**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, record review, pharmacy delivery manifests, and interviews, the facility failed to ensure medications were available and administered as ordered, for 1 of 1 resident (Residents (R)6), reviewed for pharmacy services. Specifically, R6 missed six scheduled doses of a controlled pain medication (Oxycodone), over a three-day period. Finding Include: Review of the facility policy titled Medication Management Program last revised 01/15/25 revealed, The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements .Administering the Medication Pass . 15. If a medication is unavailable, contact the pharmacy and document accordingly. Notify physician for possible alternatives available in e-kits at time of discovery. Review of R6's Face Sheet revealed he was admitted to the facility on [DATE], with diagnoses including but not limited to: pain, spondylosis with radiculopathy, parkinsonism and hemiplegia and hemiparesis. Review of R6's significant change in status Minimum Data Set Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/10/25, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Review of R6's Physician Order Report dated 04/25 showed an active order, originally started on 03/20/24, for Oxycodone 10 milligrams (mg), four times daily (QID) with special instructions to notify MD [as needed] PRN. Review of the Pharmacy Delivery Manifest revealed the following deliveries of Oxycodone 10 mg: 1. 03/12/25, 4:10 AM - Two packs of 30 tablets. 2. 03/28/25, 4:19 AM - 28 tablet. 3. 04/13/25, 11:19 PM - Three packs of 30 tablets and one pack of 28 tablets. Review of a Controlled Drug Receipt/Record/Disposition Form dated 03/28/25, revealed, a total of 58 tablets of Oxycodone 10 mg were received. However, no medication administration was recorded from 04/11/25 at 12:00 AM to 04/14/25 at 12:00 AM. Review of R6's Medication Administration Record (MAR) for the period 04/01/25 - 04/30/25, revealed six missed doses of Oxycodone 10 mg from 04/11/25 through 04/14/25, with the following documentation noted: 1. 04/12/25 at 12:00 AM - Not given: Medication unavailable (noted on 04/11/25 at 11:28 PM). 2. 04/12/25 at 6:00 AM - Not given: Medication unavailable (noted on 04/12/25 at 5:44 AM). 3. 04/13/25 at 12:00 AM - Not given: Medication unavailable (noted on 04/12/25 at 11:21 PM). 4. 04/13/25 at 6:00 AM - Not given: Medication unavailable (noted on 04/13/25 at 5:34 AM). 5. 04/13/25 at 12:00 PM - Not given: Medication unavailable (noted on 04/13/25 at 12:20 PM). 6. 04/13/25 at 6:00 PM - Not given: Awaiting delivery from pharmacy (noted on 04/13/25 at 5:46 PM). Review of R6's Electronic Medical Record did not reveal documentation to indicate the facility staff attempted to obtain the medication through an emergency supply system, or that the pharmacy was notified. During an interview on 05/04/25 at 11:43 AM, R6 stated, I am scheduled to receive oxycodone every 6 hours due to pains in my legs, but on several occasions, I've gone without my pain medication. During an interview on 05/06/25 at 9:18 AM, Licensed Practical Nurse (LPN)1 stated, All nurses are responsible for monitor medications and place orders for more if we notice that it is running low. When medication levels are low, we can initiate a refill directly in the MAR during medication passes. However, with narcotics, we typically remove the medication sticker and fax it to the pharmacy for a refill. During an interview on 05/06/25 at 9:31 AM, the Director of Nursing stated, When a narcotic medication runs out, a new prescription is required. The nurse currently passing medications should have contacted the pharmacy or physician if the medication was unavailable. All nurses have access to the Emergency (E-Kit), and they have been trained to use it in situations like this. Additionally, the nurses could have contacted the physician for an order for pain management or to replenish the medication from the E-Kit to control the resident's pain.

Based on observation, interview, and policy review, the facility failed to maintain infection prevention and control practices designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was evidenced by medication administration observations of Resident (R)1 and R18. The findings include: Review of the facility policy titled, Hand Hygiene/Handwashing dated 5/15/23 documented, Procedures: 1. Hand hygiene/hand washing is done: Before: A. Before patient/resident contact .After: .B. After patient/resident contact. C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids, blood or wounds .J. Contact with environmental surfaces in the immediate vicinity of patients/residents. Review of the facility policy titled, Blood Glucose Monitoring dated 5/5/23 documented, .If the manufacturer doesn't specify how the device should be cleaned and disinfected, then it shouldn't be shared. Review of the facility policy titled, Infection Prevention and Control Policies and Procedures dated 5/15/23 documented, Subject: Transmission Based/Standard Precautions, and Enhanced Barrier Precautions, Standard Precautions vs. Transmission Based Precautions .B. Personal Protective Equipment: determined by the nature of staff interaction, extent of anticipated blood, body fluid or pathogen exposure. Appropriate use of PPE includes but is not limited to: Gloves .4) Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient/resident .E. Patient/Resident-Care Equipment .2) Verify that reusable equipment is cleaned, disinfected, and reprocessed appropriately. Review of R1's electronic medical records, revealed an admission date of 3/6/24, and diagnosis list that consisted of Type Two (2) Diabetes Mellitus with Diabetic Neuropathy, Acute Osteomyelitis unspecified femur, Acquired Absence of Right Leg Above the Knee, Cardiomyopathy among other conditions not listed. Resident #1 Physician's Orders showed an order for Insulin Aspart U-100 solution; per sliding scale to be given subcutaneously four (4) times a day. In an observation on 10/7/24 at 11:31 a.m. made during medication administration of R1, Registered Nurse (RN)1 was seen placing the gauze, an open alcohol swab, the glucometer and gloves on the seat of a chair in the resident's room, with no barrier underneath, while donning Personal Protective Equipment (PPE) gown after performing hand hygiene. Then RN1 put on gloves and gathered the supplies. Next RN #1 placed the same supplies on the resident's bed, wiped the resident's finger with the opened alcohol swab and performed the finger stick to check R1's blood glucose. The first attempt was unsuccessful, so RN1 wiped the resident's finger with the same swab and made a second attempt to collect a blood sample. After collecting the sample and getting the resident's blood glucose reading, RN1 took off her gloves and set them on the resident's bed, doffed the PPE gown, returned to their assigned medication cart and placed the glucometer inside without cleaning or disinfecting it. Review of R18's electronic medical records, revealed a current admission date of 9/1/21, and also the latest return admission date of 8/12/24 and diagnosis list that consisted of Type Two (2) Diabetes Mellitus without complications, Chronic Kidney Disease, Squamous Cell Carcinoma of Skin among other conditions not listed. R18's Physician's Orders showed an order for Humalog U- 100 solution Insulin: per sliding scale to be given subcutaneously three (3) times a day. An observation on 10/7/24 at 11:38 AM, made during medication administration of R18 revealed RN1 performed hand hygiene, walked into the resident's restroom to get a pair of gloves, and was seen placing the gauze, an open alcohol swab, the glucometer and gloves on the resident's bedside table with no barrier underneath. RN1 wiped the resident's finger with the opened alcohol swab and performed the finger stick to check R18's blood glucose. The first attempt was unsuccessful, so RN1 wiped the resident's finger with the same swab and made a second attempt to collect a blood sample. After collecting the sample and getting the resident's blood glucose reading, RN1 returned to their assigned medication cart and placed the glucometer inside without cleaning or disinfecting it. RN1 returned to R18's room to administer the resident's medication. RN1 performed hand hygiene, then touched the resident's restroom door, donned gloves, then with gloved hands touched the restroom door to close the door and administered insulin injection to R18. In an interview with RN1 on 10/7/24 at 11:45 AM, she stated that there was no reason why they placed the items down without a barrier underneath, only used one alcohol swab, or did not clean glucometer between residents. RN1 did state that they understood the reason for infection control, but