Based on interview and record review it was determined the facility failed to notify a resident prior to change of administration of medication for 1 of 1 sampled resident (#139) reviewed for informed consent. This placed residents at risk for lack of informed consent. Findings include: Resident 139 admitted to the facility in 2024 with diagnoses including depression. A 3/26/24 admission MDS indicated Resident 139 was cognitively intact. admission orders signed 3/28/24 revealed Citalopram (an anti-depressant) 60mg at bedtime and Imipramine (an anti-depressant) 50mg at bedtime for depression. An 4/9/24 provider order specified Citalopram 20mg at bedtime and Imipramine 25mg at bedtime for depression. An 4/18/24 provider note indicated the provider spoke with Resident 139 and she/he had no unaddressed concerns. A review of Resident 139's chart revealed no documentation to indicate Resident 139 was notified of the changes to her/his medications. On 11/18/24 at 2:49 PM Resident 139 stated she/he was taking Citalopram 60mg and Imipramine 50mg at bedtime as a successful depression treatment for years. She/He stated the facility reduced her/his medications without her/his knowledge or consent. On 11/20/24 at 12:10 PM Staff 23 (Social Services Director/Admissions) verified no other information was present in Resident 139's chart regarding notification of medication changes.

Based on observation, interview, and record review it was determined the facility failed to provide a meaningful activity program for 1 of 1 sampled resident (#3) reviewed for activities. This placed residents at risk for lack of social engagement. Findings include: Resident 3 admitted to the facility in 8/2023 with a diagnosis of paralysis. A 7/23/24 annual MDS revealed Resident 3 was cognitively impaired, preferred to stay in bed, and required assistance with ADLs. When interviewed, Resident 3 indicated choosing activities was very important. Activities important to Resident 3 included interaction with pets and reading. A care plan initiated on 8/23/23 and revised on 10/7/24 indicated Resident 3 was at risk for little activity involvement related to physical mobility, decreased ROM, impaired motor skills, and deficits in judgement. Activities to offer included to invite Resident 3 to group activities, provide 1:1 visits, and to provide reading material. An 10/23/24 Activities Quarterly Participation Review form indicated Resident 3 preferred to self-direct her/his own activities, did not want to participate in group activities, and 1:1 visits were acceptable. The form indicated there was only one 1:1 activity provided during the previous quarter. Resident 3's favorite activities included reading the bible, looking out her/his window, napping, and visits with family and her/his roommate. An Activity Participation log from 10/22/24 through 11/16/24 indicated Resident 3 participated in independent activities. The activity identified was snack offered. No 1:1 visits were provided, no reading, and no other visits occurred. On 11/18/24 at 12:30 PM Resident 3 stated there was not much to do for activities. Resident 3 was not able to articulate what she/he wanted to do. On 11/19/24 at 2:45 PM Staff 8 (CNA) stated Resident 3 did not like television, but enjoyed talking and joking. Staff 8 stated staff offered Resident 3 group activities, but she did not like group activities. Observations revealed: -On 11/18/24 at 12:30 PM Resident 3 was in bed, awake, window blinds closed, and there was no television or music playing in the background. -On 11/19/24 at 10:18 AM Resident 3 was observed in bed with her/his eyes shut, there was no music or television playing in the background. -On 11/20/24 at 8:51 AM Resident 3 was observed in bed with her/his eyes shut and her/his window blinds closed. -On 11/20/24 at 9:22 AM Resident 3 was in bed, awake, and her/his blinds were shut. On 11/20/24 at 8:27 AM Staff 3 (Activity Supervisor) stated both she and her/his assistant provided 1:1 visits with residents. If a visit was provided it was documented in the resident's clinical record. Staff 3 stated the facility had a volunteer with a dog visit the facility, but it was very infrequent. Staff 3 acknowledged Resident 3 liked pets and there were some facility staff who had pets in the facility which Resident 3 may enjoy. Staff 3 stated Resident 3 slept a lot but was awake for meals and showers. Staff 3 indicated 1:1 visits could be scheduled during the times Resident 3 was awake. Staff 3 stated she was not sure if Resident 3 was able to read and stated the facility had an audible book player, but did not offer it to Resident 3. Staff 3 acknowledged the resident only had snacks as documented activities and family did not come in very often. On 11/20/24 at 9:21 AM Staff 7 (CMA) stated Resident 3's blinds were often shut, but Resident 3, on occasion, asked staff to open her/his blinds.

Based on interview and record review it was determined the facility failed to properly assess a pressure ulcer and revise treatments for 1 of 1 sampled resident (#5) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 5 admitted to the facility in 3/2017 with diagnoses including dementia and failure to thrive. An 4/11/24 Annual Pressure Ulcer CAA indicated Resident 5 was at risk for pressure ulcers, was unable to make position changes independently, and had recurrent MASD (Moisture Associated Skin Damage). A 7/4/24 Unavoidable Pressure Injury Evaluation indicated Resident 5 had MASD which resulted in a pressure injury due to fragile skin and impaired skin integrity despite pressure injury interventions. An 10/2/24 Quarterly MDS indicated Resident 5 had a facility acquired Stage 3 (full thickness tissue loss) pressure ulcer. An 10/12/24 physician order indicated Resident 5 was to receive wound care to her/his coccyx (tailbone) every evening which included to cover the wound bed with calcium alginate (dressing to treat wounds with moderate to heavy drainage), apply marathon (wound protective layer) to the peri-wound (tissue surrounding the wound) and cover the wound with a foam dressing. An 10/29/24 Wound Evaluation revealed Resident 5's Stage 3 coccyx wound was improving, the peri-wound area was denuded (surface area removed), the wound exudate (fluid) was moderate and measured 0.51 cm x 0.76 cm and was 0.1 cm in depth. The progress notes indicated the wound was healing and current treatment continued. A 11/4/24 Wound Evaluation revealed Resident 5's wound was deteriorating, the exudate was light and bloody, and the wound measured 1.71 cm x 3.89 cm and it was 0.1 cm in depth. Progress notes indicated the current treatment continued. A 11/15/24 Wound Evaluation revealed Resident 5's wound continued to deteriorate, the exudate was light and bloody, and the wound measured 7.67 cm x 14.69 cm and it was 0.1 cm in depth. Progress notes indicated the wound size greatly increased due to the adhesive from the dressing which irritated the skin, but the pressure injury was nearly resolved. No new notes related to wound treatment were found. On 11/19/24 at 5:14 PM Staff 14 (LPN) stated she completed Resident 5's wound treatment weekly, the wound was improving but the surrounding area around the wound appeared to worsen. Staff 14 stated Staff 4 (RN-Patient Care Coordinator) assessed Resident 5's wound weekly and determined what treatments were necessary. On 11/20/24 at 1:46 PM Staff 15 (LPN) stated a few weeks earlier she observed two to three new red spots near Resident 5's coccyx wound that remained closed but wanted to open (indication of a Stage 1 pressure ulcer when the skin is intact and appears red). Staff 15 stated Resident 5's entire coccyx wound area appeared worse compared to prior observations and Staff 4 was aware. On 11/20/24 at 3:28 PM Staff 4 stated she believed Resident 5's coccyx wound was healing and wanted to focus on the coccyx wound before the surrounding skin issue was addressed. Staff 4 stated she did not consider an alternative to the residents' current wound treatment despite the changes observed to the surrounding skin. At 11/20/24 at approximately 3:30 PM Staff 2 (DNS) reviewed the wound documentation and acknowledged Resident 5's wound should be assessed as two separate wounds with a new treatment regimen considered at the time the surrounding skin area of the initial wound deteriorated.

