**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to ensure that medications were properly and securely stored when medications were left in a resident's room for 1 of 71 (Resident #60) sampled residents. The findings include: 1. Review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals dated 8/7/2023, revealed .Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size .Store all drugs and biologicals in locked compartments .permanently affixed compartments, permitting only authorized personnel to have access .Facility should ensure that all medications and biologicals, including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration . Review of the facility policy titled, Self Administration of Medications dated 11/28/2016, revealed .Facility .should assess and determine, with respect to each resident whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition .Facility should ensure that orders for self-administration list specific medication(s) the resident may Self-Administer .Facility should document the Self-Administration of medications in the resident's care plan .Facility should document the self-storage of medications in the resident's care plan . 2. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE], with diagnoses including Osteoarthritis, Diabetes, Fibromyalgia, and Fusion of the Spine. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #60 was cognitively intact. Review of the Medication Self-Administration review dated 5/14/2024, revealed Resident #60 was not assessed for self-administering the medication Hylands Restful legs [used to calm restless legs]. Review of the Care Plan dated 6/14/2024, revealed Resident #60 was not care planned for medication self administration. Review of the Physician Orders dated July 2024, revealed .Hylands Restful legs Give 3 tablets every 4 hours as needed for restless legs . Random observation in the Resident's room on 7/22/2024 at 9:15 AM, revealed 3 white tablets in a medication cup on the Resident's nightstand. During an interview on 7/22/2024 at 9:18 AM, Licensed Practical Nurse (LPN) B confirmed that the medication should have been administered to Resident #60 the previous night (7/21/2024) and medications should not be left at the bedside. During an interview on 7/23/2024 at 3:42 PM, the Interim Director of Nursing confirmed that medications should not be left at a Resident's bedside.

Based on policy review, observation, and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse [LPN] A) nurses followed proper infection control measures to prevent the potential spread of infection and cross contamination while performing blood glucose monitoring during Medication Administration. The findings include: 1. Review of the facility's policy titled Cleaning and Disinfection of the Glucometer dated 9/20/2023, revealed .To prevent the spread of infection, specifically blood borne pathogens through the use of point of care blood glucose monitoring, by cleaning and disinfecting glucometers after each resident use . 2. Observation in Resident #6's room on 7/23/2024 at 7:37 AM, revealed Licensed Practical Nurse (LPN) A gathered supplies, removed the glucometer from the medication cart drawer, and placed it on top of the medication cart. LPN A preceded to perform a blood glucose check on Resident #6 and returned the glucometer to the medication drawer. LPN A failed to clean the glucometer in accordance with the facility policy. During an interview on 7/23/2024 at 11:59 AM, LPN A confirmed that she should have cleaned the glucometer before and after use. During an interview on 7/23/2024 at 3:42 PM, the Interim Director of Nursing confirmed that the glucometer should be cleaned before and after each resident use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Amended 9/24/2023 Based on policy review, medical record review, observation, and interview, the facility failed to ensure all residents' right to be treated with dignity and respect when 1 of 6 staff member (Licensed Practical Nurse (LPN) #9) failed to provide privacy for Resident #225 during administration of medication through a Percutaneous Endoscopic Gastrostomy tube. The findings include: 1. Review of the facility's policy titled, .Dignity, dated 9/30/2022, revealed .Each resident has the right to be treated with dignity and respect. Interactions .with residents by staff .must focus on maintaining and enhancing the resident's self-esteem, self-worth . 2. Review of the RESIDENT admission AGREEMENT .Section 11: Resident Rights .The resident has a right to personal privacy includes .medical treatment .personal care . 3. Review of the medical record revealed Resident #225 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Diabetes, Sepsis, Congestive Heart Failure, Polyneuropathy, Dysphagia, Gastrostomy, Cardiomegaly, and Pneumonitis. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #225 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated resident had moderate cognitive impairment and required extensive assistance with for bed mobility, dressing and personal hygiene. Observation in the resident's room on 8/31/2023 at 9:03 AM, revealed the LPN #9 administered medications through Resident #225's Percutaneous Endoscopic Gastrostomy tube (a tube inserted into the stomach through the abdomen). LPN #9 failed to close the blinds, leaving him exposed while administering his medications. There were 2 staff and 3 residents sitting outside the window in the smoking area. During an interview on 8/31/2023 at 9:20 AM, LPN #9 was asked should you have closed his blinds so residents and staff outside could not see him. LPN #9 stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to ensure residents' right to be free from verbal and physical abuse for 1 of 7 (Resident #39) sampled residents reviewed for an allegation of abuse. The findings include: 1. Review of the facility's RESIDENT admission AGREEMENT, revised 2022, revealed, .The resident has the right to be free from abuse, neglect . Review of the facility's policy titled, Abuse - Conducting an Investigation, dated 7/18/2023, revealed .It is the policy of this facility that allegations of abuse .are promptly and thoroughly investigated. The facility will prevent further abuse, neglect .and mistreatment from occurring while the investigation is in progress .The facility must develop and implement written policies and procedures .Prohibit and prevent abuse, neglect . 2. Review of medical record, revealed Resident #39 was admitted [DATE] with a readmission on [DATE], with diagnoses of Rhabdomyolysis, Crohn's Disease, Dysphagia, Anxiety Disorder and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Metal Status (BIMS) score of 5, which indicated she was severely cognitively impaired with no behaviors identified and required physical help for most activities of daily living (ADLs). Review of the Social Services Note dated 5/5/2023, revealed .Pt's [patient's] mood throughout assessment was fairly pleasant with a couple isolated instances of tearfulness r/t [related to] home and her husband . Review of the Social Services Note dated 6/19/2023, revealed .SSD [Social Service Director] spoke with pt and husband on 6/18/2023. Both Mr. and Mrs. [Named last name] voicing agitation with one another . Review of the 24-hour Spiral Notebook dated 8/6/2023, revealed .6p-6a [6:00 PM- 6:00 AM] [Named Resident #39] awake @ [at] 6:15p [6:15 PM] .Husband yelling at staff threatening to take her home bc [because] staff would not leave her in bedroom while she was restless & [and] attempting to ambulate without assist . Review of the 24-hour Spiral Notebook undated, revealed . [Named Resident #39] not getting along with husband. Slept in empty room near nurses Station. Please ask weekend Sup [supervisor] to ask him [Resident #39's husband] to leave . Review of the Social Services Note dated 8/14/2023, revealed .Pt's [patient's] husband dropped by SSD's [Social Service Director's] office to discuss ICF [Intermediated Care Facility] plans for September .Requested an estimated cost for ICF .Husband then spoke of wife's confusion and critical statements she makes of him which is often frustration. SSD encouraged husband to take time away from the facility prn [as needed] . Observation and interview in the resident's room on 8/31/2023 at 3:30 PM, revealed Resident #39 covered with blanket