felt that the facility layout made it difficult, saying, It's kind of hard here, I get it, but it is nit-picky. In an interview on 10/9/24 at 8:56 AM with Licensed Practical Nurse (LPN)1, the current unit nurse manager on they stated that the expectation was to improve on infection control, putting down barriers, hand sanitizer use, for the safety of residents and staff and to re-educate. In an interview on 10/9/24 at 9:17 AM with the Director of Nursing (DON) and the Administrator, the DON stated that the expectation was to do better, and that RN1 said that they knew better and should not have exhibited those behaviors. The Administrator stated that re-education with staff had already occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy, the facility failed to ensure 1 out of 3 residents was free from significant medication errors for 1 out of 30 days for the month April 2024. Resident (R)1 received Lyrica; 1 capsule by mouth, 1 time a day and Norco 325 milligrams (mg); 1 tablet, 2 times a day. R1's Controlled Drug Receipt/Record/Disposition Form revealed medication was pulled and reported not administered, which heightened the likelihood of a decline in medical conditions. Findings include: Review of facility's policy titled, Medication Management Program with a revision date of 05/05/23 documented under Administering Medication Pass (8) The authorized staff member or licensed nurse must identify the resident before administering any medication. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to;anxiety, dementia, chronic obstruction pulmonary disease and heart failure. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R1 is cognitively intact. Review of R1's Medication Administration History documented the following orders for April 22, 2024: Lyrica 25 mg; 1 time a day (10am) for muscle weakness; Hydrocodone-acetaminophen; twice a day (10:00AM and 9:00PM) for pain. Review of R1's Controlled Drug Receipt/Record/Disposition Form dated 04/08/24 for Pregabalin cap 25 mg, generic for Lyrica, documented on 04/22/24 signature signed off as administered by Registered Nurse (RN)1. Hydrocodone/APAP tab 325 mg generic for Norco, 1 tablet by mouth two times a day as needed for pain signature signed off on 04/22/24, as administered by RN1. Review of RN1's Suspension Pending Investigation dated 04/23/24 documented the suspension of RN1 for the allegation of medication administration errors. Review of RN1's Corrective Action Form dated 05/03/24 documented violation of facility policy action required: termination of RN1. In an interview on 06/03/24 at 11:24 AM in resident's room, R1 stated he remembered when he didn't get his medication. R1 stated the administration of medication on both halls are very strange because he is included on the South Hall, when he resides on the North Hall. In an interview on 06/03/24 at 1:37AM, RN1 stated she was running behind all day, she stated she was new to hall and the halls are split, it's confusing. RN1 stated when she got to R1, he was not in his room, and she thought he wanted dialysis. She stated she was working with a new orientee, and she had checked back several times. RN1stated when she was asked if R1 received his medications that day, she was honest and stated she hadn't given them to him. RN1 stated she told the truth. RN1 stated she had pulled the narcotic medications, but did not administer them. R1 stated she pulled and wasted the narcotic medications. RN1 stated to dispose, you must have two signatures. RN1 stated she had the new orientee to sign off the medication narcotic sheet witnessing she disposed of the medications. RN1 stated she could not remember the new orientee's name. In an interview on 06/03/24 at 2:28 PM, the Director of Nursing (DON) stated that RN1 stated she disposed of meds. DON stated the disposition of the meds should be listed on the narcotic sheet with two signatures, one as a witness; but this was not done on R1's narcotic sheet. DON stated RN1 admitted to her she did not administer the medications on that day to R1. In an interview on 06/03/24 at 3:16 PM, Administrator stated she expects Nursing staff not to pull medications until the resident is standing in front of them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviews and interviews, the facility failed to implement the Comprehensive Plan of Care for Resident (R)24 related to a significant weight loss for 1 of 2 residents reviewed with a significant weight loss. The facility further failed to implement the Comprehensive Plan of Care related to the provision of activities of interest for R24 to attain or maintain the resident's highest practicable-physical, mental and psychosocial well being for 1 of 1 residents reviewed for activities. Findings include: The facility admitted R24 on 01/31/24 with diagnoses including, but not limited to, depression, anxiety, bipolar disorder and schizophrenia. Review on 04/22/24 at 01:55 PM of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. Review on 04/22/24 at 01:55 PM of the medical record for R24 revealed the following weights: On 02/01/24, R24 weighed 243.8 pounds. This was the weight on admission. On 02/05/24, R24 weighed 239.0 pounds. On 02/06/24, R24 weighed 237.6 pounds. On 02/13/24, R24 weighed 224.6 pounds. On 03/09/24, R24 weighed 215.8 pounds. On 03/11/24, R24 weighed 218.6 pounds. On 03/12/24, R24 weighed 215.6 pounds. On 03/19/24, R24 weighed 213.8 pounds. On 03/26/24, R24 weighed 213.8 pounds. On 04/02/24, R24 weighed 211.2 pounds. On 04/09/24, R25 weighed 215.0 pounds. Total weight loss from 01/31/24 until 04/09/24 is 28.8 pounds. Review on 04/22/24 at 02:10 PM of the Comprehensive Plan of Care revealed a nutritional status problem area and states: Resident is at risk for malnutrition. She is receiving a regular diet with thin liquids. The goal dated 02/01/24 reads: Resident will maintain nutritional status as evidenced by no significant weight change through next review. The interventions listed are: Encourage to dine in dining room as is appropriate, honor food preferences as feasible, monitor and encourage intakes of foods and fluids, offer alternates if intakes are less than adequate. Monitor weights, skin report, and labs per policy, offer snacks per policy, provide assistance with meals and snack if needed and provide diet as ordered by the physician. During an interview on 04/23/24 at 10:00 AM with the Registered Dietician (RD), he stated that he put in an order for a dietary supplement today. The RD was asked what interventions were put into place to prevent significant weight loss, and he stated, R24 was obese and sometimes weight loss is a good thing. The RD was asked how he found out about weight loss and he stated that he looks at the weights in the computer by just looking them up, but no one informs him of weight loss within the residents. During an interview on 04/23/24 at 12:05 PM with the Director of Nursing concerning the weight loss, she stated that her expectations were that staff would notify the physician and the RD. She stated that she will look at weights from time to time and staff do offer the resident snacks, eventhough there is no documentation to ensure the snacks are offered or consumed. Review on 04/22/24 at 3:18 PM of the activity attendance sheets for R24 revealed no one to one activities, and no activities documented for February 24 and only socialization for March 24. Review on 04/22/24 at 3:48 PM of the Comprehensive Plan of Care R24 revealed a problem area of activities and states: Resident is non-verbal and will be receiving one to one visits with documentation by activity staff in an effort to meet her physical, emotional, and intellectual needs. The goal states: Resident will actively participate in one on one visits with activity staff until next review. The interventions start date is 03/18/24 and include, staff will provide one to one pet therapy, staff will provide one to one religious visits, one on one music hour, and one to one reading. Staff will provide one on one socialization. Staff will observe and document her participation level during activities. Staff will provide one on one outdoor activities, staff will provide one to one beauty/barber as tolerated. Staff will provide manicures as tolerated and staff will provide monthly activity calendar. No documentation could be found in the medical record for R24 to ensure R24 was receiving the one to one activities. During an interview on 04/23/24 at 09:00 AM with the Activity Director, this surveyor had her to take a look at the activity attendance sheets she had provided to me for January, February and March 24. She stated this resident has been in and out of the hospital. I asked her about the Comprehensive Plan of Care which had a start date of 03/18/24 for one to ones, and she did provide a sheet from 04/01/24 through 04/22/24. She confirmed that no one to one activities as listed on the plan of care were provided to R24 and no activities were offered or documented in February '24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor behaviors and medication side effects for Resident (R)60 and 20 for 2 of 5 residents reviewed for unnecessary medications. Findings include: Review of the facility policy titled Nursing Policies and Procedures Subject: Medication Management Program revision date 05/05/23 revealed, Policy: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. Scope and Roles: 3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life. Guidelines for Implementing an Efficient Medication Pass: 1B. The facility will ensure the schedules for administering medications: 1) Maximize the effectiveness of the medications. 