**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility grievance logs, observations and interviews, the facility failed to maintain clean, comfortable, sanitary and homelike conditions, for 2 residents (Residents #17 and #18) of 18 sampled residents, in 1 of 2 buildings, on 2 of 12 nursing units observed for environment. The facility failure resulted in unsanitary conditions in resident rooms and bathrooms for the impacted residents. Medical record review showed Resident #17 was admitted to the facility on [DATE] with diagnoses including Aphasia Following Cerebral Vascular Accident, Hemiplegia, Type 2 Diabetes, Hypertension, Depression and Barrett's Esophagus. Resident #17 discharged from the facility on 1/16/2023 at request of the family. Review of facility grievance logs showed Resident #17's family filed grievances related to care concerns prior to the resident's discharge on [DATE]. Interview with the Housekeeping Services Director (HSD) on 3/27/2023 at 5:52 PM in the conference room, revealed he had received complaints from the Administrator and Director of Nursing (DON) related to conditions inside Resident #17's room on 1/13/2023, shortly after the resident arrived for admission. The HSD reported he did go the room and inspect concerns voiced by the resident and his family, after they arrived for admission, viewed the bathroom, and determined it had not been adequately cleaned to the facility standards. The HSD reported he then exited the bathroom and immediately apologized to the family, then ordered staff to deep clean the entire room.The HSD reported the room flooring and bathroom flooring had water stains on it, debris near the junction of the wall and floor tiles, and it did not appear clean. The HSD reported the toilet and floor of the bathroom were also unkempt and appeared to not have been cleaned to facility expectations in advance of the new admission, per facility standards. Interview with the Administrator and observations of the [NAME] building on 3/27/2023 at 7:20 PM, revealed the Administrator reported on 1/16/2023, he was called to the [NAME] building to speak with the resident's daughter regarding complaints about room conditions which began on admission. The Administrator reported he viewed the bathroom in Resident #17's room, determined it was not sufficiently cleaned to the facility standards, apologized to the family for the oversight, contacted the housekeeping supervisor, then ordered the situation rectified at once. The Administrator confirmed the facility failed to provide clean, comfortable and sanitary conditions for Resident #17. Medical record review showed Resident #18 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Type 2 Diabetes, Major Depression, Generalized Anxiety, Atherosclerotic Heart Disease, Congestive Heart Failure, Bipolar Disorder, and Peripheral Vascular Disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #18 was severely cognitively impaired, had behaviors directed at self or others, impaired thought processes and was dependent upon one or two persons for all activities of daily living (ADLs). Observations of Resident #18's room on 3/27/2023 at 4:50 PM, showed the floor was stained with water marks and dark debris near the edges of the tiles nearest the walls, and the floor was sticky when walked on. Continued observations of the bathroom showed the bathroom was also dirty, with sticky floors, stained tile, fecal material was in the toilet, and observations of the commode showed a dark brown to black ring around the entire circumference of the base of the commode, where it was affixed to the floor. Observations of Resident #18's room, conducted with the facility Administrator on 3/27/2023 at 7:15 PM, showed conditions were unchanged from the prior observations. The Administrator confirmed the room was not cleaned to facility expectations and confirmed the facility failed to maintain clean, comfortable and homelike conditions in Resident #18's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to submit a PASRR (Preadmission Screening and Resident Review) Level II evaluation for 1 resident (Resident #193) of 6 residents reviewed for PASRR Level II evaluation. The findings include: Review of the facility policy PASRR Policy, undated, showed .Individuals who have or are suspected to have MI [Mental Illness] or ID/DD [Intellectual Disability/Mental Retardation] or related conditions have a level II PASRR review .when individuals with MI or ID/DD have a significant change in physical or mental condition, a new level II PASRR completed .all new orders .are reviewed no less frequently than weekly .an updated PASRR will be completed and submitted .to determine if the resident requires specialized services . Resident #193 was admitted to the facility on [DATE] with diagnoses including Depression, Anxiety, Type 2 Diabetes, Chronic Kidney Disease, and Hypertension. A diagnosis of Dementia with Behavioral Disturbances was added on 7/27/2017, and Delusional Disorder was added on 10/5/2017. Review of Resident #193's PASRR dated 7/6/2017 showed resident .has mild Depression and Anxiety Disorder suspected his symptoms are well controlled and managed with medications as listed. Level I Outcome No Level II Condition-Level I Negative . Review of Resident #193's medical record showed a PASRR Level II was not submitted after Resident #193 received the diagnoses of Dementia with Behavioral Disturbances and Delusional Disorder on 7/27/2017. During an interview on 06/08/2022 at 2:23 PM, the MDS Coordinator confirmed a PASSR Level II was not submitted when new diagnoses for Dementia with Behavioral Disturbances was added on 7/27/2017 and when Delusional Disorder was added on 10/5/2017.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the medical record review and interviews the facility failed to provide restorative nursing care for 1 resident (Resident #91) of 10 residents reviewed. The findings include: Resident #91 was admitted to the facility on [DATE] with diagnoses including Surgical Aftercare Following Surgery, Open Wound of Lower Back and Pelvis, Muscle Weakness, Difficulty Walking, Adult Failure to Thrive, Pressure Ulcer, Stage 4, and Major Depressive Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #91 had moderate cognitive impairment. He required extensive assistance of 2 staff persons with bed mobility, extensive assistance of 1 staff person with dressing, toileting, and personal hygiene. The resident required set up assistance with meals and could eat independently. Resident #91 received 170 minutes of occupational therapy services and 134 minutes of physical therapy services. Review of the Physician Order dated 4/11/2022 showed .Restorative ROM .B LE as tolerated . Review of the care plan dated 4/11/2022 showed .Restorative ROM [Range of Motion] .B LE [Bilateral Lower Extremity] as tolerated .[NAME] tech [Restorative technician] will provide AAROM [Active Assisted Range of Motion] B LE .x 10 reps [repetitions] x 2 sets or as tolerated . During an interview on 6/8/2022 at 3:55 PM, the Physical Therapy Assistant Director stated there is an active order, but restorative had not seen Resident #91 since 4/19/2022. During an interview on 6/9/2022 at 7:48 AM, Licensed Practical Nurse (LPN) #1 stated she had not observed therapy/restorative working with Resident #91 recently. During an interview on 6/9/2022 at 8:23 AM, the Director of Therapy and Restorative Services confirmed Resident #91 had not received restorative services since 4/19/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews, the facility failed to address the Pharmacist's recommendations for 1 resident (Resident #114) of 5 residents reviewed for unnecessary medications. The findings include: Resident #114 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Vascular Dementia, Anxiety Disorder, Major Depressive Disorder, Encounter for Palliative Care (Hospice), and Unspecified Dementia without Behavioral Disturbance. Review of the Clinical Pharmacist Review dated 3/10/2022 showed .Haloperidol [a medication to treat mental disorders] .Seroquel [a medication to treat mental disorders] XR [extended release] 50 mg [milligrams] .Valium [an anxiety medication] 5 mg .Please review for possible trial gradual dose reduction if patient is ineligible, document reason . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #114 had moderate impaired cognition. Review of the 7 day look back showed the resident received antipsychotic and antidepressants medications for 7 days. During an interview on 6/9/2022 at 9:15 AM, the Director of Nursing stated her office was responsible for sending the pharmacy recommendations to the provider. The DON further stated she had contacted the Nurse Practitioner by telephone, and he was unable to recall if he received the recommendations dated 3/10/2022. The DON confirmed the pharmacy recommendation dated 3/10/2022 for Resident #114 was not addressed to the provider.