resting in bed asleep and husband sitting on empty bed eating a snack. Unable to conduct interview, husband appeared confused and rambling when asked a question. During an interview on 8/30/2023 at 2:28 PM, Certified Nursing Assistant (CNA) #1 was asked if she had observed Resident #39's husband being physically abusive and yelling at her. CNA #1 stated Yes ma'am .I seen him smack her on the hand .I turned it in . he was yelling at her .I was down the hallway .I came back up to her room .she was reaching for the call light .he took it from her and smacked her hand . CNA #1 was asked if Resident #39's husband was banned from the facility after yelling at the staff and after being abusive to the wife. CNA #1 stated, .I believe [Named Social Services Director] escorted him out of the facility . CNA #1 was asked if she wrote a statement and reported the allegation of alleged abuse incident to anyone. CNA #1 stated, .Yes .I don't think I wrote a statement .I informed and reported it to the nurse [LPN #3] .the nurses they have a 24-book they write in when we report it [abuse] . During an interview on 8/30/2023 at 2:44 PM, CNA # 6 was asked if she witnessed Resident #39's husband yelling or being abusive towards her. CNA #6 stated .I was here maybe 2 weeks ago with her .when I seen [saw] him get irritated with her not keeping her feet up while pushing her in her wheelchair .he ran over her foot pushing the wheelchair . CNA #6 was asked if she reported the incident to anyone. CNA #6 stated, .Yes .told the nurse [Named LPN #3] . During an interview on 8/30/2023 at 2:54 PM, Licensed Practical Nurse (LPN) #4 was asked if she was aware of Resident #39's husband being abusive towards her. LPN #4 stated, .Yes .nobody has reported to me .I heard it during change of shift .the nurse would say he was caught yelling at her or talking back to her . LPN #4 was asked if she was aware Resident #39's husband was banned from the facility. LPN #4 stated, .it seems like it was one time they [management] asked him to go home for a few days . During an interview on 8/30/2023 at 3:15 PM and on 8/31/2023 at 8:15 AM, LPN #3 was asked if she had a staff member report an allegation of abuse related to Resident #39. LPN #3 stated .Yes .I had a CNA come to me awhile back .she [CNA #1] came to me told me she saw him [Resident #39's husband] hit her on her hand .I told [Named Social Service Director] or [Named Assistant Director of Nursing (ADON)] . LPN #3 was asked if she had completed an incident report, documented the incident, and gathered statements from staff. LPN #3 stated, .No . LPN #3 was asked if she completed a skin assessment on Resident #39. LPN #3 stated .No . During an interview on 8/30/2023 at 4:07 PM, the Social Service Director was asked if she had investigated the allegation of abuse related to Resident #39. The Social Service Director stated, .I went down to investigate the allegation .I spoke with him [Resident #39's husband] .it was brought to my attention .he said he was trying to get her not to push call light again .she did not need anything .so he was taking the call light from her .we did talk about him getting agitated .him needing to go home .I encourage him to take time for himself .he did verbalize agitation with her confusion .he said he did not hit her, it was brought to my attention he grabbed her hand . The Social Service Director was asked if she should have gathered statements and start an investigation if a staff member reported the husband had slapped/smacked Resident #39's hand. The Social Service Director stated, .Yes .correct .I should have completed an investigation . During an interview on 8/30/2023 at 6:48 PM, CNA #5 was asked if she had witnessed Resident #39's husband being abusive towards her. CNA #5 stated .No . I was briefed on him .by the nurse and the CNA .to keep an eye out because he has been known to . [yell at her] .I was informed [during training] .I was told about certain things I need to watch for . During an interview on 8/30/2023 at 6:54 PM, CNA #4 was asked if she ever witnessed Resident #39's husband yelling or being physically abusive towards his wife. CNA #4 stated, .he has gotten loud with her .he would get mad and try to yell at her [Resident #39] .I would just tell him to calm down .the only time heard him yelling .I was physically in the room . CNA #4 was asked if she had seen the husband being physical abuse to Resident #39. CNA #4 stated .maybe mentally and emotionally never first hand witness physical abuse . CNA #4 was asked if she reported this to anyone. CNA #4 stated, .the nurse [Named LPN #8] .she would go down there and talk to him .we have been told to watch him . [Named DON (Director of Nursing)], Named ADON and Named Scheduler] .they told us to observe and make sure it was not continuing .the hollering .making sure he was not putting his hand on her . The facility was unable to provide documentation the allegation of abuse was reported and thoroughly investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse for 1 of 4 (Resident #39) sampled residents reviewed for allegation of abuse. The findings include: 1. Review of the facility's policy titled, Abuse - Protection of Residents, revised 7/18/2023, revealed .The facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation .Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident . 2. Review of medical record revealed Resident #39 was admitted [DATE] with a readmission on [DATE], with diagnoses of Rhabdomyolysis, Crohn's Disease, Dysphagia, Anxiety Disorder and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Metal Status (BIMS) score of 5, which indicated she was severely impaired with no behaviors identified and required physical help for most activities of daily living (ADLs). Review of the medial records reviewed there was no documentation of the allegation of abuse related to Resident #39. During an interview on 8/30/2023 at 2:28 PM, Certified Nursing Assistant (CNA) #1 was asked if she had observed Resident #39's husband being physically abusive and yelling at her. CNA #1 stated, .Yes ma'am .I seen him smack her on the hand .I turned it in before .he was yelling at her .I was down the hallway .I came back up to her room .she was reaching for the call light .he took it from her and smacked her hand . During an interview on 8/30/2023 at 3:15 PM, Licensed Practical Nurse (LPN) #3 was asked if she had a staff member report an allegation of abuse related to Resident #39. LPN #3 stated, .Yes .I had a CNA come to me awhile back .she [CNA #1] came to me told me she saw him [Resident #39's] husband hit her on her hand .I told [Named Social Service Director] or [Named Assistant Director of Nursing (ADON)] . During an interview on 8/30/2023 at 4:07 PM, the Social Service Director was asked if she got a report of an allegation of abuse should it be reported to the State Agency. The Social Service Director stated, .Yes . The facility failed to report an allegation of abuse to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 of 4 (Resident #39) sampled residents reviewed for allegation of abuse. The findings include: 1. Review of the facility's policy titled, Abuse - Conducting an Investigation, dated 7/18/2023, revealed .It is the policy of this facility that allegations of abuse .are promptly and thoroughly investigated. The facility will prevent further abuse, neglect .and mistreatment from occurring while the investigation is in progress .When an incident or suspected incident of resident abuse .is reported, the administrator .will investigate the occurrence .The facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary .The administrator .will review the Incident Report for completeness .The written summary of the investigation should include, but is not limited to .A review of the Incident Report .An interview with the person (s) reporting the incident .Interviews with any witness to the incident .Interview with staff members on all shifts having contact with the resident at the time of the incident .If the accused individual is a family member .the person will be denied unsupervised access to the resident .pending the results of the investigation . 