Based on interview and record review it was determined the facility failed to ensure a resident was provided an RA program for 1 of 1 sampled resident (#3) reviewed for mobility. This placed residents at risk for increased weakness. Findings include: Resident 3 admitted to the facility in 8/2023 with a diagnosis of paralysis. A 7/23/24 annual MDS indicated Resident 3 had impaired cognition, was bed bound, required a mechanical lift for transfers, and assistance with ADLs. An 8/3/24 PT Discharge Summary revealed Resident 3 was provided therapy services to assist her/him with increased independence with bed mobility, sitting balance while in a wheelchair, and improve ROM to her/his legs. The benefit of therapy was to prevent contractures and muscle wasting. Discharge recommendation included a RA program. The RA program was for ROM for feet mobility and leg rotation. The RA program was also to assist in maintaining the resident's ability to sit at the side of the bed, transfer to the wheelchair, and participate in bed mobility. A care plan revised on 10/30/24 revealed Resident 3 had a walking deficit and impaired bed mobility due to decreased ROM, decreased cognition, impaired balance, and weakness. Interventions indicated therapy was to be provided as needed, but she/he had poor therapy participation. The care plan indicated Resident 3 did not walk and she/he was dependent on one staff to assist with turning and sitting up in bed. The care plan did not include a RA program. Review of Resident 3's clinical record did not include documentation to indicate a RA program was implemented. On 11/19/24 at 4:09 PM Staff 22 (Therapy Director) verified Resident 3 participated in therapy from 6/25/24 to 8/3/24 for leg ROM. Staff 22 verified a RA program was established. If RA was determined to be appropriate the RA staff would be trained in the program and then the program would be implemented. Staff 22 stated she did not see a RA program in the RA book. On 11/19/24 at 4:42 PM Staff 5 (RA) stated he worked in the facility for many years and never worked with Resident 3. On 11/19/24 at 4:55 PM Staff 4 (RN Patient Care Coordinator) stated if therapy recommended a RA program, they set up the exercises and provided a copy of the referral to her. She then ensured the resident was provided restorative services. After a period of time if the resident did not participate the RA program would be re-reevaluated and determined if it should continue or discontinue. Staff 4 stated Resident 3 historically refused therapy. Staff 4 stated she was never provided a RA referral to implement for Resident 3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure respiratory treatments were implemented timely and diagnostic results were available in the medical record timely for 1 of 1 sampled resident (#1) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 1 admitted to the facility in 8/2021 with a diagnosis of a stroke. Progress Notes revealed: -10/8/24 Resident 1 was assessed by her/his NP for shortness of breath and orders were placed for a PRN nebulizer (machine which turns liquid medicine into a mist that can be inhaled to treat lung conditions). The note was not signed by the NP as completed until 10/26/24. -10/10/24 Resident 1 had shortness of breath, wheezing, and the physician was faxed to obtain an order for a nebulizer. -10/11/24 Resident 1 had chest pain with deep breaths, an order for a chest x-ray was obtained, and staff were waiting for results. -10/17/24 staff called radiology for x-rays obtained on 10/11/24. -10/21/24 staff confirmed radiology was completed on 10/11/24. Resident 1's 10/2024 MAR revealed her/his nebulizer was started on 10/10/24 and not started on 10/8/24 when prescribed by the NP. Resident 1's record indicated the x-ray ordered on 10/11/24 was faxed to the facility on [DATE]. On 11/19/24 at 2:00 PM Staff 4 (RN Patient Care Coordinator) stated when a medical provider assessed residents they communicated their findings with facility staff, or wrote orders. Staff 4 stated if an x-ray was ordered and obtained, the results were usually in the chart within one week. If the results were not in the record staff called for the results. Staff 4 acknowledged the x-ray was not faxed to the facility until 10/28/24. Staff 4 was not sure the reason why the nebulizer was not started on the day the NP assessed Resident 1.

Based on interview and record review it was determined the facility failed to monitor a resident's thyroid hormone level for 1 of 5 sampled residents (#1) reviewed for medications. This placed residents at risk for a non-therapeutic medication regimen. Findings include: Resident 1 admitted to the facility in 8/2021 with a diagnosis of obesity. A 9/20/24 Order Summary Report revealed Resident 1 was administered Synthroid (hormone to increase thyroid levels). The start date was 10/9/21. Resident 1's clinical record revealed her/his last TSH (thyroid stimulating hormone; monitors thyroid function) test was obtained on 11/20/22 and the results were within therapeutic range. No additional TSH test results were in the clinical record. On 11/19/24 at 2:00 PM Staff 10 (LPN IP) stated TSH levels were usually checked annually. A request was made to Staff 10 to provide documentation a TSH level was obtained yearly after 2022 or a rationale was in the resident's record indicating it was not required. No additional information was provided. On 11/19/24 at 5:00 PM in interview with Staff 4 (RN Patient Care Coordinator) and Staff 2 (DNS), Staff 2 stated stated the pharmacy reported the TSH was usually checked annually.