2) Prevent potential for significant medication interactions .Preparing for the Medication Pass 8. Documentation of medications administered is completed according to State and Federal requirements. The initials and verifying signature are generally required. Administering the Medication Pass 11. Immediately after administering the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR. If a medication is not administered, the authorized staff or licensed nurse must explain why it was not given. Review of R60's Face Sheet revealed R60 was admitted to the facility on [DATE] with diagnoses including but not limited to: acute respiratory failure, chronic obstructive pulmonary disease, diabetes mellitus, major depressive disorder, and myocardial infarction. Review of R60's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R60 was cognitively intact. Review of R60's Care Plan with a start date of 11/05/2020 and target date 05/24/2024 documented, the problem: R60 .has potential for discomfort & adverse effects r/t [related to] use of antipsychotic & antidepressant medications. Documented goal: R60 .will be free of discomfort or adverse effects of antipsychotic & antidepressant use through next review. Documented approach revealed, Observe for muscle rigidity, increased temp, hypotension, dry mouth, sedation, tremors, tardive dyskinesia, increased confusion, change in LOC, sudden change in mood/behavior status. Additionally, the care plan documented, the problem: R60 .has potential for side effects r/t use of multiple rx [prescription]. Documented goal: R60 .will experience no drug related side effects. Documented approach revealed, Observe for inc confusions, insomnia, nervousness, tremors, changes in loc, dec appetite, wt loss. Additionally, the care plan documented, the problem: R60 .has hx [history] of verbally abusive behavioral symptoms. Documented goal: R60 .will have a decreased number of verbally abusive episodes through next review. Documented approach revealed, Assess whether the behavior endangers the resident and/or others. Intervene if necessary. The care plan had a start date of 03/15/21 and target date 05/24/24, documented the problem: R60 .has potential for difficulty falling asleep & [and] remaining asleep r/t [related to] dx [diagnosis] of Insomnia. Documented goal: R60 .will be comfortable as evidenced by verbalization of getting enough sleep most of the night through next review. Documented approach revealed, Meds as ordered per MD. Review of R60's Medication Administration Record (MAR) for 04/01/24 - 04/22/24 revealed an order for Behavior Monitoring twice daily: ANTIDEPRESSANT Drug ** DULOXETINE. CRYING/SADNESS. Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Other I: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, W. Worsened Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Behavior Monitoring twice daily: ANTIPSYCHOTIC Drug Use **CRYING/SADNESS Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Removal of Stressors J: Other K: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Behavior Monitoring twice daily: HYPNOTIC Drug Use **MELATONIN. CHANGES IN SLEEP PATTERN. Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Removal of Stressors J: Other K: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: ANTIDEPRESSANTS Special Instructions: SIDE EFFECTS: 0. NONE 1. Dry Mouth 2. Blurred Vision 3. Constipation 4. Urinary Retention 5. Hypotension 6. Appetite Changes 7. Headache 8. Insomnia 9. Dyspepsia 10. Weight Changes 11. Suicidal ideations; Wishes of death; Attempts to harm self Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: ANTIPSYCHOTIC DRUG USE Special Instructions: SIDE EFFECT CODES: 0. NONE 1. Neck Stiffness 2. Confusion 3. Muscle Rigidity 4. Involuntary Movements 5. Drooling 6. Tremors 7. Restlessness 8. Sleep Disturbances 9. Dry Mouth 10. Blurred Vision 11. Constipation 12. Sedation Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: HYPNOTICS Special Instructions: SIDE EFFECT CODES: 0. NONE 1. Sedation 2. Dizziness 3. Confusion 4. Nightmares 5. Daytime Anxiety 6. Hallucinations 7. Fatigue 8. Headache 9. Sedation Twice A Day 07:00 - 19:00, 19:00 - 07:00. Review of R60's Physician Order with a start date of 02/13/24 documented, Behavior Monitoring twice daily: ANTIDEPRESSANT Drug ** DULOXETINE. CRYING/SADNESS. Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Other I: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, W. Worsened Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Behavior Monitoring twice daily: ANTIPSYCHOTIC Drug Use **CRYING/SADNESS Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Removal of Stressors J: Other K: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Behavior Monitoring twice daily: HYPNOTIC Drug Use **MELATONIN. CHANGES IN SLEEP PATTERN. Special Instructions: INTERVENTIONS: A: Physical Needs Met B: Distraction C: Redirection D: Validation E: Activity Program F: Quiet Time/Rest G: Increased Observation H: Removal of Stressors J: Other K: No interventions needed OUTCOMES: 1. Improved, 2. Unchanged, Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: ANTIDEPRESSANTS Special Instructions: SIDE EFFECTS: 0. NONE 1. Dry Mouth 2. Blurred Vision 3. Constipation 4. Urinary Retention 5. Hypotension 6. Appetite Changes 7. Headache 8. Insomnia 9. Dyspepsia 10. Weight Changes 11. Suicidal ideations; Wishes of death; Attempts to harm self Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: ANTIPSYCHOTIC DRUG USE Special Instructions: SIDE EFFECT CODES: 0. NONE 1. Neck Stiffness 2. Confusion 3. Muscle Rigidity 4. Involuntary Movements 5. Drooling 6. Tremors 7. Restlessness 8. Sleep Disturbances 9. Dry Mouth 10. Blurred Vision 11. Constipation 12. Sedation Twice A Day 07:00 - 19:00, 19:00 - 07:00. The MAR also revealed an order for, Monitor for side effects twice daily: HYPNOTICS Special Instructions: SIDE EFFECT CODES: 0. NONE 1. Sedation 2. Dizziness 3. Confusion 4. Nightmares 5. Daytime Anxiety 6. Hallucinations 7. Fatigue 8. Headache 9. Sedation Twice A Day 07:00 - 19:00, 19:00 - 07:00. During an interview on 04/23/24 at 11:42 AM, the Director of Nursing (DON) stated that her expectations are that physician orders are followed for medication administration. She reported that the facility ensures accuracy of documentation on the MAR by pulling a compliance report daily and either the DON or Assistant Director of Nursing (ADON) addresses identified issues. Education is provided to staff. She stated that unfortunately they use a lot of agency nurses, which makes it challenging. During an interview on 04/23/24 at 4:34 PM, Licensed Practical Nurse (LPN)1 verified that there was no documentation for behavior monitoring related to antidepressant use on 04/19/24 at the 7A-7P timeframe on the MAR, no documentation for side effect monitoring related to antipsychotic use on 04/19/24 at the 7A-7P and 7P-7A timeframes on the MAR, and no documentation for side effect monitoring related to hypnotic use on 04/19/24 at the 7A-7P timeframe on the MAR. LPN1 stated that the expectation is to have this documentation completed by the end of the shift. A review of the facility policy titled, Pharmacy Services Policies and Procedures- Medication Management, revised 04/01/2022, indicated the facility will ensure that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing. R20 was admitted to the facility with diagnoses including but not limited to, schizoaffective disorder, generalized anxiety disorder, urinary tract infection, bipolar disorder, depressive episodes, and dementia. A review of R20's annual MDS with an ARD of 04/10/24, indicated R20 is ordered to take, but is not limited to, antipsychotic and antidepressant medications. A review of R20's care plan indicated a potential for discomfort & adverse effects related to the use of antipsychotic and antidepressant medications. A review of