2. Review of medical record, revealed Resident #39 was admitted [DATE] with a readmission on [DATE], with diagnoses of Rhabdomyolysis, Crohn's Disease, Dysphagia, Anxiety Disorder and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Metal Status (BIMS) score of 5, which indicated she was severely impaired with no behaviors identified and required physical help for most activities of daily living (ADLs). During an interview on 8/30/2023 at 2:28 PM, Certified Nursing Assistant (CNA) #1 was asked if she had observed Resident #39's husband being physically abusive and yelling at her. CNA #1 stated Yes ma'am .I seen him smack her on the hand .I turned it in . he was yelling at her .she was reaching for the call light .he took it from her and smacked on her hand . CNA #1 was asked if she wrote a statement and reported the allegation of abuse incident to anyone. CNA #1 stated .I don't think I wrote a statement .I informed and reported it to the nurse [LPN #3] . During an interview on 8/30/2023 at 3:15 PM, Licensed Practical Nurse (LPN) #3 was asked if she had a staff member report an allegation of abuse on Resident #39. LPN #3 stated, .Yes .I had a CNA come to me awhile back .she [CNA #1] came to me told me she saw him [Resident #39's] husband hit her on her hand .I told [Named Social Service Director] or [Named Assistant Director of Nursing [ADON] . LPN #3 was asked if she had completed an incident report, documented the incident, and gathered statements from staff members. LPN #3 stated, .No . During an interview on 8/30/2023 at 4:07 PM, the Social Service Director was asked if she had investigated the allegation of abuse related to Resident #39. The Social Service Director stated .I went down [Resident #39's room] to investigate the allegation .I spoke with him [Resident #39's husband] .it was brought to my attention .he said she was trying to get her not to push call light again .she did not need anything .so he was taking the call light from her .we did talk about him getting agitated and him needing to go home .I encourage him to take time for himself .he did verbalize agitation with her confusion .he said he did not hit her .it was brought to my attention he got/grabbed her hand . The Social Service Director was asked if she should have gathered statement and started an investigation if a staff member reported the husband had slapped/smacked her hand. The Social Service Director stated .Yes .correct .I should have completed an investigation . The facility failed to complete a thorough investigation of an allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to conduct Care Plan meetings which included the Interdisciplinary Team (IDT) for 1 of 3 sample resident (Resident #35) reviewed for care plan meetings. The findings include: 1. Review of the facility's policy titled, Comprehensive Care Plans and Conferences, dated 8/22/2023, revealed .Interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative .is involved in developing the care plan and making decision about his or her care .The IDT [Interdisciplinary Team] must, at a minimum, consist of the resident's attending, physician, a registered nurse and nurse aide with responsibility for the resident, a member of the food and nutrition services staff .the resident and resident representative .The facility should provide the resident and resident representative if applicable with advance notice of care planning conferences to enable resident/resident representative participation . Review of the RESIDENT admission AGREEMENT dated 2022, revealed .The resident has the right to be informed of, and participate in, his or her treatment .the right to participate in the development and implementation of his or her person-centered plan of care . 2. Review of medical record revealed Resident #35 was admitted on [DATE], with diagnoses of Diabetes, Peripheral Vascular Disease, Hypertension, and Chronic Pain. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #35 had a Brief Interview For Mental Status (BIMS) score of 15 which indicated he was cognitively intact and required total care for most of his Activity of Daily Living (ADLS). Review of the CARE PLAN CONFERENCE RECORD dated 3/7/2022, revealed only the Activity Director, Dietary Manager and the Social Service Director signed as attending the meeting. The Care Plan Conference Record had no documentation of what was covered in the meeting. Review of the medical record revealed there were no quarterly Care Plan meetings held for Resident #35 on 6/30/2022, 9/14/2022, 11/16/2022, 2/16/2022, and 5/19/2023 according to the quarterly MDS schedule. Review of the Care Plan Meeting schedule revealed Resident #35 was scheduled for a Care Plan meeting on 11/23/2022 and 4/12/2023. Review of the Progress Note dated 6/7/2023, revealed .Pt [patient] participated in his Care Plan meeting held today. Orders reviewed. Pt very aware of his current care plan and agreeable . FULL code POST reviewed/discussed with pt expressing no desire to make changes at this time. Current plan of care to continue. The facility was unable to provide documentation of who attended the care plan meeting held on 6/7/2023. The facility was unable to provide documentation the Care Plan meeting was held according to the RAI (Resident Assessment Instrument) manual. During an interview on 8/30/2023 at 9:34 AM, Resident #35 was asked if he attended a Care Plan meeting with the social worker on 6/7/2023. Resident #35 stated, .yes with [Named Social Service Director] and the Scheduler only . During an interview on 8/30/2023 at 11:16 AM, the Assistant Director of Nursing (ADON) was asked to tell about the process for the Care Plan meeting and who attend the meeting. The ADON stated, .If me and the Director of Nursing [DON] are here one of us attend .the Scheduler .Social Service Director .MDS Coordinator .Dietary Manager .Therapy .Activity if available she attend also .the resident or the Responsible Party [RP] .we have a paper form we sign .filed in the resident chart .scanned into Point Click Care [PCC] .document what was discussed in the meeting .the meetings are held quarterly .letters are sent out to the RP and resident . During an interview on 8/30/2023 at 12:11 PM, the MDS Coordinator was asked how the Care Plan meetings are scheduled. The MDS Coordinator stated, .I schedule the meeting off MDS schedule .I try to make sure we have them quarterly every 3 months . The MDS Coordinator was asked where Care Plan meetings are documented. The MDS Coordinator stated, .they are documented in PCC .we do have the care plan conference report . The MDS Coordinator was asked who should attend the care plan meeting. The MDS Coordinator stated, .a nurse representative .Social Services .Dietary Manager .Activity .ideally a CNA [Certified Nursing Assistant] direct care .collaborate with the IDT .Nurse Practitioner sometimes comes .the DON and ADON .as for a nurse I attend . The MDS Coordinator was asked did the meeting held on 3/7/2022 have representation from the IDT. The MDS Coordinator stated, .No . During an interview on 8/28/2023 at 3:34 PM, the Social Service Director was asked if she had any documentation of Resident #35's care plan meeting. The Social Service Director stated, .No . I don't have any documentation on the care plan meetings .