Based on observation, interview and record review it was determined the facility failed to maintain water temperatures for 2 of 6 sampled residents (#s 27 and 88) reviewed for environment and accidents. This placed residents at risk for burns. Findings include: 1. Resident 27 admitted to the facility 10/2024 with a diagnosis of a wedge compression fracture. An 10/2024 admission MDS revealed Resident 27 was cognitively intact. Resident 27 resided in Birch Hall. On 11/19/24 at 10:54 AM Resident 27 stated on one occassion she/he used the sink to wet her/his hair. On 11/19/24 at 10:56 AM Staff 6 (Maintenance Director) used a digital thermometer to test the hot water temperature at the tap of the sink in Resident 27's room. The thermometer indicated the hot water temperature was 125 degrees F. Staff 6 acknowledged the temperature of the hot water in Resident 27's room needed to be dialed down. 2. Resident 88 admitted to the facility 11/2024 with a diagnosis of hip surgery. A 11/14/24 admission MDS revealed Resident 88 was cognitively intact. Resident 88 resided in Cedar Hall. On 11/18/24 at 2:59 PM te hot water at the tap of the sink in Resident 88's bathroom was hot to touch when checked by the surveyor. On 11/19/24 at 9:30 AM Resident 88 stated the water was very hot if she/he was not careful, but she was able to adjust the temperature. On 11/19/24 at 9:51 AM Staff 6 (Maintenance Director) measured the temperature of the hot water in Resident 88's bathroom and it was observed to be 126 degrees F. Staff 6 stated the hot water heater was in a room adjacent to Resident 88's bathroom. On 11/19/24 at 2:21 PM Staff 6 stated he performed weekly water temperature checks in random resident rooms. Staff 6 indicated his goal was to keep the water temperature between 113 and 118 degrees F. Staff 6 stated no one reported concernsregarding excess water temparature in resident rooms.

Based on observation, interview and record review it was determined the facility failed to ensure concerns regarding proper food temperatures were addressed for Resident Council and 2 of 5 sampled residents (#s 9 and 25) reviewed for food. This placed residents at risk for food that was not palatable. Findings include: A 9/9/24 computer dashboard communication revealed CNAs were provided a reminder to not reheat anything for a resident in a microwave oven because resident safety and staff licenses were at risk. Staff were given the following direction: Coffee-offer to get them a new cup. Food-ask the kitchen to reheat the food. 1. On 11/20/24 at 11:00 AM nine residents attended a Resident Council meeting. A majority of the residents in attendance agreed staff were not allowed to warm or address cold food concerns when a resident stated she/he was concerned about cold food. On 11/20/24 at 8:04 AM Staff 11 (Dietary Manager) stated the kitchen had one additional meal available if a resident requested warmer food during a meal service. Staff 11 stated food handled by a resident could not be reheated in the kitchen due to cross-contamination. Staff 1 (Administrator) stated she was not aware of reports related to residents' cold food and acknowledged staff education was necessary to address residents' cold food concerns. 2. Resident 9 admitted to the facility in 2020 with diagnoses including chronic pain and dementia. A 9/19/24 Annual MDS indicated Resident 9 had mild cognitive impairment. On 11/20/24 at 12:06 PM Resident 9 was observed in her/his room eating lunch with frozen strawberries on her/his plate. Resident 9 stated she/he was waiting for the strawberries to thaw before she ate them and indicated staff did not know how to address issues with cold food. Resident 9 stated she/he was mobile and routinely went to the kitchen to directly address concerns regarding cold food. On 11/20/24 at 8:04 AM Staff 11 (Dietary Manager) stated the kitchen had one additional meal available if a resident requested warmer food during a meal service. Staff 11 stated food handled by a resident could not be reheated in the kitchen due to cross-contamination. Staff 1 (Administrator) acknowledged staff education was necessary to address residents' cold food concerns. 3. Resident 25 admitted to the facility in 6/2023 with diagnoses including stroke and malnutrition. The 8/9/23 Orders Details for Resident 25's diet indicated she/he received regular nutritionally enhanced meals. A 5/31/24 revised care plan indicated Resident 25 had poor intake and to encourage and offer alternatives with respect to her/his preferences. On 11/18/24 at 12:10 PM Resident 25 stated she/he ate meals slowly and staff did not reheat her/his meals or beverages to accommodate her/his needs. Resident 25 stated she/he would eat more if her/his food was warmed including fruit. On 11/19/24 at 12:48 PM Staff 17 (CNA) stated staff were not allowed to reheat residents' food once a meal was touched by a resident. Staff 17 stated Resident 25 complained about cold food about 25 percent of the time, but nothing could be done to address Resident 25's concerns. On 11/19/24 at 3:39 PM Staff 18 (CNA) stated staff were not allowed to reheat residents' food, but the kitchen was to provide new servings of the meal if a resident requested warmer food. On 11/20/24 at 8:04 AM Staff 11 (Dietary Manager) stated the kitchen had one additional meal available if a resident requested warmer food during a meal service. Staff 11 stated food touched by a resident could not be reheated in the kitchen due to cross-contamination. Staff 1 (Administrator) acknowledged staff education was necessary to address residents' cold food concerns.

