**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 in 2 of 5 medication storage areas (North Back Medication Cart and South Middle Hall Medication Cart) that were left unlocked and unattended, and when 1 of 1 nurses (Licensed Practical Nurse (LPN) #A) failed to ensure medications were not left unattended. The findings include: 1. Review of the facility's policy titled, Storage of Medications, dated 5/2015, revealed .The facility shall store all drugs and biologicals in a safe, secure, and orderly .The facility shall not use discontinued, outdated, or deteriorated drugs .All such drugs shall be returned .or destroyed .Compartments (including, but not limited drawers, cabinets .carts .) containing drugs and biologicals shall be locked when not in use .carts .shall be not be left unattended if open . Review of the facility's policy titled, Insulin Administration, dated 5/2015, revealed .To provide guidelines for the safe administration of insulin .If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening) .28 Day Exp. [Expiration] Date (after first use) Lantus, Novolog, Humalog 42 Day Exp. Date (after first use) . Review of the facility's policy titled, Insulin Storage, dated 10/2016, revealed .Insulin vials .should be dated and initialed when opened .should be discarded after the expired date . Review of the facility's policy titled, Administering Medications, dated 11/2017, revealed .During administration of medications, the medication cart is kept closed and locked when out of sight .No medications are kept on top of the cart . 2. Random observation on [DATE] at 8:46 AM, revealed on top of the 300 Hall North Back Medication Cart was the following unattended, opened, and expired insulin (medication for Hyperglycemia) vials: a. An opened vial of Resident #11's Levemir insulin with no open date or expired date. The Physician order dated [DATE], revealed Resident #11 had an order for Levemir .inject 50 unit subcutaneously at bedtime . b. An open vial of Resident #11's Insulin Aspart (Novolog), with an open date of [DATE] and expiration date of [DATE]. The Physician's Order dated [DATE] revealed Resident #11 had an order for Novolog .inject as per sliding scale . c. An opened vial of Resident #12's Humalog labeled with no open date or expired date. The Physician's Order dated [DATE], revealed Resident #12 had an order for Humalog .inject as per sliding scale . d. An opened vial of Resident #14's Humalog with no open date and no expired date. The Physician's order dated [DATE], revealed Resident #14 had an order for Humalog Injection Solution .inject as pr sliding scale . e. An opened vial of Resident #13' s Lantus, with an open date of [DATE] and an expired dated of [DATE]. Physician's Order dated [DATE], revealed Resident #13 had an order for Lantus .inject 28 units subcutaneously two times per day . During an interview on [DATE] at 8:51 AM, Licensed Practical Nurse (LPN) A confirmed the vials of insulin should not have been left unattended on the med cart and the expired insulin vials should have been discarded. 3. A random observation and interview in the South Hall on [DATE] at 8:55 AM, revealed the South Medication Cart was unlocked and unattended. LPN B was asked about the med cart. LNP B stated, .there has been issues with the cart's lock, it takes a few tries before it will lock .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure proper infection control practices for 1 of 3 (Resident #7) residents reviewed for Tuberculosis (TB) Two Step Mantoux Test Results. The facility had a census of 63. The findings include: 1. Review of the facility's policy titled, Infection Prevention and Control Program, dated 10/2018, revealed An infection prevention and control program .is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission, of communicable diseases and infections .Surveillance tools are used for recognizing the occurrence of infections .detecting outbreaks . Review of the facility's policy titled, Tuberculosis ., dated 8/2013, revealed .This facility shall screen all residents for tuberculosis infection . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Malignant Neoplasm, Infectious Gastroenteritis and Colitis, and Abdominal Pain. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #7 is cognitively intact. Review of the Medication Administration Record (MAR) dated October 2024, revealed Resident #7 received the 1st intradermal injection for Two Step Mantoux Test on 10/25/2024. The results are to be read on 10/27/2024 for results. Review of the MAR dated October 2024 revealed there was no documentation the Two Step Mantoux Test was read for a negative or positive result. During an interview on 12/18/2024 at 11:20 AM, with the Infection Control Nurse was asked if Resident #7's Two Step Mantoux TB skin test was completed. The Infection Control nurse confirmed that staff did not read the results of the Two Step Mantoux test. During an interview on 12/18/2024 at 12:00 PM, with the Director of Nurses (DON), the DON confirmed the staff did not read the Two Step Mantoux as they should have.