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to administer medications as prescribed by the physician and as recommended for 1 of 3 (Resident #52) sampled residents reviewed for medication administration. The findings include: 1. Review of the facility policy titled, Administration of Medications, dated 8/25/2022, revealed, .The facility will ensure medications are administered safely and appropriately per physicians order to address resident' diagnoses and signs and symptoms .Staff who are responsible for medication administration will adhere to the 10 Rights .Right Drug .Every drug administered must have an order from the provider. Compare the order with the medication administration record (MAR) for accuracy. Compare the label of the drug to the information on the M. A. R. [Medication Administration Record] three times .Right Resident .Right Dose .Right Route .Right Time and Frequency .Right Documentation .Right Assessment .Right to Refuse .Right Evaluation .Right Education and information . Review of the facility policy titled, LTC (Long Term Care Facility's Pharmacy Services and Procedures Manual, dated 1/4/2023 revealed .the procedures relating to automated medication dispensing systems (AMDS) .Assure removal and replacement of controlled substance .is witnessed by Facility staff .Medications removed from the AMDS must have a corresponding Physicians/Prescriber's order .When a facility that has adopted a policy to have another nurse witness the removal of a controlled substance from the AMDS .the nurse removing the dose should have a nurse on the unit or the nursing supervisor verify .the medication .the strength .dosage form .the quantity removed .The verification by the unit nurse or supervisor should be documented in the resident's medical records or the perpetual inventory record . Review of the facility policy titled, Medication Reconciliation across the Continuum of Care, dated 8/17/2022, revealed, .Medications will be reconciled by the Licensed nurse. Clinically significant medications issues identified will be communicated the physician, acted upon, and documented in the medical record .Drug Regimen Review .A drug regimen review includes medication reconciliation, which is a review of all medication a resident is currently using, and a review of the drug regimen to identify and, if possible, prevent potential clinically significant medication adverse consequences .Procedure .Upon admission /readmission or as close to the actual time of admission as possible, medication will be reconciled by the licensed nurse . 2. Review of medical record, revealed Resident #52 was admitted on [DATE], with diagnoses of Dementia, Diabetes, Chronic Kidney Disease, Heart Failure, Anxiety Disorder, and Malignant Neoplasm of Large Intestine. Review of [Named Hospital] records dated 1/26/2023, revealed .Rytary 23.75-95 mg . Take one capsule by mouth 3 .times a day . Review of the Physician Order dated 1/26/2023, revealed .diazePAM Oral Tablet 2 MG [Milligram] (Diazepam) [used to treat anxiety disorders] .Give 1 tablet by mouth two times a day for anxiety for 10 Days .Rytary [treat symptoms of Parkinson's disease] Oral Capsule Extended Release 23.75-95 MG (Carbidopa-Levodopa) Give 3 capsule by mouth three times a day related to .TREMOR . Review of the Order Audit Report dated 1/26/2023, revealed .Created Dated .1/26/2023 .confirmed By . [Named LPN #3] .Queued [a sequence of stored data or programs awaiting processing] By . [Named Director of Nursing (DON)] .Electronic .Signed By . [Named Medical Doctor] on 1/30/2023 . Review of the Incident report dated 2/5/2023, revealed .Resident prescribed 2mg [2 milligrams] Valium [Diazepam] used to treat anxiety disorders] BID [twice a day]. This nurse [Licensed Practical Nurse (LPN) #2] went to Omnicell [automated medication dispensing systems], entered code and pulled 10mg [10 milligrams] of Diazepam used to treat anxiety disorders]. Med [medication] was given. Was later found to be on 2mg [2 milligrams] not 10mg . The nurse administered 10 mgs instead of the 2 mgs prescribed. Review of Progress Note created on 2/7/2023, revealed .Resident prescribed 2mg Valium [Diazepam] BID. This nurse [LPN #2] went to Omnicell, entered code and pulled 10mg of Diazepam. Med was given. Was later found to be on 2mg not 10mg . Review of the Synopsis of a Medication Reconciliation Error revealed .The patient was admitted to [Named Facility] after a hospitalization at [Named Hospital] due to major neuro [neurological]-cognitive disorder on 1/26/2023. On 2/22/2023 it was identified that patient had an order for Rytary 23.75-95 mg [milligrams], transcribed on EMAR [Electronic Medication Administration Record] for 3 caps [capsules], TID [three times a day] for other specified form of tremors. Actual order should have been Rytary 1 cap [capsule], TID [Named LPN #3], LPN completed the reconciliation of mediations after the DON entered the medication in error . [Named Medical Doctor] notified on 2/22/2023 . [Named Daughter] aware on 2/22/2023 . [signed by the DON] . The resident should have been given 1 capsule three times a day and not the 3 capsules three times a day he was administered. Review of Progress Note dated 3/1/2023, revealed .Resident was seen and examined for monthly rounds. Siting [sitting] in wheelchair in the hall. Appears well. Staff report his mental status is improved, he had had some confusion recently. Medication adjustments have been made . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated he was moderately impaired with no behaviors identified and required total care for most activities of daily living (ADLs). Review of the Witness Interview/Statement Form dated 8/29/2023, signed by the ADON revealed . [Named LPN #3] .I second checked The admission orders. I clicked Confirm after reviewing all the orders and continued to work on the rest of the admission. I overlooked the dosage amount on one of his medications when I second checked . Review of the Witness Interview/Statement Form dated 8/29/2023, signed by the Assistant Director of Nursing (ADON) revealed . [Named LPN #2] .Medication not in The drawer. Medication was Valium [Diazepam] 2 mg. I called pharmacy and got code to pull valium 2 mg. I got [Named RN Supervisor] to be witness and I pulled from the Omnicell [automated medication dispensing systems] Valium 5 mg 2 tablets instead of Valium 2 mg one tablet. I administered the medication. The next day, [Named DON] called me to come to the facility because there was a Med [medication] error. I went to facility and did incident report and contracted MD [Medical Director] and family . Review of the Witness Interview/Statement Form dated 8/29/2023, signed by the ADON revealed . [Named RN Supervisor] . [Named LPN #2] asked me for my help to pull Diazepam [Valium] from the Omnicell [automated medication dispensing systems]. We went to the med [medication] room and [Named LPN #2] pulled the medication from Omnicell and I was the witness and had to put my username and fingerprint in After [Named LPN #2] pulled the mediation .I saw [Named LPN #2] had [Named Resident #52] as the resident and Diazepam was the medication pulled . There was no documentation in Resident #52's medical records that he was evaluated by the MD after the medication error that occurred on 2/5/2023 and the medication error that was discovered from 1/26/2023 to 2/22/2023. During an interview on 8/28/2023 at 10:07 AM, Licensed Practical Nurse (LPN) #1 was asked if she could tell me about Resident #52's medication errors. LPN #1 stated, .his daughter is the one who caught it [Rytary medicating error] when she came .there were the orders [Rytary 3 capsules three times a day] in the computer .so that is what he was getting .I just remember it was 3 capsules .he was to get 1 capsule three times a day instead of the 3 capsules three times a day .when first came in he would sleep all the time .we did medication reviews to try and figure out what was making him sleep all the time .on 2/22/2023 they changed medication to 1 capsule three times a day .they discontinued the medication on 4/11/2023 .per family request .the daughter .I know they did a medication error on the Valium [Diazepam] .I don't know what happen .pharmacy called the facility .I answered the phone .they said need to speak to someone .a wrong order had been pulled .the normal dose he gets was 2 mg .I understand it was [Named LPN #2] . LPN #1 was asked at any time did Resident #52 have low blood pressures. LPN #1 stated, .he had a few low blood pressures back in January .it was when he was sleeping .we did his blood pressure first thing in the morning .that would explain that . During an interview on 8/28/2023 10:53 AM, LPN #2 was asked to tell me about the medication error with Resident #52. LPN #2 stated .we needed to pull it [the Valium/ Diazepam] .I went in [Medication room] and had dose in my head .I pulled the wrong dose .I had a second person with me .it was a mistake I made .they [DON] called me .she told me I made a medication error .I need to come and correct it .do the paper work .I contacted the family .the doctor .I had worked the weekends .It was on Monday when the DON called me .I was not aware I gave wrong dose .I thought I checked the dose .I had a witness with me .