Based on interview and record review it was determined the facility failed to provide appropriate care and treatment, and failed to follow physician orders for 1 of 1 sampled resident (#1) reviewed for injury of unknown origin. This placed residents at risk for injuries and lack of physician oversight. Findings include: Resident 1 was admitted to the facility in 1/2021 with multiple fractures of ribs. a. A 12/15/21 revised care plan revealed Resident 1 had moderate to severe calcific tendinitis (calcium deposits form in the tendon) to her/his hands. Interventions for Resident 1 were described as areas of pain to the left shoulder, left knee pain and right wrist/hand. A 1/10/22 Incident Note indicated Resident 1 was noted to have blisters on her/his abdominal area. Resident 1 was unable to describe how they occurred. Resident 1 was placed on alert charting. A 1/10/22 at 11:38 AM New Skin Issue investigation indicated Resident 1 was found to have intact blisters on her/his lower abdominal area during cares. Resident 1 was unaware of the blistering. The injury location was indicated as the front right and left iliac crest (the three most significant bones that make up the hip bone). The blisters were around the umbilical area from three o'clock to seven o'clock. There was a total of three blisters around her/his belly button with the larger blister measuring five cm by six cm. There was some pale and blanchable redness around the large blister. A hot water bottle was not found in Resident 1's room and was ruled out as a contributing factor during the investigation. After the investigation was completed, it was determined the hot water bottle was not used for more than 12 hours. The last use was on the prior evening shift and was placed on Resident 1's hand with a pillowcase over the water bottle to prevent direct contact with her/his skin. Resident 1 indicated the hot water bottle was used on her/his hand and the way she/he sat up in her/his chair if the water bottle rolled out of place or got dropped it would land on her/his upper abdomen and not where the blisters were located. The hot water bottle was removed from her/his room to prevent potential future skin issues and Resident 1 was aware of the removal. An undated handwritten statement by Staff 12 (CNA) indicated she bought hot packs for Resident 1 earlier in 12/2021 and was informed the hot packs were allowed because they did not require to be microwaved. The hot packs were bladder bags which were filled with warm tap water. On 1/9/22 before Resident 1 presented with blisters, when staff put her/him into bed, Resident 1 liked a large pillow under each arm and rested her/his hands on those pillows. Resident 1's hot packs were placed on the top of the pillows and did not meet her/his skin on her/his abdomen. The hot packs were only for her/his hands because she/he had pain. Staff placed them into a pillowcase or placed a towel over them so there was no direct contact to her/his skin. No documentation was found in clinical records that Resident 1 was care planned or had a physician order for treatment or intervention using hot packs, hot water bottles or warm rags to be placed on her/his hands. A 3/15/22 Wound Clinic Progress Notes indicated Resident 1 presented with an open wound to the abdomen caused by a hot water bottle. The burn wound was debrided, the history came from the family and Resident 1's medical records. The age of the wounds was 10 weeks and they measured 9.5 cm by 8.5 cm by 0.1 cm, with a total wound area of 80.75 cm2. There was subcutaneous (beneath all layers of skin) eschar (dead tissue which is cast off from the surface of the skin, particularly after a burn injury but also can be seen in gangrene, ulcer, fungal infections, and bite wounds), granulation (new connective tissue which forms on the surface of a wound during healing process) was 10 percent, slough (necrotic tissue which needs to be removed) was 30 percent, unstable eschar was 50 percent, stable eschar was 10 percent, and serosanguineous (both blood and liquid part of the blood which is yellowish in color) drainage was present. The pain level was noted at five out of 10 since the last visit. Resident 1 was diagnosed with a burn of the abdomen with an unspecified burn degree. A 9/19/22 Significant Change MDS indicated Resident 1 had a BIMS of 9 indicating moderate cognitive impairment. On 12/8/22 at 7:59 AM Witness 1 (Complainant) stated the physicians who saw Resident 1's blisters indicated it was caused from burning to the skin. Witness 1 stated she was first told by the facility it was from a medication reaction, but never heard what medication. She was then informed it was from Resident 1's incontinent brief which caused the blisters on her/his abdomen. Witness 1 stated she believed the CNAs were trying to help Resident 1 with her/his cold hands when placing the hot water bottle. On 12/8/22 at 10:10 AM Resident 9 stated she/he was Resident 1's roommate in 1/2022 and she/he saw staff using a hot water bottle on Resident 1 once or twice and heard a conversation that they could no longer use the hot water bottle for Resident 1 anymore. On 12/13/22 at 10:30 AM Witness 7 (Wound Clinic Family Nurse Practitioner) stated she did not believe the wounds on Resident 1's abdomen were caused by an incontinent brief. Witness 7 stated her assessment was the wounds were burns caused by the hot water bottle as the wounds were in the shape of a hot water bottle. On 12/14/22 at 12:38 PM Staff 2 (DNS) stated she knew the hospital and the wound clinic described Resident 1's abdominal wounds as burns and that is what the family believed. Staff 2 stated she believed that was why the hospital and wound clinic documented the wounds as burns. Staff 2 stated Staff 3 (RNRCM) ruled out the wounds as burns and the investigation found the blisters were caused from Resident 1's incontinent briefs which developed eschar as they evolved. On 12/16/22 at 9:51 AM Staff 31 (RN) stated she observed the hot water pack in Resident 1's room and she removed it from the room. On 12/16/22 at 10:59 AM Staff 10 (CNA) stated she used warm rags which she put in a pillowcase for Resident 1 but she did not use a hot water packs. Staff 10 stated someone gave Resident 1 a water bag thing but she never saw any one use it. Staff 10 stated she saw the wounds on Resident 1's abdomen and they were above her/his belly button. Staff 1 stated Resident 1's brief went below her/his belly button for comfort. Staff 10 stated there were two to three wounds in one area and one was bigger and they were not all the same size. Staff 10 stated since working as a CNA for 19 years she never saw a brief cause wounds like Resident 1 had on her/his abdomen. Staff 19 stated she did not see burns on a resident in her 19 years working as a CNA. On 12/20/22 at 12:23 PM Staff 12 (CNA) stated she was the staff member who purchased the hot packs for Christmas in 12/2021 for Resident 1's hands. Staff 12 described the hot pack as an old-fashioned pack which was balloon shaped, was made of rubberized material, and it was pleated from the base to the top which had the lid in which to put in either cold or warm water. Staff 12 stated she spoke to the RCM before purchasing the hot packs to make sure it was okay to use. Staff 12 stated she used warm tap water in the pack and either placed them into a pillowcase or placed a towel on top of the pack before placing on Resident 1's hands. On 12/21/22 at 9:33 AM Staff 38 (Nurse Practitioner) stated she believed the abdominal blisters could have been caused by the brief from the plastic fold and from the brief being too small on Resident 1. Staff 38 stated it was also possible the blisters could have been caused from a burn. On 12/22/22 at 10:01 AM Staff 1 (Administrator) and Staff 2 (DNS) confirmed Resident 1 did not have physician orders and was not care planned for the use of a hot water packs. b. A 1/10/22 Incident Note indicated Resident 1 had blisters to her/his abdominal area. Resident 1 was unable to describe how they occurred. Resident 1 was placed on alert charting. A revised 2/1/22 care plan indicated Resident 1 required one staff for incontinent care, she/he may use two staff for comfort, and she/he was totally incontinent of bowel. Resident 1 used bariatric size disposable incontinent briefs. A 1/10/22 at 11:38 AM New Skin Issue investigation indicated Resident 1 was found to have intact blisters on her/his lower abdominal area during cares. Resident 1 was unaware of the blistering. Notes written on 1/11/22 indicated staff noted multiple fluid fill blisters on Resident 1's abdomen. The blisters were around the belly button area from three o'clock to seven o'clock. There was a total of three blisters around her/his belly button and the larger blister measured five cm by six cm. There was some pale and blanchable redness around the large blister. Staff indicated they used a different size incontinent brief as the bariatric brief normally used for Resident 1 was on back-order and was out of stock at the facility. The staff used a brief which was one size smaller on Resident 1. Staff stated the brief was a bit snugged on her/him and might have caused compression and friction creating the blisters on her/his lower abdomen and belly button area. An undated handwritten statement by Staff 12 (CNA) indicated she was assisting Resident 1 into bed and her/his brief was not the right size because they were not available. Staff 12 noticed a small open area on her/his left side where the brief was fastened and mentioned the briefs were too small. Staff 12 proceeded to fasten the brief as loose as possible so it was not cutting into her/his skin. A 1/14/22 Physician/ARNP/PA Note indicated Staff 38 (Nurse Practitioner) indicated Resident 1 was evaluated for a large fluid filled blister to lower abdomen. Staff 38 wrote CAN believe blister came with using different adult briefs causing reaction, and recommended to allow the blister fluid to reabsorb into Resident 1's body. On 12/8/22 at 7:59 AM Witness 1 (Complainant) stated she was first told by the facility the blistering was from a reaction to medication, but never heard what medication, and she was then informed it was from Resident 1's brief which caused the blisters on her/his abdomen. On 12/14/22 at 12:38 PM Staff 2 (DNS) stated Staff 3 (RNRCM) ruled out the abdominal wounds as burns and the investigation found the blisters were caused from Resident 1's incontinent briefs which developed eschar as they evolved. On 12/20/22 at 12:23 PM Staff 12 (CNA) stated she had to use smaller size briefs for a while as the facility was out of stock for Resident 1's size. Staff 12 stated the brief fit under Resident 1's abdominal fold and Staff 12 usually placed a pillowcase in Resident 1's abdominal fold for comfort. Staff 12 stated the brief was not touching the area of the abdominal wounds and she did not know how the wounds occurred. Staff 12 stated it was super random. On 12/21/22 at 9:33 AM Staff 38 (Nurse Practitioner) stated she believed the blisters could have been caused by the brief from the plastic fold and from the brief being too small on Resident 1. On 12/22/22 at 10:01 AM Staff 1 (Administrator) and Staff 2 (DNS) stated when the facility became aware Resident 1's brief size was out of stock and on back-order the facility placed an order with a different company. Staff 2 stated if a smaller size brief had to be used on a resident it was suggested not to attach the tabs. c. A 1/20/21 admission Profile revealed Resident 1 had ace wraps on both lower legs and usually wore stockings at home which would be on during the day and off during the night. Resident 1 used the ace wraps 24 hours a day seven days a week since she/he went to the hospital. Lotion was applied to Resident 1's legs and the wraps were put back into place. A review of Resident 1's clinical medical records revealed no physician order for the leg wraps to be applied on 1/20/21. On 12/22/22 at 10:23 AM Staff 1 (Administrator) and Staff 2 (DNS) stated it was expected of staff to reach out to a physician for an order if Resident 1 insisted on having the leg wraps be put on.

Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 2 of 6 sampled residents (#s 1 and 11) reviewed for pressure ulcers and change of condition. This placed residents at risk for inaccurate clinical records. Findings include: 1. Resident 1 was admitted to the facility in 1/2021 with diagnoses including diabetes. A 2/24/22 Weekly Non-Pressure Skin Condition Assessment revealed Resident 1 had what started as superficial wounds on the gluteal cleft and bilateral buttocks area. The wound bed was red and the Periwound was macerated. The measurement of the wound was 2 cm length by 1 cm width, and a depth of 0.28 cm, with a small amount of serous exudate (clear, thin and watery discharge). Wound bed granulation tissue was present which was pale pink to beefy red in color, and the surrounding skin was bright red and blanchable. The progress of the wound was noted as improved but fragile, and the treatment of calcium alginate on the open and moist wounds would continue. A 3/2/22 Hospital Wound Care Progress Note revealed Resident 1 had a Stage 2 sacrum pressure ulcer which was present on admission. A 3/7/22 admission Profile for readmission revealed Resident 1 had non-pressure skin conditions which were present on admission. The profile indicated Resident 1 did not have a pressure ulcer, venous stasis, arterial or diabetic ulcers. Resident 1 had an open area to the sacrum and right buttock with no measurements of the wounds. No other information was provided about the sacrum or right buttock wounds. A 3/7/22 Skin Condition assessment sheet with body diagrams indicated an open area to Resident 1's sacrum area and right buttock. A 3/15/22 Wound Clinic Progress Notes revealed Resident 1 had a diagnosis of a Stage 2 pressure ulcer to the sacral region. The wound measured 2 cm in length by 0.5 cm in width with a depth of 0.1 cm, and an area of 1 cm2. A 3/18/22 Weekly Non-Pressure Skin Assessment revealed Resident 1 had superficial wounds to the gluteal cleft with a length of 2 cm by width of 1 cm and a depth of .28 cm. No documentation was found in clinical records for a pressure ulcer assessment of Resident 1's sacrum Stage 2 pressure ulcer. On 12/22/22 at 10:05 AM Staff 1 (Administrator) and Staff 2 (DNS) stated when Resident 1 first developed the wound on her/his buttocks it was determined to be moisture associated skin damage. When Resident 1 discharged to the hospital the wound presented as a pressure ulcer and the hospital did not see the wound in its initial stages. The hospital provided their determination to the wound clinic and the facility did not agree with the staging of the wound and felt it was a moisture associated wound. 2. Resident 11 was admitted to the facility in 11/2022 with diagnoses including hip dislocation. A 12/2022 TAR instructed staff to administer Thera Worx Relief (topical solution to relieve muscle spasms) topically every four hours PRN for spasms. It was documented Resident 11 was administered Thera Worx on 12/3/22 and 12/7/22 at 9:24 AM. On 12/7/22 at 11:53 AM Resident 11 was screaming and requesting the blue thing to be removed from between her/his legs as it was causing her/him pain. On 12/8/22 at 9:29 AM Staff 8 (LPN) stated she administered the Thera Worx to Resident three instances on 12/7/22 and she forgot to document the second two administrations on the TAR. Staff 8 stated the blue wedge was in between Resident 11's legs so her/his hip would not become dislocated. On 12/9/22 at 9:37 AM Resident 11 stated the muscle spasms she/he was having the last few days caused her/him to scream out in pain as she/he could not move to relieve the pain. On 12/22/22 at 10:45 AM Staff 1 (Administrator) and Staff 2 (DNS) stated each time a PRN medication was used it should be documented on the TAR.

Based on observation and interview it was determined the facility failed to provide dignity during dining for 1 of 1 sampled dining rooms observed for dining assistance. This placed residents at risk for an undignified dining experience. Findings include: On 1/13/20 at 6:10 PM Staff 10 (CNA) was observed standing and assisting two residents with dining during the evening meal. On 1/14/20 at 12:30 PM and 1/15/20 at 12:23 PM Staff 6 (CNA) was observed standing while assisting two residents with dining during the afternoon meal. On 1/15/20 at 4:12 PM Staff 2 (DNS) stated she expected staff to interact with residents during meals and not stand over them.