**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 enteral feedings were labeled and dated for 1of 1 (Resident #55) sampled residents reviewed for enteral feeding. The findings include: 1. Review of the facility's policy titled, Enteral Tube Feedings, revised 1/2014, revealed .On the formula label document initials, date and time the formula was hung/administered . 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses including Dysphagia and Gastroparesis. Review of the quarterly Minimum Data Set, dated [DATE], revealed Resident #55 had a Brief Interview for Mental Status score of 5, which indicated the resident was severely cognitively impaired and had a Percutaneous Endoscopic Gastrostomy (PEG) feeding. Observation in the resident's room on 6/12/2024 at 1:33 PM, revealed Resident #55's enteral feeding bag was not labeled with the resident's name, the date, time, and rate, and the nurse's initial. During an interview on 6/12/2024 at 1:35 PM, LPN #A confirmed Resident #55's enteral feeding was not labeled with the resident's name, date, time, rate, and the nurse's initial.

**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 proper infection control practices were followed when 1 of 1 Licensed Practical Nurse (LPN #A) failed to follow Enhanced Barrier Precautions in a resident's room while giving care. The findings include: 1. Review of the facility's policy titled, Enhanced Barrier Precautions, dated August 2022, revealed .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply .Gloves and gown are applied prior to performing the high contact resident care activity .Examples of high contact .activities . include .device care or use .feeding tube .any skin opening requiring a dressing .indwelling medical devices . 2. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE], with diagnoses of Dysphagia, Gastrostomy Status, and Gastroparesis. Review of the quarterly Minimum Data Set, dated [DATE], revealed Resident #55 had a Brief Interview for Mental Status score of 5, which indicated the resident was severely cognitively impaired, and had a Percutaneous Endoscopic Gastrostomy (PEG) feeding. Review of the facility's list of residents on enhanced barrier precautions revealed Resident #55 was placed on enhanced barrier precautions on 4/1/2024. Observation in the resident's room on 6/12/2024 at 1:35 PM, revealed LPN #A failed to wear gown and gloves when disconnecting Resident 55's enteral feeding tube from the PEG tube. During an interview on 6/13/2024 at 9:14 AM, the Regional Clinical Corporate Nurse Regional Clinical Corporate Nurse confirmed staff should wear a gown and gloves when a resident's enteral feeding tube is disconnected from the PEG site tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to assess 1 of 1 sampled resident (Resident #57) reviewed for self-administration of medication. The findings include: Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses of Chronic Bronchitis, Interstitial Pulmonary Disease, Congestive Heart Failure, Chronic Kidney Disease, and Chronic Obstructive Pulmonary Disease. Review of the July 2021 Physician's Order revealed .Pulmicort 0.5 MG [Milligrams] / [per] 2ML [Milliliter] GIVE ONE VIAL VIA NEBULIZER TWICE DAILY . Review of the Self Administration of Medication form dated 7/10/2018, revealed, .Patient Name .[Resident #57] .Do you wish to administer your own medication .[x mark] .No . Observation in the resident's room on 7/29/2021 at 8:09 AM, revealed Resident #57 was sitting on the bedside holding a nebulizer mask up to her face receiving a nebulizer breathing treatment, unattended by nursing staff. During an interview on 7/29/2021 at 10:55 AM, Licensed Practical Nurse (LPN) #11 confirmed that Resident #57 had not been assessed to administer her own medication. LPN #11 confirmed residents should not be left unattended when receiving a nebulizer treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to acknowledge a resident's self-determination of food choices when 2 of 20 staff members(Certified Nursing Assistant (CNA) #7 and Nurse Aide (NA) #4) failed to offer an alternative food item when a resident (Resident #12) voiced her dislike and smell of food. The finding include: Review of the facility's policy titled, Resident Rights Policy, revised 11/2016, revealed .