[Named RN Supervisor] . During an interview on 8/29/2023 at 9:55 AM, the daughter was asked about how she found out about the medication errors. The daughter stated .there was an instance I was called .I don't remember the dosage of the medication with Valium [Diazepam] .staff called to tell me that his blood pressure had dropped that weekend .I was not aware of the over medication till the nurse called me later .he was over medicated .I called the facility and they did some checking on the prescription [Rytary] .it was not what I had or what we sent [orders] .I called the facility and they said they have to call me back .there was an medication error made .but not sure what happen .the DON would not go into details .they paid for all the medication he was billed for .when he left [Named Hospital] .they sent a medication list with him .the DON informed me a mistake .he got 3 pills three times a day .they made a mistake .I found it .when I got the bill . During an interview on 8/29/2023 at 12:02 PM, the ADON was asked what the process was for entering orders for a new admission. The ADON stated, .we have an admission audit check list to remind the nurse to have 2 nurses .one nurse puts the order in .the other nurse checks the orders .the second nurse verifies the orders when the resident come with new orders .check what we have [orders] .reconcile the orders .when the residents arrives we check for changes .make sure all the orders match .we let the MD know when we get a new admission .the MD looks at the orders and signs off on the orders .we initiate the order in PCC [Point Click Care computer system] for each resident .it automatically goes to the MD . The ADON was asked what the process when the facility identifies a medication error. The ADON stated, .notify MD and RP [Responsible Party] .open an incident report .complete an acknowledgement sheet .write the details .what happened .what caused the medication error .why did it occur . The ADON was asked if the facility should have completed an incident report on the medication error for the Rytary and gathered statements for each medication error. The ADON stated, .Yes . The ADON was asked what the process for pulling medications from the automated medication dispensing systems. The ADON stated .when a nurse needs to pull a narcotic .the nurse has to call pharmacy .tell them what resident and what drug .the pharmacy verify current correct script with the dosage .pharmacy gives the nurse a code to pull the drug .need 2 nurses to pull the drug .make sure have the right resident and the right drug .it will say witness needed .the witness hits confirmed .the drawer will open after the witness puts in her identification .the nurse checks right dose .expiration date .right route .right frequency .right resident .the nurse should check the medication before administering . During a telephone interview on 8/29/2023 at 2:37 PM, the Medical Doctor (MD) was asked if she was aware of the medication error with Resident #52. The MD stated, .the nurse put in Rytary 3 pills three times a day and I signed off the medication .the daughter got an incorrect bill .that's when we found out about it .the nurse alerted me, looks like February 22 .the nurse called me, said the DON and nurse put the medication in wrong .the Valium [Diazepam] I don't recall that I was told about it . The MD was asked what type of side effects Resident #52 could have from a higher dose of Valium. The MD stated, .it could drop the blood pressure and cause extra sedation .the respirations could be lower . The MD was asked should the staff follow the 5 rights of medication administration and check the order for accuracy. The MD stated .Yes ma'am .

Based on facility policy review, observation, and interview, the facility failed to ensure that medication records were in order and that an account of all controlled medications were maintained and reconciled for 1 of 6 (Registered Nurse (RN) #1) nurses for 5 of 7 (Resident #14, #34, #35, #63, and #71) residents. The findings include: 1. Review of the facility policy titled, Management of Controlled Substances dated 8/28/2022, revealed .disposition of all controlled drugs .enable an accurate reconciliation .an account of all controlled drugs is maintained . 2. Observation and interview at the B Hall Medication (Med) Cart on 8/30/2023 at 11:37 AM, revealed RN #1 was asked to review Resident #14's narcotic reconciliation. Review of the Controlled Drug Record for Resident #14 revealed, .GABAPENTIN (used to treat seizures and nerve pain) .300 MG [Milligram] CAPSULE .Amount Remaining .11 . Review of Resident #14's narcotic card revealed a count of 10 Gabapentin capsules remained. RN #1 was asked about the difference in the number and stated, I just gave her one, let me sign it out. RN #1 signed out the Gabapentin at that time. RN #1 was asked what time it was given. RN #1 stated, About 10ish [1 hour and 37 minutes prior to this time] He confirmed that 1 Gabapentin was administered and it should have been signed out right away. 3. Observation and interview at the B Hall Med Cart on 8/30/2023 at 11:47 AM, RN #1 was asked to verify Resident #34's Oxycodone count. RN #1 stated, I just gave her one too .about 9:40 [AM] . Review of the Controlled Drug Record for Resident #34 revealed, .Oxycodone (used to treat moderate to severe pain) .Amount Remaining .14 . Review of Resident #34's narcotic card revealed 13 Oxycodone tablets remained. RN #1 was asked to verify all his narcotic counts. RN #1 stated, They're all gonna be the same [incorrect count] . 4. Observation at the B Hall Med Cart on 8/30/2023 beginning at 11:49 AM, revealed the following: a. Review of the Controlled Drug Record for Resident #14 revealed, .HYDROCODONE-ACET [Acetaminophen] (used to treat pain) 7.5-325MG TABLET .Amount Remaining .11 . Review of Resident #14's narcotic card revealed 10 Hydrocodone-Acetaminophen tablets remained. b. Review of the Controlled Drug Record for Resident #35 revealed, .GABAPENTIN .300 MG CAPSULE .Amount Remaining .13 . Review of Resident #35's narcotic card revealed 12 Gabapentin tablets remained. c. Review of the Controlled Drug Record for Resident #35 revealed, .MORPHINE SULFATE 30MG TABLET .Amount Remaining .23 . Review of Resident #35's narcotic card revealed 22 Morphine Sulfate tablets remained. d. Review of the Controlled Drug Record for Resident #63 revealed, .HYDROCODONE-ACET 7.5-325MG TABLET .Amount Remaining .26 . Review of Resident #63's narcotic card revealed 25 Hydrocodone-Acetaminophen tablets remained. e. Review of the Controlled Drug Record for Resident #71 revealed, .HYDROCODONE-ACET 10-325MG TABLET . Review of Resident #71's narcotic cared revealed 8 Hydrocodone-Acetaminophen tablets remained. During an interview on 8/30/2023 at 11:58 AM, RN #1 was asked what the facility's process was for signing out narcotics. RN #1 stated, Should sign them out immediately once you pull them. RN #1 was asked could he explain what happened this morning when all the narcotics were not signed out. RN #1 stated, No, I don't have a good explanation for that. During an interview on 8/30/2023 at 12:00 PM, the Regional Director of Clinical Services (RDCS) confirmed narcotics should be signed out when given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation and interview, the facility failed to ensure medications were properly stored when opened and undated medications and expired formula were observed in 2 of 5 (D Hall Medication Storage Room and D Hall Medication Cart) medication storage areas. The findings include: 1. Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals dated [DATE], revealed .Facility staff should record the date opened on primary medication container . 2. Observation of the D Hall Medication Cart on [DATE] at 5:03 PM, revealed: One opened and undated box of Ipratropium Bromide and Albuterol Sulfate 0.5/3mg (milligrams) (medication used to treat asthma, chronic bronchitis, and emphysema). One opened and undated bottle of Potassium Chloride 20 milliequivalents (used to treat low potassium). 3. Observation of the D Hall Medication Storage Room on [DATE] at 1:19 PM, revealed the following: 202 individual cartons of Glucerna 1.0 calorie (high calorie nutrition) with an expiration date of [DATE]. 48 individual cartons of Glucerna 1.0 calorie with an expiration date of [DATE]. 