R20's care plan and progress notes did not reveal that R20 refused medications on 04/15/24 or 04/16/24. A review of R20's physician orders indicate Monitor for side effects every shift: Antipsychotic Drug Use with a start date of 07/13/2023, Monitor for side effects twice daily: Anticonvulsant with a start date of 07/26/2023, Monitor for side effects twice daily: Antidepressant with a start date of 07/13/2023. A review of R20's Behavior Monitoring Administration History, from 04/01/2024 until 04/23/2024, indicated that R20 did not receive Behavior Monitoring Every Shift: Antipsychotic Drug Use- Olanzapine, Behavior Monitoring twice daily: Anticonvulsant Drug- Depakote, Behavior Monitoring twice daily: Antidepressant- Trazadone/Paxil, Monitor for side effects every shift: Antipsychotic Drug Use, Monitor for side effects twice daily: Anticonvulsant, and Monitor for side effects twice daily: Antidepressants on 04/15/2024 during the day shift. During an interview on 04/23/24 at 03:00 PM, the DON expressed they expect nurses to document the MAR and TAR once completing a task ordered by the physician. The DON confirmed that there were several blanks on R20's TAR and MAR for April 2024, but was unsure why there were several blanks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of R91's Face Sheet revealed R91 was admitted to the facility on [DATE] with diagnoses including but not limited to; sepsis, mycosis, pain, dysphagia, muscle weakness, long term use of opiate analgesic, nausea, constipation, major depressive disorder, urinary tract infection, diabetes, anxiety disorder, unsteadiness, lack of coordination, and cognitive communication deficit. Review of R91's Quarterly MDS with an Assessment Reference Date (ARD ) of 03/18/24 revealed a BIMS score of 05 out of 15, indicating R91 has severe cognitive deficits. Review of R91's Nutrition note dated 04/09/24, revealed the Reason for Referral: Weight Review. Diet Order: Pureed with thin liquids. Supplements: Glucerna and Sugar free ice cream with lunch/dinner. Documented intake: Poor. Snacks provided appropriately, HS. Weight: 121.6 pounds (lbs)(4/7/24); 125 pounds (3/13/24); 142 pounds (1/23/24); 166 pounds (10/10/23). BMI: 19.04. Medications reviewed. Skin Integrity intact. Blood glucose values within target goal range X ~ 30 days. Nutrition Diagnosis: 1) Unintended weight loss related to intake as evidenced by significant decrease-CONTINUE. 2) Diet consistency difficulty related to chronic condition as evidenced by mechanically altered diet-CONTINUE. Summary: Poor intake continues, family providing Ensure - resident accepts well. Note GI referral due to persistent vomiting. Undesired weight loss continues. Recommendations/Plan: 1) Discontinue Glucerna 2) Add Ensure Plus or equivalent TID 3) RDN available PRN or when nutrition status changes; will follow as needed. 4) Weights as ordered. Goals: 1) Maintain a healthy weight status without further significant/severe change. 2) Maintain skin integrity. 3) Tolerate PO. Review R91's of Progress Note dated 03/19/24 documented, Nutrition Note. Reason for Referral: Quarterly Review and Weight Review. Diet Order: Pureed with thin liquids. Supplements: Glucerna with lunch/dinner. Documented intake: Poor. Snacks provided appropriately, HS. Weight: 125 pounds (3/13/24); 132 pounds (2/6/24); 150 pounds (12/5/23); 181.6 pounds (9/15/23). BMI: 19.58. Medications include Cyproheptadine, Omeprazole, Mirtazapine and Vitamin D. Skin Integrity intact. Blood glucose values within target goal range X ~ 30 days. Nutrition Diagnosis: 1) Unintended weight loss related to intake as evidenced by significant decrease-CONTINUE. 2) Diet consistency difficulty related to chronic condition as evidenced by mechanically altered diet. Summary: Diet downgraded 3/15/24, which may be contributing to continued poor intake-receiving 2 appetite stimulants (second added recently and to increase mg) and supplements to encourage intake. Undesired weight loss continues, although it has slowed recently. Skin intact. Blood glucose values within target goal range. Recommendations/Plan: 1) Continue plan of care. 2) RDN available PRN or when nutrition status changes; will follow as needed. 3) Weights as ordered. Goals: 1) Maintain a healthy weight status without further significant/severe decrease. 2) Maintain skin integrity. 3) Tolerate. No changes were made even after a steady weight loss and a noted -7.04 weight loss in March. Review of R91's weights on Electronic Medical System revealed for the past six months from November 2023 to April 24, he lost -23.62 lbs. R91's weights were recorded as follows: 04/07/24 - 121.6 lbs 03/13/24 -125 lbs. 02/06/24-132 lbs. 01/23/24-142 lbs. 12/05/23-150.0 lbs. 11/04/23-159.2 lbs. Review of R91's Intake report from 11/01/2023 to 04/23/24 documented minimum intake of meals and fluids. During an interview on 04/23/24 at 9:59 AM, the RD acknowledged R91's weight loss. He stated they added ensure and sugar free ice cream, but in March '24, the RD noted weight loss, but they did not make any additional revisions to address weight loss. During an interview on 04/23/24 at 12:11 PM, the DON stated, she expects staff to notify the Doctor and RD if there is a weight loss. She stated if she is aware of a noted weight loss, she will intervene. She stated she would let the doctor know and notify the RD. She stated she pulls weights often. She stated R91 has an upcoming appointment for digestive problems. Based on review of the facility policy titled,Weighing the Resident, records reviews and interviews, the facility failed to ensure Resident (R)24 and R91 received care and services to prevent significant weight loss or to decrease the likelihood of further weight loss for 2 of 2 residents reviewed with significant weight loss. Findings include: Review of the facility policy titled, Weighing the Resident, states as the policy statement, Patient/Resident weights will be recorded and monitored at least monthly. Under the section on titled, Procedures states, 2. If the month-to-month weight shows more than a five-percent gain or loss, the patient/resident is reweighed in the presence of licensed personnel. 3. Record all weights per facility protocol. 4. If there is an actual 5% or more gain or loss in one month, notify the patient/resident/family, physician, and the Registered Dietician. Document this notification per facility protocol. 5. The facility Dietitian reviews the patient's/resident's nutritional status and makes recommendations for intervention if significant weight change is noted. 7. Update the plan of care with goals and approaches/interventions listed. 9. Unplanned and undesired weight variance will be evaluated for significance utilizing the following guidelines: 3% in one week; 5% in 30 days; 7.5% in 90 days; 10% in 180 days. The facility admitted R24 with diagnoses including, but not limited to, depression, anxiety, bipolar disorder and schizophrenia. Review on 04/22/24 at 01:55 PM of the admission minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe cognitive impairment. Review on 04/22/24 at 01:55 PM of the medical record for R24 revealed the following weights: On 02/01/24, R24 weighed 243.8 pounds. This was the weight on admission. On 02/05/24,R24 weighed 239.0 pounds. On 02/06/24, R24 weighed 237.6 pounds. On 02/13/24, R24 weighed 224.6 pounds. On 03/09/24, R24 weighed 215.8 pounds. On 03/11/24, R24 weighed 218.6 pounds. On 03/12/24, R24 weighed 215.6 pounds. On 03/19/24, R24 weighed 213.8 pounds. On 03/26/24, R24 weighed 213.8 pounds. On 04/02/24, R24 weighed 211.2 pounds. On 04/09/24, R25 weighed 215.0 pounds. Total weight loss from 01/31/24 until 04/09/24 is 28.8 pounds. During an interview on 04/23/24 at 10:00 AM with the Registered Dietician (RD), he stated that he put in an order for a dietary supplement today. He went on to say that the resident had been in the hospital. He stated R24 was obese and sometimes weight loss is a good thing. I informed him that unless the physician orders a weight loss program then interventions should be put into place to ensure the residents do not have significant weight loss. I asked how he found out about weight loss and he stated that he looks at the weights in the computer by just looking them up. No one notifies him of weight loss. I also stated that a dietitian note had recommended a supplement but was not ordered. During an interview on 04/23/24 at 12:05 PM with the Director of Nursing (DON) concerning the weight loss, she stated that her expectations were that staff would notify the physician and the RD. She stated that she will look at weights from time to time. She stated that staff do offer the resident snacks, eventhough there is no documentation to ensure the snacks are offered or consumed.