Based on interview and record review it was determined the facility failed to ensure narcotic drug records were in order and an account of all controlled drugs was maintained for 3 of 4 medication carts reviewed for medication storage. This placed residents at risk for drug diversion. Findings include: On 1/14/20 at 9:45 AM the D hall medication cart Narcotic log book revealed 24 times out of 107 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 1/14/20 at 10:30 AM the A hall medication cart Narcotic log book revealed 27 times out of 107 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 1/14/20 at 11:00 AM the B hall medication cart Narcotic log book revealed 17 times out of 109 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 1/14/20 at 10:22 AM Staff 2 (DNS) verified the missing signatures in the Narcotic books. Staff 2 acknowledged the Narcotic book always needed to be signed by two nurses to verify the count was accurate.

Based on observation, interview and record review it was determined the facility failed to provide therapeutic heart healthy diets for 1 of 1 kitchens reviewed for dining. This placed residents at risk for worsening health conditions. Findings include: On 1/15/20 at 7:22 AM Staff 5 (Cook) was observed during the breakfast meal portioning hot food according to a typed document posted on the wall near the kitchen steam table titled Portion Sizes and Diets. The document included the following statements: -CCHO (Controlled Carbohydrate) diets-regular protein, regular vegetables, half serving starch, half serving desserts or diabetic dessert. -Heart Healthy-Regular Portions??? Small serving of desserts. On 1/15/20 at 8:10 AM Staff 4 (Dietary Manager) indicated she was not aware of the Portion Sizes and Diet document posted on the kitchen wall. Staff 4 confirmed staff were to follow therapeutic diets as order by the physician for each resident and provide portion sizes and food restriction of therapeutic diets according spreadsheets provided by the Registered Dietitian. Staff 4 also confirmed the posted document did not have the correct portions sizes or food restrictions of a heart healthy therapeutic diet. On 1/15/20 at 2:17 PM Staff 8 (RD) stated she was not aware of the Portion Sizes and Diets document and staff were to follow the therapeutic diet spreadsheets provided. On 1/15/20 at 4:23 PM Staff 11 (RNCM) provided documentation indicating six residents had orders for a heart healthy therapeutic diet at the time of the survey. On 1/16/20 at 9:32 AM Staff 9 (RD) indicated the last kitchen assessment she completed was during the summer when she observed staff following the therapeutic diet spreadsheets. Staff 9 also stated she was not aware of the Portion Sizes and Diets document. On 1/16/20 at 12:16 PM Staff 2 (DNS) stated the kitchen was to provide therapeutic diets as ordered.

Based on observation, interview and record review it was determined the facility failed to ensure comprehensive assessments were completed for falls and pain for 2 of 8 sampled residents (#s 14 and 21) reviewed for accidents and unnecessary medications. This placed residents at increased risk for pain and falls with injury. Findings include: 1. Resident 14 was admitted to the facility in 11/2017 with diagnoses including Stage 3 lymphoma (cancer), compression fractures of the back and arthritis. Resident 14's 11/20/17 admission orders included the following medications to treat pain: gabapentin (nerve pain), Voltaren (topical analgesic) and Percocet (opioid analgesic). On 4/26/18 at 6:50 PM Witness 4 (Family) revealed Resident 14 had experienced pain issues for years and her/his pain continued to worsen due to the resident's recent fall and arthritis. Resident 14's 11/27/17 admission MDS did not include a Pain CAA. On 4/30/18 at 11:15 AM Staff 7 (RNCM) acknowledged a Pain CAA was not completed for Resident 14 upon admission. 2. Resident 21 was admitted to the facility in 3/2018 with diagnoses including heart attack with bypass surgery and weakness. Resident 21's 2/23/18 hospital record revealed she/he experienced a fall at home prior to transport to the hospital. The resident's 3/12/18 admission MDS Falls CAA indicated she/he had weakness and was at risk for falls but did not include Resident 21's history of falls. In an interview on 5/1/18 at 9:44 AM Staff 6 (RNCM) stated she missed the documentation regarding Resident 21's fall at home and did not include it in the Fall CAA.

Based on interview and record review it was determined the facility failed to ensure a comprehensive psychotropic drug care plan was developed for 1 of 5 sampled residents (#14) reviewed for unnecessary medications. This placed residents at risk for unmet medication needs. Findings include: Resident 14 was admitted to the facility in 11/2017 with diagnoses including depression and compression fractures of the back. The resident's 11/20/17 admission orders included Zoloft (antidepressant) for treatment of depression. Psychotropic Drug Reviews on 12/5/17 and 1/10/18 revealed no psychotropic medication care plan noted. On 1/19/18 (two months after admission) a focus area for psychotropic medication therapy related to depression was added to the comprehensive care plan. On 4/30/18 at 3:29 PM Staff 6 (RNCM) acknowledged Resident 14's psychotropic medication care plan was not completed timely.