4. During an interview on [DATE] at 1:27 PM, the Regional Director of Clinical Services (RDCS) confirmed the expired formula should not be in the medication room and that medications should be dated when they are opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to maintain an effective pest control program in 3 of 60 (Resident #7, Resident #13, and Resident #35) resident rooms, failed to prevent parasites or possible maggots for Resident #22, and 1 of 4 (C Hall) Halls on 3 of 4 (8/29/2023, 8/30/2023, and 8/31/2023) days of onsite observations. The findings include: 1. Review of the facility policy titled, Pest Control, dated 6/4/2023, revealed .The facility will maintain an effective pest control program that provides frequent treatment of the environment for pests so that the facility is free of pests .The facility's staff will do monitoring of the environment. Pest control problems will be reported to the Director of Maintenance promptly . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Chronic Respiratory Failure, Dementia, Schizophrenia, and Severe Protein-Calorie Malnutrition. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated she was cognitively intact. Observation and interview in the resident's room on 8/31/2023 at 8:37 AM, revealed a fly was observed flying around Resident #7's covered meal tray. Resident #7 waved the fly away and stated, He stays in this room .I don't like to fight with him every day . 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Cardiomyopathy, Chronic Kidney Disease, Squamous Cell Carcinoma, and Anemia. Review of the quarterly MDS dated [DATE] revealed Resident #22 had a BIMS score of 5, which indicated he had severe cognitive impairment. Review of the Wound Observation Tool dated 7/28/2023, revealed .Acquired .11/23/2022 .right ear .Type .other .Unchanged .Length .3.6 [centimeters (cm)] .Width .4.2 [cm] .Depth .0.3 [cm] .No improvement expected. Resident often removes dressing and picks at ear .strong foul odor .Xeroform gauze [nonadherent dressing] 3x[times]/wk[week]/prn [as needed] . Review of the Event Note dated 8/5/2023 at 4:00 AM, revealed .Resident remove [removed] dressing to right ear. Blood noted to face and hands. While attempting to perform wound care, staff noted movement in wound. Upon further observation, appears like a parasite to wound bed. Review of Health Status Note dated 8/5/2023 at 4:00 AM, revealed .CNA [Certified Nursing Assistant] asked for resident's bandage to be replaced to his right eat. After assessing the area, MD [Medical Doctor] was notified. Order for wound nurse to come and address the area. Order also received for Ivermectin [anti-parasite to treat infections caused by roundworms, threadworms, and other parasites] and new treatment to area. Review of the physician order dated 8/5/2023 6:00 AM, revealed .CLEAN RGHT EAR WITH DAKINS [a solution used to kill germs in wounds] .APPLY DAKINS DAMP GAUZE WITH AND COVER WITH DRESSING .every day shift for SKIN CANCER AND as needed .Ivermectin .15 milligram (mg) .one time a day every 2 weeks .until 8/12/2023 . Review of the Wound Observation Tool dated 8/5/2023, revealed .Acquired .11/23/2022 .right ear .Type .other .worsening .Length .3.6 [cm] .Width .4.2 [cm] .Depth .0.3 [cm] .Noted small parasites to wound bed. Notified MD with new orders notes .odor remains but not as strong today .Dakin's daily . Review of the Wound Observation Tool dated 8/7/2023, revealed .Acquired .11/23/2022 .right ear .Type .other .improving .Length .4 [cm] .Width .4.2 [cm] .Depth .0.4 [cm] .No parasites noted at this time. Previous strong odor very mild at this time .Dakin's daily . Review of the Wound Observation Tool dated 8/14/2023, revealed .Acquired .11/23/2022 .right ear .Type .other .improving .Length .4 [cm] .Width .4.2 [cm] .Depth .0.4 [cm] .dermatology appointment today. Not a candidate for radiation. Surgeon to call in am [AM] about possible surgical interventions .Dakin's daily . Observation on the C Hall on 8/31/2023 at 8:27 AM, revealed a fly in the hallway outside Resident #22's room. Resident #22's door was opened. 4. Observation in the resident's room on 8/29/2023 at 5:03 PM, revealed a fly was on the light above the head of Resident #13's bed while medications were administered through the resident's percutaneous gastrotomy (PEG) tube. Observation in the resident's room on 8/30/2023 at 9:34 AM, revealed a fly landed on Resident #35's forehead during the resident's interview. Observation on the C Hall on 8/31/2023 at 8:30 AM, revealed a fly in the hallway outside the central bath. 5. During an interview on 8/30/2023 at 4:42 PM, the Regional Director of Clinical Services (RDCS) was asked about the incident on 8/5/2023 where Resident #22 was observed with something moving in his ear wound. The RDCS stated, Sometime that night the patient pulled off his dressing .picked at his ear a lot .CNA told the nurse that he had pulled it off and the nurse had seen something moving in it .she called the Director of Nursing (DON), the DON called the wound nurse and called me .the DON came here to the building, the wound nurse came to the building .she [wound nurse] assessed his ear and notified the doctor, notified the family, obtained the orders . The RDCS was asked did they determine what was in his ear wound. The RDCS stated, They wasn't sure but they thought it was maggots . The RDCS was asked how Resident #22 had gotten maggots in his ear wound. The RDCS stated, I do know that he pulls his dressing off .can only assume there had to be some kind of interaction with a fly . The RDCS confirmed facility staff assessed all residents and no other residents had any skin changes. Continued interview revealed housekeeping came out that day to monitor for pest concerns, they added fly protection measures, and conducted staff in-services. During an interview on 8/30/2023 at 5:36 PM, the Treatment Nurse confirmed that she was notified about Resident #22's ear by text message on 8/5/2023. The Treatment Nurse stated, .I called and came up here .went and looked at it, he had some things moving around in there .called the doctor and got the treatment changed .all the time he was taking the dressing off .squamous cell [carcinoma on right ear] .when I got here Saturday I cleaned it up .I came back later because I had missed some of the bugs .cleaned it up again .came back Sunday and there were none [maggots] Sunday . The Treatment Nurse was asked what the bugs looked like. The Treatment Nurse stated, The little white tiny [bugs] .there were probably a couple of dozen . The Treatment Nurse confirmed there was not a dressing on Resident #22's ear when she arrived at the facility because the resident refused to allow staff to apply one. The Treatment Nurse was asked when she cleaned the wound did Resident #22 say he could feel the bugs. The Treatment Nurse stated, I don't really think he knew they were there . During an interview on 8/31/2023 at 8:00 AM, LPN #6 confirmed that she was working on 8/5/2023 and stated, The CNAs came down and told me his bandage was off his ear and there was blood on his sheets .I took all the stuff to clean the area had never done that treatment before. There was no bandage on there .there was like a clot of blood on his ear and when I cleaned it off that's when I saw the little bitty worms . LPN #6 confirmed that she called the Nurse Practitioner and obtained new orders. LPN #6 stated, Flush it with [hydrogen] peroxide then clean it with soap and water and put a bandage on it. Then she called me back with a medication to order for him. LPN #6 confirmed the Nurse Practitioner ordered Ivermectin. LPN #6 was asked what the bugs looked like. LPN #6 stated, Little tiny white squirmy little bitty worms. LPN #6 was asked what happened when she cleaned the wound with the hydrogen peroxide. LPN #6 stated, They were like trying to get away from it .squirming . LPN #6 confirmed the bugs looked like maggots and they were still present in Resident #22's ear wound after she cleaned it with hydrogen peroxide. LPN #6 confirmed she reported the incident to the DON. During an interview on 8/31/2023 at 11:08 AM, the Administrator stated, We contacted the pest control company .come out .sprayed .gave us 5 fly bags to put out .they are outside the facility out back. The Administrator confirmed the pest control company sprayed Resident #22's room. The Administrator stated, They [flies] had stopped completely and it rained on Sunday [8/27/2023] and we had seen them on occasion, so we contacted the pest control company for them to come back out. The Administrator was asked when they were contacted. The Administrator stated, Tuesday, I believe [8/29/2023].