**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 ensure infection control practices were followed for 1 resident (Resident #540) of 4 residents reviewed for transmission-based precautions which had the potential to result in transmission of COVID-19 (an infectious disease caused by the SARS-CoV-2 virus). The findings include: Review of the facility's undated policy titled, INFECTION PREVENTION AND CONTROL PROGRAM/PLAN, showed .will maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .Transmission-based Precautions are used additionally with Standard Precautions when caring for those residents who are known or suspected to be infected or colonized with pathogens that can be transmitted by contact or by droplets .A medical staff order is needed for the application and removal of transmission-based precautions .Patients with medical staff orders for transmission-based precautions are identified with the presence of an isolation kit located outside of the patient's care area with the appropriate donning apparel. The type of transmission-based precaution is identified on the isolation kit with instructions for facility staff . Resident #540 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Bacteremia, Major Depressive Disorder, and Pulmonary Nodule. Review of the Physician Order Report dated 6/1/2022 - 6/8/2022, showed .Transmission Based Precautions - Covid Isolation (Contact & [and] Droplet) .Start Date .06/02/2022 .End Date .06/16/2022 . During an observation on 6/6/2022 at 12:30 PM, there was a sign on Resident #540's door that read, OBSERVATION ROOM .MASK, GOWN & EYE PROTECTION REQUIRED TRANSMISION PRECAUTIONS IN PLACE . Further observation showed Certified Nursing Assistant (CNA) #1 entered Resident #540's room wearing a mask and eye protection. The CNA did not don a gown or gloves for the resident care interaction. During an interview on 6/6/2022 at 12:31 PM, CNA #1 stated .I don't know .I think the signage is old . when asked if Resident #540 was in isolation. During an interview on 6/6/2022 at 12:32 PM, with Unit Manager #1 and CNA #1, Unit Manager #1 confirmed Resident #540 was in Transmission Based Precautions due to a recent return from the hospital on 6/2/2022. CNA #1 confirmed a gown and gloves were not donned for the interaction with Resident #540. During an interview on 6/8/2022 at 4:51 PM, Unit Manager #1 and Unit Manager #2 confirmed it was their expectation for staff to don appropriate Personal Protective Equipment (PPE) for residents in Transmission Based Precautions. Further interview confirmed CNA #1 should have donned a gown, gloves, mask, and eye protection prior to entering Resident #540's room. During an interview on 6/9/2022 at 9:23 AM, the Director of Nursing confirmed it was her expectation for staff to observe and wear appropriate PPE when entering isolation rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and interview, the facility failed to refer 1 resident (#90) identified with a possible serious mental disorder to the state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) of 6 residents reviewed for PASARR of 37 sampled residents. The findings include: Medical record review revealed Resident #90 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, End Stage Renal Disease, and Post-Traumatic Stress Disorder. Medical record review of a PASARR Level I assessment dated [DATE] revealed the resident had no diagnosis of mental illness. Medical record review of a Psychiatric Evaluation dated 3/11/19 revealed .Worsening depression .she reports the increase of Wellbutrin [medication to treat depression] did not help .she does admit to a history of mood swings and thinks she may have bipolar [a psychiatric disorder] .Diagnosis .Bipolar 1 Disorder . Interview with the Minimum Data Set (MDS) Coordinator on 7/30/19 at 1:39 PM, in the conference room, confirmed the facility failed to refer Resident #90 to the state-designated authority for a Level II PASARR evaluation to determine if the resident required specialized services after her diagnosis of a serious mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to implement a comprehensive care plan for pain management for 1 resident (#266) of 3 residents reviewed for pain of 37 residents sampled. The findings include: Medical record review revealed Resident #266 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Intervertebral Disc Degeneration Lumbar Region, Spinal Stenosis Lumbar Region, Chronic Pain Syndrome, Fibromyalgia, Hemiplegia, and Muscle Weakness. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t [due to] decreased mobility, and dx [diagnosis] of OA [osteoarthritis, a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down], Chronic pain syndrome and Fibromyalgia [widespread muscle pain and tenderness] . administer medications as ordered . Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .Oxycodone [a pain medication] .Chronic pain syndrome .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM dose of Oxycodone had been administered at 10:52 PM, the 7/4/19 9:00 PM dose of Oxycodone had been administered at 10:48 PM, the 7/10/19 9:00 PM dose of Oxycodone had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM dose of Oxycodone had been administered at 11:59 PM, the 7/15/19 9:00 PM dose of Oxycodone had been administered at 11:56 PM, and the 7/18/19 9:00 PM dose of Oxycodone had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock [PM] meds [medications] until 11:30 [PM] at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock [PM] .