was asked who was responsible for the two treatment carts. The wound nurse stated the treatment carts belonged to them. They were asked what the treatment carts contained. They stated treatment supplies which included wound cleanser and medicated ointments. The wound nurse was asked how treatments were secured. They stated the carts were stored in the office when not in use. They were asked why the carts were not secured/locked. They stated because the carts were in the office where CNA #1 was located. The wound nurse was informed of the surveyor's observation of the unattended, unlocked/unsecured treatment carts. The wound nurse stated the treatments carts should have been locked. On 08/26/22 at 11:02 a.m., the 100 hall medication cart was observed to be unlocked/unsecured and unattended. On 08/26/22 at 11:06 a.m., LPN #1 was observed to approach the medication cart. They were asked who was responsible for the medication cart. They stated they were responsible for the medication cart. They were asked how they ensured medications were properly stored/secured. They stated they usually locked the cart. LPN #1 was asked why the medication cart was unlocked/unsecured. They stated they had just placed medications in the cart and went to a resident room. On 08/26/22 at 2:18 p.m., the DON was asked how they ensured medications and treatments were properly stored/secured. They stated medications were stored in medication rooms and treatment/medication carts. They stated they were kept secure by locks. The DON was told of the surveyors' observations and was asked why the treatment and medication carts were observed to be unlocked/unsecured. The DON stated they thought the staff probably had interruptions but the expectation was to keep them locked.