Based on review of the facility policy, staffing documentation and interview, the facility failed to ensure that each Certified Nursing Assistant (CNA) employed by the facility received the required no less than 12 hours of in-service education based on their individual performance reviews and is calculated by their employment date with the facility during review of Sufficient and Competent Nurse Staffing. Findings include: Review of the facility policy titled Staff Education/Orientation Policies and Procedures, without a date or revision date listed. The policy states, The facility will provide orientation and training to fulfilling the organization's mission thus creating a culture that foster staff self development and continued learning. (1). Day 1: All new employees receive the general facility orientation program on day one of employment and it is completed with the designated member of the facility staff. (2). Day 2: Each new employee will receive their specific department orientation starting on day 2 and continue through to completion of the department specific orientation. Role and department specific orientation includes any state or local level requirements that are in addition to or more inclusive than federal requirements. (3). Individualized: The facility leadership has the discretion to increase the new employee's orientation if deemed necessary. (4). Annually: The employee completes the competency/performance evaluation(s) and educational requirements according to state specific regulation. Review on 04/23/24 at approximately 11:45 AM of the facility's CNA annual 12-hour in-service training based on performance reviews revealed less than the required 12 hours of training from the date of hire for CNAs. There was no documentation in the CNA's personnel files that verified the required training. There were 3 out of 5 CNAs who did not receive training in resident's rights, abuse, neglect, exploitation, and dementia training; CNA2 hire date 05/23/19, CNA3 hire date 02/01/23, and CNA5 hire date 03/10/23 revealed no training of the required areas. During an interview on 04/23/24 at approximately at 3:42 PM with the Director of Nursing (DON) revealed, to ensure the staff are competent and have the knowledge and skills to care for the residents, they attend an annual training and a skills check. If there are any concerns, we will provide additional training. DON stated staff are evaluated by the staff development coordinator to ensure competency levels. The DON confirmed the staff had not met their required hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility's policy titled, Medication Management Program with a revision date of 05/05/23 documented under Preparing for Medication Pass, Section Q (4), Authorized staff must understand: (D) The 8 Rights for administering medication: (4). The Right Time (6). The Right Charting (7). Medications are administered no more than one hour before to one hour after the designated medication pass time. Review of R5's Face Sheet revealed R5 was admitted to the facility on [DATE] with diagnoses including but not limited to; chronic kidney disease, muscle weakness, peripheral vascular disease, lack of coordination, insomnia, diabetes, anxiety disorder, dementia, chronic obstruction pulmonary disease and heart failure. Review of R5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD ) of 02/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R5 is cognitively intact. Review of R5's Medication Administration Record for March '24 revealed the following medication errors: Advair Diskus (fluticasone propion-salmeterol); two times daily (10am/9pm) for Chronic Obstructive Pulmonary disease was charted late 25% for the month. Daily multi-vitamin (multivitamin) tablet; once daily (9am) for Vitamin D deficiency was charted late 12% for the month. Eliquis 5 milligrams (mg); 2 times daily (10am/9pm) for heart failure, charted late; 29% for the month. Folic Acid 1 mg; 1 time daily (10am) for Vitamin D deficiency; charted late; 12% for the month. Furosemide 40 mg; 2 times daily (10am/9pm) for renal dialysis; charted late; 25% for the month. Lyrica 25 mg; 1 time a day (10am) for muscle weakness; charted late; 19% for the month. Melatonin 3 mg; 1 time a day (9pm) for insomnia; charted late; 12% for the month. Metoprolol tartrate 25 mg; 2 times a daily (10am/9pm) for peripheral vascular disease; charted late; 25% for the month. Pantoprazole 20 mg; 2 times daily (10am/10pm) for gastro-esophageal reflux disease; charted late; 12% for the month. Paroxetine HCl 30 mg; 1 time daily (9pm) for anxiety; charted late; 12% for the month. PreserVision AREDS-2 (vit c,e-zn-coppr-lutein-zeaxan) capsule; 250-90-40-1 mg; 1 time daily (10am); charted late; 12% for the month. Pro-Stat AWC (amino acids-protein hydrolys) liquid; 17-100 gram-kcal/30 mL; 2 times a day(10am/9pm); charted late 9% for the month. Procardia XL 30 mg; 1 time daily (10am) for hyperparathyroidism; charted late 16% for the month. Ropinirole .25 mg; 1 time daily (9pm) for cramps (hyperparathyroidism); charted late 12% for the month. Sevelamer carbonate 800 mg; 3 times daily (10am/2pm/9pm) for chronic kidney disease; charted late 29% for the month. Tradjenta 5 mg; 1 time daily (10am) for Diabetes; charted late 16% for the month. Trazodone 50 mg; 1 time daily (9pm) for anxiety; charted late 12% for the month. Tums 200 mg; 1 time daily (10am) for dependence on renal dialysis; charted late 16% for the month. Vitamin C 500 mg; 1 time daily (10am) for chronic kidney disease; charted late 16% for the month. In an interview on 04/23/24 at 3:53 PM, Director of Nursing stated her expectations is for staff to administer medications within the one-hour window before and after scheduled times and document immediately thereafter. In an interview on 04/23/23 at 4:25 PM, Administrator stated she expects medication to be given within the time frame of medication administration or one hour before or after. Based on Staff Education/Orientation for administering Insulin via an Insulin Pen, record reviews, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent. The medication error rate was 10.71 percent (%). Additionally, R5's medications were administered and charted late for 22 out of 31 days in March '24. Findings Include: Review of the facility's Staff Education/Orientation Policies and Procedures, the nursing,Competency: Medication Administration-Insulin Pen, states under Priming The Pen, 1. Remove the outer needle cap and dial 2 units. 2. Point the pen up and press the plunger button to expel 2 units of insulin. 3. Repeat these steps as needed until a drop or stream of insulin appears at the needle tip. NOTE: A new pen may have to be primed up to 6 times before it will expel insulin. 4. Shake the insulin off the needle top. During an observation on 04/22/24 at 08:22 AM of medication administration revealed Registered Nurse (RN)1 administering Miralax 17 grams (g) to R84. RN1 measured the 17 grams and emptied it into a 5 ounce (oz.) cup and then added water. The Miralax is to be mixed in 6 to 8 ounces of a liquid for administration. RN1 was not available for interview. An observation on 04/23/24 at 08:30 AM of medication administration revealed Licensed Practical Nurse (LPN)1 administering Lantus Insulin via an Insulin Pen to R90. The resident was to receive 45 units. The insulin pen only had 42 units after the priming of the pen so LPN1 opened a second Lantus Pen for the resident. LPN1 took an alcohol wipe and cleaned the rubber stopper on the end of the pen, then applied the insulin needle. She dialed up the 2 units for priming the pen and did not remove the cover from the needle and held the pen horizontally and pushed the dose button to expel the 2 units used to prime the pen and then dialed up the 42 units for the dosage to be administered to the resident. LPN1 then opened the new Lantus Insulin Pen and cleaned the rubber stopper on the end of the pen and applied the needle leaving the needle covered and holding the pen horizontally she pushed the dose button to expel the 2 units she had dialed up to prime the pen. Then she dialed up the 3 units needed to make up the 45 units as ordered. LPN1 then went into the resident's room and administered the 45 units of insulin with the 2 pens. During an interview on 04/23/24 at 08:40 AM with LPN1, she confirmed that she had held the 2 pens with the needle covered horizontally and expelled the 2 units used to prime the pens. She could not confirm that she saw insulin come out of the needle. She stated that pharmacy had in-serviced the staff on the correct administration of insulin via a pen and they had demonstrated holding of the pen horizontally and not vertically.