1. Based on interview and record review it was determined the facility failed to initiate weekly wound skin monitoring for 1 of 1 sampled residents (#1) reviewed for non-pressure related skin conditions. This placed residents at risk for wound complications such as delayed healing and infection. Findings include: Resident 1 was admitted to the facility in 4/2018 with diagnoses including surgical colon resection, diabetes, kidney failure and malnutrition. The care plan dated 4/7/18 included instructions to monitor skin conditions per protocol. Additionally, staff were to assess, record and monitor wound healing per policy which included to measure length, width and depth where possible. Staff were also to assess and document the status of the wound perimeter, wound bed and healing progress, report improvements and declines to the MD, and follow facility policies and protocols for the prevention/treatment of skin breakdown. The 4/14/18 Pressure Ulcer CAA indicated the resident had a decline in ADL functioning, needed continued assistance, and came into the facility with multiple ulcers. The resident's skin was fragile due to weakness and the presence of ulcers such as SDTI (suspected deep tissue injury) on bilateral heels, open areas on the upper back, bilateral buttock shearing (denuded tissue) and SDTI on the top of the right and left toes. Resident 1 had diagnoses including diabetes, kidney failure and malnutrition which could contribute to poor wound healing. The resident remained at risk for new skin breakdown, non-healing ulcers and ulcer infections. Staff were to monitor the resident's skin condition. The 4/20/18 Nutrition Risk Assessment indicated the resident had multiple skin issues. There were open areas on the spine and bilateral buttocks, an opened blister area on the right heel, SDTIs on the left heel and two great toes and two surgical incisions on the abdomen; one for colonoscopy and one from laparoscopy. The resident's appearance was described as cachectic (physical wasting with loss of weight and muscle mass due to disease). The facility's policies and procedures for Non-Pressure Skin Condition Evaluation instructed staff to monitor non-ulcer wounds such as the bilateral buttocks shearing to ensure appropriate care was provided, promote healing and prevent infection. Staff were to complete and update weekly a Non-Pressure Skin Condition Evaluation for a skin condition likely to result in complications. The Evaluation was to include dates, numbered body diagrams identifying locations and condition of skin issues, measurements, types and amounts of exudate present, tunneling, undermining, odor, condition of wound bed, peri wound skin and wound edges. A summary of relevant findings should be included as well as documentation of the progress of wound healing, current progression of the wound and planned treatment and preventative interventions. During a review of Resident 1's medical record no Non-Pressure Skin Condition Evaluation sheets were located for the bilateral buttocks shearing skin condition. On 5/1/18 at 9:51 AM Staff 2 (DNS) acknowledged the Non-Pressure Skin Condition Evaluations for Resident 1 were not completed for the bilateral buttocks shearing. 2. Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 5 sampled residents (#s 14 and 27) reviewed for medications. This placed residents at risk for adverse side effects of medication. Findings include: a. Resident 27 was admitted to the facility in 2018 with diagnoses including diabetes. The 3/22/18 physician order indicated Resident 27 was to receive tramadol (pain medication) every four hours PRN for pain. The 3/2018 and 4/2018 MARs indicated Resident 27 received tramadol on 17 occasions with a pain level of zero. On 4/26/18 at 11:38 AM Staff 4 (RNCM) acknowledged Resident 27 received tramadol on the above listed occasions when her/his pain was zero and the resident should be given pain medication only when pain is documented. b. Resident 14 was admitted to the facility in 11/2017 with diagnoses including Stage 3 lymphoma (cancer), compression fractures of the back and arthritis. The facility's House Bowel Protocol Instructions included the following guidance: - The day shift licensed nurse reviews the bowel records daily on their shift and create the bowel list. - If the resident has not had a BM (bowel movement) for 3 days / 9 shifts or has only had 3 small BMs in a 5 day period: Step 1: At the beginning of evening shift administer milk of magnesia or Dulcolax. If Step 1 offers no results, Step 2: at the end of night shift administer a suppository. If no results, Step 3: at the end of the day shift administer an enema. Notify MD for further orders should protocol not resolve bowel problem. Resident 14's medical record revealed she/he did not have a BM for 10 shifts from 4/1/18 through 4/4/16. On 4/4/18 the eleventh shift without a BM, the resident was administered Ducolax that was effective. The medical record indicated Resident 14 did not have a BM for 16 shifts from 4/5/18 through 4/11/18 (six days). During this period the resident was administered a Dulcolax on 4/8/18 and it was ineffective. No additional bowel care was provided and the resident did not have a BM until the seventeenth shift. Resident 14's medical record revealed the resident did not have a BM for 14 shifts from 4/12/18 through 4/16/18 (four days). On 4/16/18, the fourteenth shift with no BM, the resident was administered a Dulcolax and she/he had a BM on the next shift. The medical record revealed Resident 14 did not have a BM for 18 shifts from 4/17/18 through 4/22/18 (six days). During this period the resident had three small BMs recorded and was administered Dulcolax on 4/21/18 but no results were recorded. The resident did not have a BM until the nineteenth shift and no additional bowel care was provided. On 4/26/18 at 6:50 PM Witness 4 (Family) indicated Resident 14 had problems with constipation because she/he was not able to move well because of pain and she/he did not leave the room very often. On 4/30/18 at 10:03 PM Staff 13 (LPN) confirmed at the start of each shift nurses were to review each resident's BM record and provide bowel care according to protocol. In an interview on 4/30/18 at 3:37 PM Staff 6 (RNCM) acknowledged Resident 14 experienced episodes of constipation and was not provided with bowel care as ordered by the physician.

2. Resident 27 admitted to the facility in 2018 with diagnoses including diabetes. The 3/14/18 pharmacy recommendation indicated Resident 27 received PRN haloperidol (antipsychotic) three times daily and had not received any PRN doses. The recommendation was to discontinue PRN haloperidol. The pharmacy recommendation was not signed by a physician until 3/22/18 which was 8 days after the recommendation. On 4/30/18 at 1:24 PM Staff 2 (DNS) stated her expectation for a pharmacy recommendation follow up for a psychotropic medication from the provider was one day and she was unaware of an existing facility protocol regarding timeliness of recommendations. On 4/30/18 at 3:01 PM Staff 4 (RNCM) provided a Timeliness of Medication Regimen Review (MRR) Reports document. It did not include timeframes for the facility and consultant pharmacist to identify a timely response to recommendations or identified irregularities. Staff 4 acknowledged the Timeliness of Medication Regimen Review was blank and did not include timeframes. Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were completed for 3 of 7 sampled residents (#s 19, 27 and 40) reviewed for unnecessary medications and catheters. This placed residents at risk for lack of medication oversight. Findings include: 1. Resident 40 admitted to the facility in 2018 with diagnoses including a leg fracture and depression. Resident 40's current physician orders included the following: - duloxetine (antidepressant) started 2/10/18 - Lexapro (antidepressant) started 2/10/18 Pharmacy reviews for 2/2018 and 4/2018 recommended the facility provide a rationale for multiple antidepressant use. Record review revealed no evidence the facility addressed the 2/2018 and 4/2018 pharmacy recommendations. On 4/30/18 at 5:10 pm Staff 4 (RNCM) confirmed the facility did not follow-up on the pharmacy recommendations to provide justification for multiple antidepressant use. 3. Resident 19 was admitted to the facility in 1/2018 with diagnoses including pneumonia and a right hip fracture. A 1/10/18 Pharmacy Consultation Report indicated Resident 19 received the antibiotics Augmentin and azithromycin and the 1/2018 MAR indicated the medications were for infection. The Consultation Report indicated a specific diagnosis was required for antibiotic use. A copy of the Pharmacy Consultation Report was signed by the physician on 1/24/18 and there was no additional information included to indicate a specific diagnosis was provided for the use of the antibiotics. On 5/1/18 at 10:43 AM Staff 6 (RNCM) stated the report was faxed to the physician by Staff 2 (DNS) and acknowledged there was no follow-up information provided.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary medications for 1 of 2 sampled residents (#45) reviewed for choices. This placed residents at risk for adverse side effects of medication. Findings include: Resident 45 was admitted to the facility in 2018 with diagnoses including heart failure. The 3/29/18 physician order indicated Resident 45 should stop taking atorvastatin (a medication for high cholesterol). The 4/2018 MAR indicated Resident 45 received atorvastatin daily from 4/1/18 to 4/9/18. On 4/26/18 at 7:15 AM Staff 4 (RNCM) acknowledged the atorvastatin was administered from 4/1/18 to 4/9/18 and it was a medication error.