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max [maximum census] is 54 but the census now is 53 sometimes it may be 10:30 [PM] or 11:30 [PM] . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain. Further interview revealed his expectation was for all medications to be given as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the comprehensive care plan had not been implemented to provide pain medications as ordered for Resident #266.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to ensure pain medication was administered timely resulting in an increase in pain for 1 resident (#266) of 3 residents reviewed for pain of 37 sampled residents. The findings include: Review of the facility policy Medication Administration dated 6/2018 revealed, .Medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in the medical management of diagnoses .Assure the medication is administered .at the right time . Medical record review revealed Resident #266 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Intervertebral Disc Degeneration Lumbar Region, Spinal Stenosis Lumbar Region, Chronic Pain Syndrome, Fibromyalgia, Hemiplegia, and Muscle Weakness. Medical record review of the comprehensive care plan dated 4/2/19 revealed, . risk for alteration of her comfort d/t [due to] decreased mobility, and dx [diagnosis] of OA [osteoarthritis, a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down], Chronic pain syndrome and Fibromyalgia [widespread muscle pain and tenderness] . administer medications as ordered .monitor for break-through pain .monitor and document response to pain meds .administer prescribed pain medication as needed/ordered to maintain patient comfort level .perform ongoing pain assessments to determine if the pain management regimen is meeting the patient's pain relief goal . Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible). Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .Oxycodone [a pain medication] .Chronic pain syndrome .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM dose of Oxycodone had been administered at 10:52 PM, the 7/4/19 9:00 PM dose of Oxycodone had been administered at 10:48 PM, the 7/10/19 9:00 PM dose of Oxycodone had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM dose of Oxycodone had been administered at 11:59 PM, the 7/15/19 9:00 PM dose of Oxycodone had been administered at 11:56 PM, and the 7/18/19 9:00 PM dose of Oxycodone had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock [PM] meds [medications] until 11:30 [PM] at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock [PM] .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max [maximum census] is 54 but the census now is 53 sometimes it may be 10:30 [PM] or 11:30 [PM] . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed, .my normal pain level is about 7 or 8 . Further interview revealed when the 9:00 PM meds are late .oh it may be a 10 by then .it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, confirmed Resident #266 had chronic pain. Further interview revealed his expectation was for all medications to be given as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the facility failed to administer Resident #266's pain medications in a timely manner resulting in an increase in pain for Resident #266.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's Assignment Sheets, review of the facility's Midnight Census Reports, resident interviews, and staff interviews, the facility failed to maintain adequate staffing levels to ensure timely administration of medications for 1 resident (#266) residing on 1 unit (2 East) of 10 units observed. The findings include: Medical record review revealed Resident #266 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Intervertebral Disc Degeneration Lumbar Region, Spinal Stenosis Lumbar Region, Chronic Pain Syndrome, Fibromyalgia, Hemiplegia, Old Myocardial Infarction, Essential Hypertension, Atherosclerotic Heart Disease, Supraventricular Tachycardia, Unspecified Atrial Flutter, History of Transient Ischemic Attack, Presence of a Cardiac Pacemaker, and Muscle Weakness. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t [due to] decreased mobility, and dx [diagnosis] of OA [osteoarthritis, a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down], Chronic pain syndrome and Fibromyalgia [widespread muscle pain and tenderness] . administer medications as ordered .Administer prescribed pain medications as needed/ordered to maintain patient comfort level .diagnosis of HTN [high blood pressure] .CVA [stroke] .GOAL .will remain free of .episodes of her diasease [disease] process .Administer medications as ordered . Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .Oxycodone [a pain medication] .Chronic pain syndrome .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM .flecainide [medication used for irregular heartbeats] . twice a day; 09:00 AM, 05:00 PM .Levetiracetam [medication used for seizures] .at bedtime; 09:00 PM .Rozerem [medication used for sleep] .at bedtime; 09:00 PM .hydralazine [medication used for high blood pressure] .at bedtime; 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM medications had been administered at 10:52 PM, the 7/4/19 9:00 PM medications had been administered at 10:48 PM, the 7/10/19 9:00 PM medications had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM medications had been administered at 11:59 PM, the 7/15/19 9:00 PM medications had been administered at 11:56 PM, the 7/16/19 5:00 PM medications had been administered at 7:41 PM, and the 7/18/19 9:00 PM medications had been administered at 11:42 PM. Review of the Facility's Midnight Census Reports dated 7/1/19, 7/4/19, 7/10/19, 7/13/19, 7/15/19, 7/16/19, 7/18/19 revealed a resident census of 53 for the 2 East Unit. Review of the Facility's assignment sheets dated 7/1/9, 7/4/19, 7/10/19, 7/13/19, 7/15/19, 7/18/19 revealed one LPN on duty on the 2 East Unit for the 7:00 PM to 7:00 AM shift. Further review of the Facility's assignment sheet dated 7/16/19 revealed one LPN on duty on the 2 East Unit for 7:00 AM to 7:00 PM shift until 9:00 AM when another nurse came on duty. Continued review of the facility assignment sheet dated 7/23/19 revealed one LPN on duty on the 2 East Unit from 3:00 PM to 5:30 PM. Further review of the facility assignment sheet dated 7/24/19 revealed on LPN on duty on the 2 East Unit for the 7:00 AM to 7:00 PM shift. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Continued interview revealed the nurses had told the resident the medications were administered late due to one nurse working on that unit. Interview with Licensed Practical Nurse (LPN) #7 on 7/28/19 at 3:50 PM, at the 2 East nurse's station, revealed she had been .pulled to another floor . on 7/23/19 and 7/24/19 leaving one nurse on the 2 East Unit. Interview with LPN #3 on 7/28/19 at 3:56 PM, at the 2 East nurse's station, revealed she works the 7:00 AM to 7:00 PM shift. Further interview revealed nurses are frequently .pulled to another floor .leaving one nurse to care for 53 residents . Continued interview revealed the last time this occurred was on 7/23/19 and 7/24/19. Interview and observation of the assignment sheets dated 7/23/19 and 7/24/19 with the Director of Nursing (DON) on 7/29/19 at 2:16 PM, in conference room A, revealed the facility's goal for staffing for the 2 East Unit was to have two LPNs on staff for the 7:00 AM to 7:00 PM shift. Further interview confirmed on 7/23/19 one LPN had been on duty from 3:00 PM until 7:00 PM due to the other LPN had been pulled to cover the 3 East Unit leaving one nurse to provide care for 53 residents. Continued interview confirmed one LPN had been on duty on the 2 East Unit on 7/24/19 for the entire shift of 7:00 AM to 7:00 PM to provide care for 53 residents. Interview with the 2 East Unit Manager on 7/29/19 at 3:39 PM, in the Unit Manager's office, revealed medications are frequently administered late when there is one nurse on duty. Further interview revealed the Unit Manager would do all of the charting, take phones calls, and take physician orders when there was one nurse on duty so the nurse can administer medications. Continued interview revealed the Unit Manager works 5 days a week and the LPN on duty would have to administer medications, chart, take phone calls, and take physician orders on the days she is not on duty. Interview with the DON on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with LPN #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM to 7:00 AM shift were often administered late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with LPN #4 on 7/30/19 at 7:23 AM, on the 2 East hallway, revealed the medications are sometimes administered late .that happens .sometimes I'm just busy with other things Continued interview revealed it was difficult to get the medications administered on time when there is one nurse on duty. Interview with LPN #5 on 7/30/19 at 7:27 AM, on the 2 East hallway, revealed medications are to be administered .1 hour before or 1 hour after the scheduled time. Further interview revealed it was difficult to administer meds on time when there was one LPN on duty .we have 52 to 53 patients . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock [PM] meds [medications] until 11:30 [PM] at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock [PM] .