Based on review of the facility policy titled Medication Storage, observations and interviews, the facility failed to ensure expired medications were removed from and not stored with medications in use for residents in 2 of 4 medication carts. Findings include: Review of the facility policy titled, Medication Storage, states: 1. Medications and biological's are stored safely, securely and properly following manufacturer's recommendations or those of the supplier, The General Guidelines for Storage of Medication and Biological's, states under number 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed. An observation on 04/23/24 at 01:45 PM of the North Hall Medication Cart B revealed Famotidine 40 milligrams, 2 tabs, manufactured by Teva USA with Lot #7337102 was expired on 02/15/24. One Lispro Kwikpen manufactured by Lilly with Lot #D27056C was opened on 03/14/24 and expired on 04/11/24. One Novolog Flex Pen with Lot #NZF6H68 was opened on 03/25/24 and expired on 04/22/24. The expired medications were confirmed by Licensed Practical Nurse (LPN)2. An observation on 04/23/24 at 02:15 PM of the South Hall Medication Cart A revealed one pen of Toujeo with Lot #3F930A in use with no open date. LPN1 confirmed the medication did not have an open date and removed it from the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility policy titled Nursing Policies and Procedures Subject: Medication Management Program revision date 05/05/23 revealed, Policy: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. Scope and Roles: 3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life. Guidelines for Implementing an Efficient Medication Pass: 1B. The facility will ensure the schedules for administering medications: 1) Maximize the effectiveness of the medications. 2) Prevent potential for significant medication interactions .3D. Insulin daily orders, sliding scale orders, and blood glucose results are documented on the same page or screen. Preparing for the Medication Pass 8. Documentation of medications administered is completed according to State and Federal requirements. The initials and verifying signature are generally required. Administering the Medication Pass 11. Immediately after administering the medication to the resident, the authorized staff or licensed nurse will return to the medication cart and document medication administration with initials on the MAR. If a medication is not administered, the authorized staff or licensed nurse must explain why it was not given. Review of R60's Face Sheet revealed R60 was admitted to the facility on [DATE] with diagnoses including but not limited to: Acute respiratory failure, Chronic obstructive pulmonary disease, Diabetes mellitus due to underlying condition with diabetic neuropathy, Type 2 diabetes mellitus with diabetic neuropathy, Major depressive disorder, Myocardial infarction, Ventricular tachycardia, Ischemic cardiomyopathy, Unspecified systolic (congestive) heart failure, and Peripheral vascular disease. Review of R60's admission MDS with an ARD of 02/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R60 was cognitively intact. Review of R60's Care Plan with a start date of 11/09/2022 and target date 05/24/24 documented, the problem: R60 .has a dx [diagnosis] of DM [diabetes mellitus] Type 2, potential for hypo [low]/hyper [high] Glycemia [glucose]. Documented goal: R60 will adhere to diet to aide in controlling glucose and HgbA1C; will not have any acute episodes of hypo/hyper glycemia episodes through. Documented approach revealed, Insulin to be administered per MD orders. Review of R60's MAR for 04/01/24 - 04/22/24 revealed an order for Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); amt: 10 UNITS; subcutaneous Special Instructions: NOTIFY MD/NP PRN. At Bedtime 9:00 PM. The document revealed no documentation from 04/08/24 for administration at 9:00 PM, blood sugar value, route, site, or units. Review of R60's Physician Order with a start date of 02/13/24 documented, Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL); amt: 10 UNITS; subcutaneous Special Instructions: NOTIFY MD/NP PRN. At Bedtime 9:00 PM. During an interview on 04/23/24 at 11:42 AM, the DON stated that her expectations are that physician orders are followed for medication administration. She stated the process for medication administration would include reading the order, checking the order against the medication label when pulling it up or preparing the medication and then administering the medication to the resident. Documentation of the medication being administered would be expected after the resident has received the medication on the MAR. The DON revealed she expects that there would be documentation even if the medication was not given along with notification to the Medical Doctor (MD) and to the resident responsible party if medication is not given. She reported that the facility ensures accuracy of documentation on the MAR by pulling a compliance report daily and either the DON or Assistant Director of Nursing (ADON) addresses identified issues. Education is provided to staff. She stated that unfortunately, they use a lot of agency nurses, which makes it challenging. The DON verified the missing documentation on the MAR for the Lantus insulin on 04/08/24. During an interview on 04/23/24 at 1:15 PM, contact information for the nurse working on 04/08/24 was requested. The DON stated that she would get the number but the nurse was from an agency and was not reliable in returning calls. During an interview on 04/23/24 at 3:21 PM, an attempted call was made to LPN4 but no answer was received and the mailbox was not set up to leave a message. Review of R5's Face Sheet revealed R5 was admitted to the facility on [DATE] with diagnoses including but not limited to: Chronic kidney disease, dependence on renal dialysis, peripheral vascular disease, chronic obstructive pulmonary disease, heat failure, and type 2 diabetes mellitus with diabetic neuropathy. Review of R5's MDS with an AED of 03/22/24 revealed a BIMS score of 15 out of 15, indicating R5 was cognitively intact. Review of R5's Care Plan with a start date of 08/27/20 and target date 05/17/24 documented, the problem as R5 .is at risk for potential cardiac problem r/t dx of HTN [hypertension], HLD [hyperlipidemia], Hyperkalemia [elevated potassium], CHF-stable [congestive heart failure]. Documented goal R5 .will have no alteration in cardiac output through next review. Documented approaches revealed, Meds per [by] MD [medical doctor] order, Observe for c/o [complaints of] chest congestion, cyanosis, or SOB [shortness of breath], s/s [signs and symptoms] of stroke (H/A, one sided weakness, facial drooping, etc.) and notify MD prn, V/S [vital signs] per protocol. Review of R5's MAR for 04/01/24-04/23/24 revealed no documentation from 04/22/24 at 10:00 AM or 9:00 PM for metoprolol tartrate tablet 25 mg amount to administer: ½; oral. Review of R5's Physician Order with a start date of 03/22/24 documented, an order for Furosemide tablet; 40 mg; amt: 40 mg; oral twice a day, metoprolol tartrate tablet; 25 mg; amt: ½; oral twice a day, Procardia XL (nifedipine) tablet extended release 24 hr; 30 mg; amt: 1: oral once a day. Additionally dialysis every T-Thur-Sat @ 6 AM obtain vital signs after dialysis and completed dialysis sheet once a day on Tue, Thur, Sat 11:00, dialysis every T-Thur-Sat @ 6 AM obtain vital signs after dialysis and completed dialysis sheet once a day on Tue, Thur, Sat 0500, dialysis every t-thurs-sat @ 