Based on interview and record review it was determined the facility failed to ensure records were accurate and complete for 1 of 5 sampled residents (#27) reviewed for medication. This placed residents at risk for unmet needs. Findings include: Resident 27 was admitted to the facility in 2018 with diagnoses including diabetes. a. The 3/14/18 pharmacy recommendation indicated Resident 27 received haloperidol (antipsychotic) 0.5 mg three times daily as needed for dementia with behaviors and had not received any PRN doses. The physician indicated Resident 27 was to receive haloperidol 0.5 mg once daily instead. The pharmacy recommendation was signed by the physician on 3/22/18. The 3/22/18 signed physician order summary indicated Resident 27 was to receive haloperidol 0.5 mg TID PRN. On 4/27/18 at 8:29 AM Staff 2 (DNS) acknowledged that both orders were signed on 3/22/18 by the physician and acknowledged the discrepancies between the haloperidol orders. b. A 3/22/18 physician order indicated Resident 27 was to receive Oxygen [02] (2) Liters per minute, Delivery: (cannula, mask) to keep sats [blood oxygen saturation] greater than ___%(02) every shift PRN orders may be discontinued if not used in 60 days. The 3/2018 and 4/2018 TARs indicated Monitor 02 sats every shift and as needed to keep 02 sats >___% (02) every shift. On 4/26/18 at 11:38 AM Staff 4 (RNCM) acknowledged the 3/22/18 physician order and the 3/2018 and 4/2018 TARs did not indicate Resident 27's minimum oxygen saturation percentage.

Based on observation and interview it was determined the facility failed to follow proper infection control techniques during a dressing change for 1 of 3 sampled residents (#32) reviewed for pressure ulcers. This placed residents at risk for acquiring an infection. Findings include: Resident 32 was admitted to the facility in 2018 with diagnoses including cellulitis. On 4/25/18 at 1:03 PM Staff 6 (RNCM) was observed to perform a dressing change for Resident 32 and did not complete hand hygiene between the glove changes after removing old dressings and placing new dressings over the wound. On 4/25/18 at 1:40 PM Staff 6 acknowledged she did not perform hand hygiene between glove changes.

Based on interview and record review it was determined the facility failed to ensure accurate assessments for 4 of 11 sampled residents (#s 14, 19, 21 and 37) reviewed for accidents, nutrition, catheter care and unnecessary medications. This placed residents at risk for inaccurate assessments. Findings include: 1. Resident 14 was admitted to the facility in 11/2017 with diagnoses including Stage 3 lymphoma (cancer), compression fractures of the back and arthritis. Resident 14's 11/27/17 admission MDS Section J - Health Conditions revealed the pain assessment was not completed and was coded resident rarely/never understood. On 4/27/18 at 11:46 AM Staff 12 (LPN) stated Resident 14 was able to verbalize her/his needs including complaints of pain. In an interview on 4/30/18 at 3:34 PM Staff 6 (RNCM) acknowledged the pain assessment in Section J was not completed and stated she was unable to remember why she did not do the interview because Resident 14 was interviewable. 2. Resident 19 was admitted to the facility in 1/2018 with diagnoses including pneumonia, a right hip fracture and chronic obstructive pulmonary disease. Resident 19's 1/15/18 admission MDS Section I - Active Diagnoses did not identify any active medical diagnoses. The resident's 1/15/18 admission MDS Section J - Health Conditions indicated Resident 19 had a condition or chronic disease with a life expectancy of less than six months. During an interview on 4/24/18 at approximately 12:15 PM Resident 19 indicated she/he was not on hospice. On 5/1/18 at 8:13 AM Staff 4 (RNCM) acknowledged the MDS was not coded accurately regarding the resident's active medical diagnoses and health conditions. 3. Resident 21 was admitted to the facility in 3/2018 with diagnoses including heart attack with bypass surgery and weakness. According to 2/23/18 hospital records Resident 21 experienced a fall at home prior to transport to the hospital. Resident 21's 3/12/18 admission MDS Section J - Health Conditions was not coded to reflect the resident's fall within the last month prior to entry to the facility. The March 2018 MAR revealed Resident 21 received Plavix (antiplatelet - prevents platelets from binding in blood) from 3/6/18 through 3/12/18. The 3/12/18 admission MDS Section N - Medications indicated Resident 21 received an anticoagulant (decreases blood's clotting ability) during the look back period (3/6/18 through 3/12/18). The RAI Manual current guidance indicated antiplatelet medications are not coded as anticoagulants. During interviews on 4/24/18 at 3:38 PM and 5/1/18 at 9:44 AM Staff 6 (RNCM) acknowledged the coding for Resident 21's fall history and Plavix use was inaccurate. 4. Resident 37 was admitted to the facility in 3/2018 with diagnoses including right hip fracture and dementia. Resident 37's 3/28/18 admission MDS Section N - Medications indicated the resident received an anticoagulant (decreases blood's clotting ability) during the seven day look back period (3/22/18 through 3/28/18). The March 2018 MAR revealed Resident 37 was administered Plavix (antiplatelet - prevents platelets from binding in blood) from 3/22/18 through 3/28/18. The RAI Manual current guidance indicated antiplatelet medications are not coded as anticoagulants. During an interview on 4/26/18 at 3:38 PM Staff 4 (RNCM), Staff 6 (RNCM) and Staff 2 (DNS) acknowledged Plavix was not an anticoagulant and the MDS was coded inaccurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to ensure proper labeling and storage of biologicals for 1 of 4 medication carts and 1 of 1 medication rooms. This placed residents at risk for receiving expired and unsafe medications. Findings include: On [DATE] at 6:49 AM the medication cart for B hall was observed to contain an unlabeled medication syringe with a clear substance inside of it. On [DATE] at 7:12 AM the medication room contained a Tuberculin vial with no open date and a Lantus (long acting insulin) pen with no open date. On [DATE] at 6:49 AM and 7:12 AM Staff 3 (LPN) acknowledged the medication syringe with clear liquid was unlabeled, the Lantus had no open date and the Tuberculin vial had no open date.