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 2 of 18 staff members (Activity Assistant and Certified Nursing Assistant (CNA) #9) failed to perform proper hand hygiene during meal service and failed to ensure temperatures for the nutrition freezers were documented daily in 2 of 2 nutrition refrigerators observed in the facility's Nutrition Rooms. The findings include: 1. Review of the facility's policy titled, Sanitation and Food Safety, dated 9/8/2022, revealed .Temperatures are recorded at least twice daily on the Refrigerator/Freezer Temperature Log using an inside thermometer placed near the door . Review of the facility's policy titled, .Hand Hygiene, with a revised date of 6/13/2023, revealed .Associates perform hand hygiene (even if gloves are used) in the following situations .Before and after contact with the resident .After contact with objects and surfaces in the resident's environment . 2. Observation in the resident's room on 8/28/2023 at 7:51 AM, revealed the Activity Assistant entered Resident #126's room, placed the tray on the overbed table, adjusted the bed with her bare hands, touched the remote, turned on the light, and touched the plug in the wall. She proceeded to set up the tray by removing the plate lid and the lids off the coffee and tea. The Activity Assistant touched the rim of the milk carton when she opened it up then proceeded to cut up the residents meat. The Activities Assistant failed to perform hand hygiene after touching dirty and contaminated objects in the residents room before setting up the resident's meal tray. Observation on the D Hall on 8/28/2023 at 8:04 AM, revealed the Activity Assistant failed to perform hand hygiene before removing a tray from the meal cart. The Activity Assistant knocked on Resident #16's door and raised the bed using the remote. She donned her gloves and set up the tray on the over the bed table. Activity Assistant failed to perform hand hygiene after taking off her gloves Observation on 8/28/2023 at 8:17 AM, revealed the Activity Assistant failed to perform hand hygiene after pulling up Resident #11 in bed. She put gloves and set up tray. She did not perform hand hygiene after taking off gloves or leaving the room. Observation in the Resident's room on 8/28/2023 at 8:22 AM, revealed the Activity Assistant placed the meal tray on the overbed table. Resident #66 requested to go to the bathroom. Activity Assistant donned gloves to assist Licensed Practical Nurse (LPN) #1 to transfer resident to the wheelchair and into the bathroom. The Activity Assistant helped Resident #66 out of the bathroom while in the wheelchair. The Activity Assistant locked the wheelchair, pushed the over the bed table up to Resident #66, and removed the lid from the breakfast tray before removing her gloves. The Activities Assistant failed to perform hand hygiene after assisting Resident #66 to restroom and then setting up the meal tray. Observation in the resident's room on 8/29/2023 at 12:31 PM, revealed CNA #9 entered Resident #116's room, placed the tray on the overbed table, adjusted the bed with the remote with her bare hands, and continued with the tray setup by removing the plate lid. CNA #9 pulled the trash can close to the bed with her bare hands and opened the lid of the trash can with her bare hands when she threw the plastic lids away. CNA #9 then cut up the meat, opened the straw with bare hands and placed straw paper into the trash can. CNA #9 failed to perform hand hygiene after touching dirty and contaminated objects in the residents room before setting up trays. During an interview on 8/31/2023 at 2:05 PM, Infection Preventionist confirmed that hand hygiene should be performed before gloves are donned and after gloves are doffed. Infection Preventionist was asked when should hand hygiene be performed during dining. Infection Preventionist stated, .before and after their [staff] hand touches anything . Infection Preventionist was asked what they should do if they raise the head of the bed. Infection Preventionist stated, They've got to wash their hands . 3. Observation in the Nutrition Room on the A/B Hall on 8/30/2023 at 4:06 PM, revealed the Nutrition Refrigerator did not have a Temperature Log attached. Observation in the Nutrition Room on the C/D Hall on 8/30/2023 at 4:15 PM, revealed the Nutrition Refrigerator did not have a Temperature Log attached. During an interview on 8/30/2023 at 4:30 PM, the ADON (Assistant Director of Nursing) confirmed the Temperature Logs were at the Nurse Station. Review of the Temperature Logs revealed only the refrigerator temperatures had been recorded in both Nutrition Rooms. Both Temperature Logs did not have freezer temperatures documented for the months of April, May, June, and July 2023. During an interview on 8/30/2023 at 5:00 PM, the ADON stated, I guess I put out the wrong temp sheet. There isn't a place to put the freezer on this sheet .I will find it and replace it. That's my fault . During an interview on 8/31/2023 at 9:59 AM, the Administrator confirmed staff should record temperatures for the freezer along with refrigerator temperatures.