5:30 AM heartline to transport resident. Pick-up time 0530 AM once a day on Tue, Thu, Sat 05:15, Perma cath to right chest. Monitor for s/s bleeding every shift. Notify MD/NP PRN every shift days 0700-1900, Nights 1900-0700. During an interview on 04/23/24 at 10:00 AM, R5 approached surveyor to show vital signs on the dialysis flowsheet taken at the facility prior to leaving which was 182/121 and at dialysis center 158/91. The resident reported that their blood pressure was high this morning because they did not receive blood pressure medication last night at 9:00 PM. When asked if the nurse was notified, the surveyor was informed that this had not been reported because they was in the bed. The surveyor immediately went to inform the ADON, who was on the medication cart of the reported situation and was told that they would check on it as the resident was assigned on the other cart not this one where the two were standing. The surveyor then spoke with LPN1 who had come out of a room while the surveyor was walking off the unit. LPN1 was standing at the other medication cart and was asked to check the orders for the resident. Upon review of the MAR on the computer screen it was observed that the resident had a nighttime blood pressure medication scheduled: Metoprolol Tartrate 25 mg tablet was scheduled for twice a day. On Monday, April 22, 24 at 10:00 AM and 9:00 PM, there were blanks observed on the MAR. During an interview on 04/23/24 at 11:42 AM, the DON stated expectations are that physician orders are followed. The process for medication administration would include reading the order, checking order against medication when pulling up and then administering to the resident. Documentation of the medication being administered would be expected. She expects that there would be documentation if medication was not given, that the MD be made aware along with the resident or responsible party be made aware if medication is not given. During an interview on 04/23/24 at 3:43 PM with LPN5 revealed that she came on shift at 11:00 PM and was not on duty when the 9:00 PM medication was due. She reported that the resident verbalized to her between 12:00 AM and 1:00 AM that the resident did not receive the scheduled blood pressure medication. This nurse stated she verified the order and observed that the MAR was blank and had not been signed by the previous nurse. LPN5 informed the resident that it was outside of the timeframe for it to be administered. The resident voiced a concern that there needed to be 6 hours for the medication to clear the blood stream before dialysis. This nurse reported the concern to LPN6 and stated that she was not sure what the proper next steps should have been although everyone working were agency nurses on last night. An attempted interview on 4/23/24 at 4:05 PM was made via telephone to LPN6 with no success. A review of the facility policy titled, Pharmacy Services Policies and Procedures- Medication Management, revised 04/01/2022, indicated the facility will ensure that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing. R20 was admitted to the facility with diagnoses including but not limited to, schizoaffective disorder, generalized anxiety disorder, urinary tract infection, and dementia. A review of R20's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/10/24, indicated R20 is ordered to take, but is not limited to, antipsychotic and antidepressant medications. A review of R20's care plan indicated a potential for discomfort & adverse effects related to the use of antipsychotic and antidepressant medications. A review of R20's care plan and progress notes did not reveal that R20 refused medications on 04/15/24 or 04/16/24. A review of R20's physician orders indicate benztropine tablet with a start date of 07/13/23, Depakote ER tablet extended release 24 hr with a start date of 11/22/23, methenamine hippurate tablet with a start date of 12/14/23, olanzapine tablet with a start date of 03/12/24, trazodone tablet with a start date of 07/19/23, UTI-Stat liquid with a start date of 03/26/24. - blanks on 4/16/24 night shift. A review of R20's Behavior Monitoring Administration History, from 04/01/24 until 04/23/24, indicated that R20 did not receive benztropine tablet; 0.5 mg, Depakote ER (divalproex) tablet extended release 24 hr; 500 milligrams (mg), methenamine hippurate tablet; 1 gram, olanzapine tablet; 5 mg, trazodone tablet; 50 mg, UTI-Stat (cran-vitc-mannose-[NAME]-bromeln) liquid; 3,875 mg/30 mL, on 04/16/24 during the night shift. During an interview on 04/23/24 at 03:00 PM, The Director of Nursing (DON) expressed they expect nurses to document the Medication Administration Record (MAR) and Treatment Administration Record (TAR) once completing a task ordered by the physician. The DON confirmed that there were several blanks on R20's TAR and MAR for April 24, but could not give a reason why there were several blanks. Based on review of the policy, Staff Education/Orientation for administering Insulin via an Insulin Pen, record reviews, observations and interviews, the facility failed to ensure Resident (R)90 received insulin via an insulin pen correctly. The facility further failed to ensure R60 received insulin as ordered, R5 received blood pressure medication as ordered and R20 received psychotropic and tremor medications as ordered and each resident was free from significant medication errors. Findings include: Review of the facility's policy titled, Staff Education/Orientation Policies and Procedures, the nursing, Competency: Medication Administration-Insulin Pen, states under Priming The Pen, 1. Remove the outer needle cap and dial 2 units. 2. Point the pen up and press the plunger button to expel 2 units of insulin. 3. Repeat these steps as needed until a drop or stream of insulin appears at the needle tip. NOTE: A new pen may have to be primed up to 6 times before it will expel insulin. 4. Shake the insulin off the needle top. An observation on 04/23/24 at 08:30 AM of medication administration revealed Licensed Practical Nurse (LPN)1 administering Lantus Insulin via an Insulin Pen. R90 was to receive 45 units. The insulin pen only had 42 units after the priming of the pen so the LPN opened a second Lantus Pen for the resident. The LPN took an alcohol wipe and cleaned the rubber stopper on the end of the pen, then applied the insulin needle. She dialed up the 2 units for priming the pen and did not remove the cover from the needle and held the pen horizontally and pushed the dose button to expel the 2 units used to prime the pen and then dialed up the 42 units for the dosage to be administered to the resident. The LPN then opened the new Lantus Insulin Pen and cleaned the rubber stopper on the end of the pen and applied the needle leaving the needle covered and holding the pen horizontally she pushed the dose button to expel the 2 units she had dialed up to prime the pen. Then she dialed up the 3 units needed to make up the 45 units as ordered. The LPN then went into the resident's room and administered the 45 units of insulin with the 2 pens. During an interview on 04/23/24 at 08:40 AM with LPN1, she confirmed that she had held the 2 pens with the needle covered horizontally and expelled the 2 units used to prime the pens. She could not confirm that she saw insulin come out of the needle. She stated that pharmacy had in-serviced the staff on the correct administration of insulin via a pen and they had demonstrated holding of the pen horizontally and not vertically.