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max [maximum census] is 54 but the census now is 53 sometimes it may be 10:30 [PM] or 11:30 [PM] . Interview with LPN #5 on 7/30/19 at 9:21 AM, on the 2 East hallway, revealed Resident #266's 5:00 PM medications had been administered at 7:41 PM on 7/16/19 .that's the day my partner [LPN #4] called in . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed .my normal pain level is about 7 or 8 Further interview revealed when the 9:00 PM meds are late . oh it may be a 10 by then . it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain and history of a stroke. Further interview revealed his expectation was for all medications to be administered as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Further interview revealed the Flecainide and Hydralazine administered late would place the resident at .potential risk for arrhythmia [irregular heartbeat] .for anything related to blood pressure .she has already had a stroke . Interview and observation of the 2 East Unit with Certified Nursing Assistant (CNA) #2 on 7/30/19 at 10:05 PM, on the 2 East hallway, revealed no nurse was on the unit. Continued interview with CNA #2 revealed the night shift nurse had called in and the Shift Supervisor had been covering the unit but was not currently on the floor. Interview with LPN #6 on 7/30/19 at 10:10 PM, at the 2 East nurse's station, revealed she had just arrived to the unit. Further interview revealed she had been called to come in to work at 11:00 PM due to the nurse who had been scheduled for the 7:00 PM to 7:00 AM shift had called in. Interview with the Shift Supervisor on 7/30/19 at 10:12 PM, at the 2 East nurse's station, revealed she had been on another unit assisting with a pharmacy delivery but was the nurse responsible for the 2 East Unit until another nurse arrived. Continued interview revealed the night shift nurse had called in. Further interview revealed the day shift nurses had stayed over to administer the 9:00 PM medications. Continued interview revealed the Shift Supervisor had been covering the 2 East Unit with a census of 53 residents from 9:30 PM until another nurse arrived at 10:00 PM but had also been assisting with the other units in that building and had not been on the 2 East Unit the entire time. Interview and observation of the Assignment sheets, Midnight Census Reports, and Administration Log Reports with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed Resident #266's 9:00 PM medications had not been administered timely on 7/1/19, 7/4/19, 7/10/19, 7/13/19, 7/15/19, and 7/18/19. Continued interview confirmed there had been 1 LPN on duty for the 7:00 PM to 7:00 AM shift with a resident census of 53 for these dates. Further interview confirmed Resident #266's 5:00 PM medications had not been administered timely on 7/16/19. Continued interview confirmed 2 LPN's had been scheduled to work the 7:00 AM to 7:00 PM shift on 7/16/19 but one of the LPN's had called in with a resident census of 53. Further interview confirmed the facility failed to provide adequate staffing to provide timely administration of Resident #266's medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure 1 resident (#266) was free from significant medication errors of 7 residents reviewed for medication administration of 37 residents sampled. The findings include: Review of the facility policy Medication Administration dated 6/2018 revealed .Medications are administered safely and appropriately to aid resident to overcome illness, relieve and prevent symptoms, and help in the medical management of diagnoses .Assure the medication is administered .at the right time . Medical record review revealed Resident #266 was admitted to the facility on [DATE] with diagnoses including Osteoarthritis, Intervertebral Disc Degeneration Lumbar Region, Spinal Stenosis Lumbar Region, Chronic Pain Syndrome, Fibromyalgia, Hemiplegia, Old Myocardial Infarction, Essential Hypertension, Atherosclerotic Heart Disease, Supraventricular Tachycardia, Unspecified Atrial Flutter, History of Transient Ischemic Attack, Presence of a Cardiac Pacemaker, and Muscle Weakness. Medical record review of the comprehensive care plan dated 4/2/19 revealed . risk for alteration of her comfort d/t [due to] decreased mobility, and dx [diagnosis] of OA [osteoarthritis, a type of arthritis that occurs when the flexible tissues at the ends of the bones wear down], Chronic pain syndrome and Fibromyalgia [widespread muscle pain and tenderness] . administer medications as ordered .Administer prescribed pain medications as needed/ordered to maintain patient comfort level .diagnosis of HTN [high blood pressure] .CVA [stroke] .GOAL .will remain free of .episodes of her diasease [disease] process .Administer medications as ordered . Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 7 on 0-10 pain scale (pain scale with zero being no pain and 10 as the worst pain possible.) Medical record review of the Physicians Order Report dated 6/29/19- 7/29/19 revealed .Oxycodone [a pain medication] .Chronic pain syndrome .Four times a day; 09:00 AM, 01:00 PM, 05:00 PM, 09:00 PM .flecainide [medication used for irregular heartbeats] . twice a day; 09:00 AM, 05:00 PM .Levetiracetam [medication used for seizures] .at bedtime; 09:00 PM .Rozerem [medication used for sleep] .at bedtime; 09:00 PM .hydralazine [medication used for high blood pressure] .at bedtime; 09:00 PM . Medical record review of the Administration Log report dated 7/1/19- 7/25/19 revealed the 7/1/19 9:00 PM medications had been administered at 10:52 PM, the 7/4/19 9:00 PM medications had been administered at 10:48 PM, the 7/10/19 9:00 PM medications had been administered at 12:00 AM on 7/11/19, the 7/13/19 9:00 PM medications had been administered at 11:59 PM, the 7/15/19 9:00 PM medications had been administered at 11:56 PM, the 7/16/19 5:00 PM medications had been administered at 7:41 PM, and the 7/18/19 9:00 PM medications had been administered at 11:42 PM. Interview with Resident #266 on 7/28/19 at 3:32 PM, in the resident's room, revealed her medications are sometimes administered late. Continued interview revealed the nurses had told the resident the medications were administered late due to one nurse working on that unit. Interview with the Director of Nursing (DON) on 7/29/19 at 4:05 PM, in the conference room, confirmed the medication administration time frame was for the medications to be administered during the period of one hour before to one hour after the scheduled administration time. Telephone interview with Licensed Practical Nurse (LPN) #1 on 7/29/19 at 7:56 PM, revealed medications on the 7:00 PM- 7:00 AM shift were often given late .when there's only one nurse for 53 patients there is no way to do 53 patients .when there's 2 nurses you can get the meds done correctly . Interview with Resident #266 on 7/30/19 at 7:33 AM, in the resident's room, revealed 9:00 PM medications are sometimes administered late .I go from my 5 o'clock meds [medications] until 11:30 at night .that's 7 hours that I wouldn't get my medication if I take my 5 o'clock meds at 4 o'clock .that's a long time to go without medicine because my pain medicine is in that and if I have to wait that long it causes me to have pain .if I don't ask for them at 8:30 [PM] or 9:00 [PM] then I may have to wait and then I'm in pain . Telephone interview with LPN #2 on 7/30/19 at 8:18 AM, revealed the 9:00 PM medication administration is sometimes late .it does take me a while sometimes .I'm the only nurse on that unit .max [maximum census] is 54 but the census now is 53 sometimes it may be 10:30 [PM] or 11:30 [PM] . Interview with Resident #266 on 7/30/19 at 10:00 AM, in the resident's room, revealed .my normal pain level is about 7 or 8 Further interview revealed when the 9:00 PM meds are late . oh it may be a 10 by then . it gets worse . Interview with the Medical Director on 7/30/19 at 2:35 PM, in the conference room, revealed Resident #266 had chronic pain and history of a stroke. Further interview revealed his expectation was for all medications to be administered as ordered. Continued interview revealed the pain medications administered late would cause the resident to have increased pain.of course it would .I think I would be complaining too if I was the patient . Further interview revealed the Flecainide and Hydralazine administered late would place the resident at .potential risk for arrhythmia [irregular heartbeat] .for anything related to blood pressure .she has already had a stroke . Interview with the DON on 7/31/19 at 9:16 AM, in the conference room, confirmed the facility failed to administer Resident #266's medications timely.

Based on review of facility policy, observation and staff interview, the facility failed to ensure all medications had been labeled with a correct expiration date for 8 bags of medication, in 1 of 10 medication storage rooms observed. The findings include: Review of the facility policy Medication Ordering, Receiving and Storage revealed .The FDA (Food and Drug Administration) requires an expiration date on all medications . Observation with the facility Risk Manager on 8/1/18 at 8:40 AM, in the 300 hall medication room, revealed 8 reconstituted 100 ml (milliliter) bags of Tazicef (antibiotic) 1 gram available for use. Continued observation revealed the 8 bags of antibiotics delivered on 7/30/18 had an expiration date of 7/30/18. Interview with the facility Pharmacist on 8/1/18 at 10:01 AM, in the conference room, confirmed the facility failed to ensure the policy for medication storage was followed by not ensuring the bags of antibiotics were labeled correctly.