Based on policy review, observation, and interview, the facility failed to ensure infection control practices to prevent the spread of infection were used when 4 of 5 (Licensed Practical Nurses (LPN) #1, #9, #10, and Registered Nurses (RN) #1) nurses failed to perform hand hygiene during medication administration. The findings include: 1. Review of the facility's policy titled, Hand Hygiene, dated 6/13/2023, revealed .The facility has adopted the CDC [Centers for Disease Control] Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings for indications for hand hygiene .Associates perform hand hygiene (even if gloves are used) in the following situations .Before and after contact with the resident .After contact with objects and surfaces in the resident's environment .After removing personal protective equipment .Before performing a procedure . 2. Observation at the C Hall Medication (Med) Cart during medication administration on 8/29/2023 at 5:05 PM, revealed LPN #9 unlocked her med cart, removed each of Resident #13's medications, and placed them in a separate pill cup. LPN #9 placed each med in a plastic pouch, crushed each med individually, then returned the crushed med to each individual pill cup. LPN #9 removed a bottled purified water from the bottom drawer of her med cart and added water to each of the pill cups. LPN #9 did not perform hand hygiene prior to preparing Resident #13's medications for administration. Observation at the C Hall Med Cart during med administration on 8/30/2023 at 8:53 AM, revealed LPN #1 unlocked her med cart and began preparing Resident #17's medications. LPN #1 locked her cart and went to Central Supply to look for a missing medication. LPN #1 opened the door to the Central Supply room, opened a medication cabinet in the Central Supply room and looked through medication bottles, but was unable to locate the medication. LPN #1 returned to her med cart and continued to prepare each of Resident #17's medications. LPN #1 did not perform hand hygiene prior to preparing the medications or after she returned to her med cart from the Central Supply room and removed the remainder of Resident #17's medications. Observation on the B Hall during medication administration on 8/30/2023 at 11:25 AM, revealed RN #1 performed hand hygiene, walked to Resident #225's room, placed an insulin pen, alcohol pads, syringe, and gloves on top of the isolation cart outside of Resident #225's door. RN #1 donned a gown, knocked on the resident's door, entered the room, donned gloves, removed the syringe from the package, attached the syringe to the insulin pen, and administered insulin to Resident #225. RN #1 failed to perform hand hygiene prior to donning gloves and administering Resident #225's insulin. Observation on the B Hall during medication administration on 8/31/2023 at 8:44 AM, revealed LPN #10 pushed her med cart from the A/B Nurses Station to the B Hall across from Resident #225's room. LPN #10 unlocked her cart, removed each of Resident #225's medication, placed them each in an individual pill cup, crushed each medication separately in a plastic pouch, and returned each medication to the individual pill cups. LPN #10 removed a bottle of purified water from the bottom drawer of her cart and added water to each pill cup. LPN #10 did not perform hand hygiene prior to preparing Resident #225's medications. During an interview on 8/31/2023 at 2:05 PM, the Infection Preventionist was asked when should hand hygiene be performed during med administration. The Infection Preventionist stated, Anytime you touch a surface, before they start it [med administration] and if they touch a surface, and then after the med pass [administration]. The Infection Preventionist confirmed staff should perform hand hygiene before gloves are donned and after gloves are removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the resident's status for antipsychotic medication, dialysis, and insulin administration for 3 of 21 (Resident #36, #49 and #70) resident assessments reviewed. The findings include: 1. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia, Delusional Disorders, Anoxic Brain Damage, Cardiac Arrest, and Major Depressive Disorder. Review of the quarterly Minimum Date Set (MDS) dated [DATE] revealed Resident #36 received antipsychotic medications on 7 of 7 days of the look back period and the resident did not receive any Antipsychotic Medications in the look back period. A physician's order dated 2/26/19 documented, .RisperiDONE .1 tablet by mouth three times a day for behaviors related to DELUSIONAL DISORDER . Review of the Medication Administration Record (MAR) for April 2019 revealed the resident received Risperidone daily for the entire month of April. Interview with MDS Coordinator #1 on 5/15/19 at 9:51 AM in the Family Room, MDS Coordinator #1 was asked if Resident #36 received any Anti-Psychotic medications during the look back period for the MDS dated [DATE]. MDS Coordinator #1 stated, Yes .No, that is not [coded] correct . 2. Medical record review revealed Resident #49 was readmitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Hypertension, Diabetes Mellitus, Atrial Fibrillation, Peripheral Vascular Disease, and Atherosclerotic Heart Disease. The facility's Order Summary Report signed 5/2/19 by the physician documented, .Dialysis patient .Receives dialysis at [named dialysis clinic] .Send to dialysis on Mon [Monday] .Wed [Wednesday] .Fri [Friday] .for dialysis treatment .order date .04/04/2019 . Review of the MAR dated 4/1/19 through 4/30/19 revealed Resident #49 received dialysis on 4/5/19, 4/8/19, 4/10/19, 4/12/19, 4/15/19, 4/17/19 and 4/19/19. Review of the annual MDS assessment dated [DATE] revealed no documentation that dialysis services had been provided to Resident #49 during the review period. Interview with MDS Coordinator #2 on 5/15/19 at 11:45 AM, in the MDS Office, MDS Coordinator #2 was asked if Resident #49 received dialysis. MDS Coordinator #2 stated, Yes, she does. MDS Coordinator #2 was asked if a resident received dialysis services during the assessment review period should it be coded on the MDS assessment. MDS Coordinator #2 stated, Yes, Ma'am, it should. 3. Medical record review revealed Resident #70 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Alzheimer's Disease, and Adult Failure to Thrive. Review of the quarterly MDS dated [DATE] revealed Resident #70 was coded as having received insulin on 7 of 7 days of the look back period. Review of the physician order's dated 5/2/19 revealed Resident #70 did not have an order for insulin. Review of the MAR for May 2019 revealed Resident #70 did not receive insulin injections. Interview with MDS Coordinator #2 on 5/15/19 at 10:10 AM, in the Family Room, MDS Coordinator #2 was asked if the quarterly MDS dated [DATE] had been coded correctly. MDS Coordinator #2 stated, No, she was not on insulin.

Based on policy review, observation, and interview, the facility failed to ensure medications were stored securely and safely when opened and undated medications were found in 3 of 6 ( A Hall, B Hall and C Hall medication carts) medication storage areas and when 1 of 6 (Licensed Practical Nurse (LPN) #5) staff members left medications out of site and unattended. The findings include: 1. The facility's Administration of Medications policy dated 4/24/19 documented, .Facility should ensure that all medications and biologicals .are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents .Facility staff should record the date opened on the medication container . 2. Observations of the B Hall medication cart during medication administration on 5/14/19 at 7:45 AM revealed 1 open undated box of Albuterol Sulfate 2.5 milligrams (mg)/(per) 3 milliliter (ml) vials of nebulizer inhalant and 1 bottle of Flonase 50 microgram (mcg) nasal spray. Observations during medication administration on 5/14/19 at 8:00 AM at the A Hall medication cart, revealed 1 open undated bottle of Flonase 50 mcg nasal spray. Interview with LPN #2 on 5/14/19 at 8:00 AM at the A Hall medication cart, LPN #2 was asked what should be done when medications are opened. LPN #2 stated, .we should date all medication when it is opened. Observations during medication administration on 5/14/19 at 8:15 AM at the C Hall medication cart revealed 1 open undated Budesonide 0.5 mg/2 ml inhaler. Interview with LPN #3 on 5/14/19 at 8:15 AM at the C Hall medication cart, LPN #3 was asked if the inhaler should have an open date. LPN #3 stated, Yes. Interview with the Director Of Nursing (DON) on 5/15/19 at 8:36 AM in the DON Office, the DON was asked what she expected staff to do when medications are opened. The DON stated, .to initial and date the medication. Observations during medication administration in Resident #58's room on 5/14/19 at 4:23 PM revealed LPN #5 entered Resident #58's room to administer medications. LPN #5 placed the medications on a barrier on the overbed table, and entered the bathroom to wash her hands, leaving the medications out of site and unattended. LPN #5 obtained Resident #58's blood glucose level, removed her gloves, placed the insulin flex pen onto the barrier on the overbed table, and entered the bathroom and washed her hands, leaving the insulin flex pen out of site and unattended. Interview with the DON on 5/15/19 at 12:30 PM in the Staff Development Office, the DON was asked what staff should do with medication when they are in a resident's bathroom washing their hands. The DON stated, .they should keep it in site .