Based on review of facility policy, observations, and interviews, the facility failed to ensure foods stored in the refrigerator and the main kitchen preparatory area were labeled, dated, and free from expiration. This failure had the potential to affect all 102 residents in the facility, who consumed food from the kitchen. Findings include: A review of the facility's policy titled, Nutrition Orientation and Competency Policy and Procedures on Food Storage with a complete revision date of 07/21/2023 stated If food is not stored properly, chances are that it will spoil quickly. Remember these pointers for storage. 1. -Follow the first in, first out (FIFO) rule. a. Always cover, label, and date leftovers that are to be stored. They should be date marked with the use-by date. 2. -Throw TCS leftovers out if not used within 3 days. On 04/21/24 at 10:27 AM, the following observations in the kitchen were made with and verified by the Dietary Manager (DM): Main refrigerator/Cooler-Two clear bags, both with 3 heads of lettuce with no open date or use-by date listed on the bag. All 6 heads of lettuce in the bags were brown with pink build-up surrounding the entire head of lettuce. Main refrigerator/Cooler-One black crate with 2 heads of lettuce with black/brown spots. No original packing, no open date or use-by date observed. Main refrigerator/Cooler-One-half of the head of lettuce, wrapped in saran wrap, with a brown/pink substance. No label was observed, and no open date or use-by date was observed. Main refrigerator/Cooler- One metal pan, approximately 6 inches deep, labeled Stewed Tom Use by date 04/20/24. On 04/21/24 at 10:39 AM observation of the main kitchen preparatory area revealed a brown cardboard box/case containing whole Idaho potatoes. 8 out of approximately 20 were rotten, containing black, grey, and green spots on potatoes. The potatoes were soft to the touch. An interview with the DM on 04/21/24 at 11:10 AM revealed I have been in this position since December 2023, about five months. DM stated, Staff is expected to check the coolers, freezers, and all other food storage areas for expired foods daily. DM stated, It's everyone's responsibility. Normally, her kitchen staff is to use the first in first out method. I am going to ensure that it is done and do another in-service on expired food. During an interview with the Director of Nursing on 04/23/24 at 3:40 PM revealed that her expectation of kitchen staff is to monitor items and dispose of items before they go bad. She stated she will talk to the kitchen staff about the monitoring and the removal of expired foods. An interview with the Administrator on 04/23/24 at 03:47 PM revealed My expectation of the kitchen is for all items to be labeled with open and use-by dates. Staff should label food as they go in and discard items that have expired to not compromise other foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record reviews and interviews, the facility failed to thoroughly investigate an elopement for 1 of 1 residents reviewed for elopement. Specifically, Resident (R)1 successfully eloped from the facility and was found down the street from the facility. Finding include: Review of the facility policy titled, Elopement with a revision date of 11/01/17, documented, Policy: . A prompt investigation and search will be conducted in a patient/resident is considered missing . Procedures: 11. Facilities Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences. Document Requirements: Incident Report, Investigative Report, Nursing notes should reflect an accurate and detailed account of situation and outcome, Social Services notes need to address emotional assessment and interventions. Missing Patient/Resident Profile and Notification Record. Review of R1's Electronic Medical Record (EMR) revealed, R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to: vascular dementia, history of hallucinations, pain, mild anxiety and history of falling. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/15/23 revealed a Brief Interview of Mental Status (BIMS) score of 10 out of 15, indicating R1 had moderately cognitively impaired. Review of R1's progress note dated 09/22/23 at 6:00 PM states, Visitor noted resident exiting the front door. Resident assisted per staff back into the building without difficulty. Resident previously noted up in a wheel chair in the day room talking with other residents. Body audit completed, 15 minute checks in place. Resident redirected without difficulty, MD, RP and DON made aware. Review of the facility reported incident revealed, Resident noted exiting the front door and staff notified immediately. Two nurses and a Certified Nursing Assistant (CNA) went to assist resident back into the building. Resident noted to be walking towards parking area when staff arrived to him. Resident assisted into wheelchair and back into building without difficulty. Body audit completed with no skin deficits noted. Resident is alert and oriented as per usual. Fifteen minute checks initiated. Wanderguard ordered and to be placed on ankle to alert staff of any other attempts to exit the building. The resident's personal representative and the physician are made aware. Further review revealed no employee statements and no investigation conducted by the facility. During an interview on 10/03/23 at 2:50 PM, Resident (R)8 stated that she was sitting in her room and happened to look out the window and saw a resident in the road. I thought to myself, he is going to get run over by a car. So I went up to a nurse that was talking to a family member and told them of a the resident in the road. During an interview on 10/03/23 at 3:02 PM, with the family member (FM) that found R1 in the street. FM stated she was talking to the hospice nurse about her family members. And R8 came up to her and stated there was a resident outside in the road. The FM stated she looked out the window and saw the resident across the street near the house at the end of the road. The FM ran out there and the resident was unstable and she rested him against her knee to prevent him from falling. The FM further stated a staff member yelled to her to bring the resident back and the FM yelled No, someone bring a wheel chair. The FM stated there were several cars stopping to ask if assistance was needed, and law enforcement came up. The FM stated she did not know if there was a police report or not. The FM concluded that she pushed the resident back into the facility after he was in the wheel chair. During an interview on 10/03/23 at 1:05 PM, the Director of Nursing (DON) stated, The nurse called and reported that a family member was leaving the facility and reported the resident in the parking lot just outside the front door. I think he walked out behind a visitor because you cannot open the front door without a code or you have to hold your hand on the door and try to push it open for 30 seconds and then it will open. The DON was not present at the time of the elopement but stated that the alarm did not sound. The DON further stated that a family member that visits her family frequently saw him in the parking lot and notified us. A request was made to see the video surveillance of the parking lot on 09/22/23, but it was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy titled, Activities of Daily Living, Optimal Function, review of medical records, and interviews, the facility failed to ensure Resident (R)2 received the care and services needed related to bathing for 1 of 1 residents reviewed that was dependent on staff for Activities of Daily Living. The findings include: Review of the facility's policy titled, Activities of Daily Living, Optimal Function, revealed under Policy: The facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individuals clinical condition demonstrate that such diminution was unavoidable. The facility provides necessary care to all resident's that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming and hygiene. The facility admitted R2 with diagnoses including, but not limited to, dementia, cognitive communication deficit, acute respiratory failure with hypoxia, sepsis, pain and protein calorie malnutrition. Review of R2's medical record revealed a shower schedule for Tuesdays, Thursdays and Saturdays. No documentation could be found to ensure R2 has received any showers at all. R2 was hospitalized on [DATE] and was discharged back to the facility on [DATE]. The documentation of baths revealed that R2 received a partial bath on 01/08/23. From 01/09/23 until discharge to the hospital on [DATE], there is no documentation to ensure R2 received any type of bath. There was no documentation of R2 refusing a bath during those 8 days. An interview on 01/20/23 at 01:25 PM with the Director of Nursing (DON) confirmed that there was no documentation to ensure R2 received a bath on any of the 8 consecutive days from 01/09/2023 until 01/16/2023 when R2 was discharged to the hospital. The DON confirmed that there was no documentation of any refusal of baths during those 8 days.