(f) Self-determination. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice . Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation, Anxiety, Anxiety, Depression, Diabetes, and Pressure Ulcer. Review of the Care Plan updated 5/14/2021, revealed .Nutritional status, at risk for decline .Allow resident to make informed decisions about dietary choices and respect resident's wishes .Evaluate refusal of meals .offer alternatives .Maintain a pleasant, odor free environment during meals . Observation in the resident's room on 7/26/2021 at 11:15 AM, revealed CNA #7 entered Resident #12's room and set up her meal tray on the over the bed table. Resident #12 stated, I don't like carrots . CNA #7 stated, .they are really sweet, I like them, don't you. Resident #12 stated, No. CNA #7 exited the room and began to remove another tray from the meal cart and failed to acknowledge Resident #12's dislike of the carrots and failed to offer an alternative food item. Observation in the resident's room on 7/27/2021 at 5:06 PM, revealed NA #4 entered Resident #12's room, sat the meal tray on the over the bed table, removed the lid. Resident #12 stated, That green stuff [Brussels sprouts] smells awful. NA #4 stated, Eat what you want it's ok. NA #4 then exited the room and returned to the meal cart. NA #4 failed to acknowledge Resident #12's dislike of the smell of the food and failed to offer an alternative. During an interview on 7/29/2021 at 8:30 AM, the Director of Nursing (DON) was asked what should a staff member do when a resident voices their dislike of the food on a their meal tray. The DON stated, They should ask if they would like something else to eat. The DON was asked should a resident have a choice of food if they voice a dislike. The DON stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review, observation, and interview, the facility failed to follow Physician's Orders for the use of oxygen and failed to ensure oxygen supplies were labeled for 2 of 4 sampled residents (Resident #17 and #27) reviewed for respiratory care. The findings include: Review of the facility's 11-7 Shift job description for Nurses, documented, .On the 3rd and 18th of every month change out nebulizer .and 02 [Oxygen] tubing and date and initial all .Mondays .replace water bottles and date and initial them . Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with the diagnoses of Anxiety, Atrial Fibrillation, Congestive Heart Failure, Depression, and History of Transient Ischemic Attacks. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #17 was assessed for the use of oxygen. Review of the Care Plan dated 5/25/2021, revealed .Oxygen binasal cannula [pronged tubing placed inside the nose] @ [symbol for at] 2L [Liters] / [per] min [minute] and titratin [keep regulated] to maintain spo2 [the amount of oxygen in the blood stream] > [symbol for greater than] 90% [symbol for percent] . Review of the Physician's Orders dated 7/23/2021, revealed .Order Date .5/19/2021 .Oxygen AT 2 LITERS BNC [By Nasal Cannula] AND TITRATE TO MAINTAIN SP O2 > 90% . Observation in the resident's room on 7/26/2021 at 9:20 AM and 2:15 PM, on 7/27/2021 at 8:05 AM and 4:30 PM, and on 7/28/2021 at 7:45 AM and 3:00 PM, revealed Resident #12 was in her room with no oxygen was being administered, and an oxygen humidifier bottle and the oxygen tubing was dated 6/8/2021. During an interview on 7/28/2021 at 5:18 PM, the Assistant Director of Nursing confirmed that the Physician's Orders should have been for the use of oxygen for Resident #17. During an interview on 7/29/2021 at 10:55 AM, Licensed Practical Nurse (LPN) #11 was shown Resident #17's oxygen humidifier bottle and was asked should the bottle have a date of 6/8/2021. LPN #11 stated, No. LPN #11 was shown Resident #17's oxygen tubing and was asked should the tubing have a date of 6/8/2021. LPN #11 stated, No, it should not, it should have been changed. Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of Fracture of Left Lower Leg, Acute Kidney Failure, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure with Hypoxia. Review of the Care Plan dated 7/9/2021, revealed, Problem .Respiratory/Pneumonia/Chronic obstructive pulmonary disease .Approaches .O2/BNC as ordered . Review of the July Physician's order revealed, .02 BNC BETWEEN 2L AND 3L TO MAINTAIN 02 SAT GREATER THAN 92 . Observation in the resident's room on 7/26/2021 at 2:04 PM, revealed Resident #27 was sitting in a wheelchair, wearing oxygen at 2L/minute BNC with no date on the oxygen humidifier bottle. Observation in the resident's room on 7/28/2021 at 7:51 AM, revealed Resident #27 was lying in the bed, wearing oxygen at 2L/minute BNC with no date on the oxygen humidifier bottle. During interview on 7/28/2021 at 10:15 AM, LPN #10 was shown Resident #27's oxygen humidifier bottle and asked if she saw a date on the oxygen humidifier bottle. LPN #10 stated, No ma'am . LPN #10 was asked should there be a date on it. LPN #10 stated Yes, ma'am .

Based on Consumer Medicine Information review, policy review, observation, and interview, the facility failed to ensure medications were not stored past their expiration date and opened medications were properly labeled and dated in 2 of 8 medication storage areas (South Hall Medication Cart and North Hall Medication Cart). The findings include: Review of the facility's policy titled, Storage of Medications revised 5/2015, revealed .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . Review of the Consumer Medicine Information dated 4/4/2017, revealed Brimonidine should be discarded 4 weeks after opening. Observation of the North Hall Medication Cart on 7/27/2021 at 8:50 AM, revealed 1 bottle of Brimonidine Tartrate eye drops with an open date of 5/15/2021. During an interview on 7/27/2021 at 8:40 AM, Licensed Practical Nurse (LPN ) #11 confirmed the eyedrops were expired based on the open date. Observation of the South Hall Medication Cart on 7/27/2021 at 11:40 AM, revealed 1 bottle of Geri-Tussin, opened and undated. During an interview on 7/27/2021 at 11:40 AM, LPN #11 confirmed that the medication should have had an open date. During an interview on 7/28/2021 at 5:00 PM, the Director of Nursing (DON) was asked should there be expired medications on the medication cart. The DON stated, There should not.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, Time Detail Reports, COVID-19 Daily Employee Screening Logs, and interview, the facility failed to follow CDC Infection Control guidelines to ensure all staff who enter facility completed the screening process for the prevention or spread COVID-19 when 30 of 108 staff members (Nurses Aide (NA) #1, #2, #3, #4, #5, #6, and #7, Certified Nurse Aide (CNA) #1, #2, #3, #4, #5, and #6, Licensed Practical Nurse (LPN) #1, #2, #3, #4, #5, #6, #7, #8, and #9, Registered Nurse (RN) #1, Dietary Staff #1, #2, and #3, Housekeeping Staff #2 and #3, and Physical Therapy (PT) Staff #1 and #3) failed to complete screenings for COVID-19 prior to working for 8 of 8 days (7/10/2021-7/17/2021) reviewed. The findings include: Review of the Centers for Disease Control and Prevention (CDC) website document titled, .Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 [Coronavirus Disease] Spread in Nursing Homes, updated 3/29/2021, revealed, .Establish a process to ensure HCP [Healthcare Personnel], (including .ancillary staff environmental services and dietary services) entering the facility are assessed for symptoms of COVID-19 .individual screening on arrival at the facility. Review of the Time Detail Reports and COVID-19 Daily Employee Screening Logs from 7/10/2021-7/17/2021 revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 7/10/2021- NA #1, CNA #1, #2, and #3, and LPN #1 and #2. b. 7/11/2021- NA #1 and #6, CNA #1 and #2, LPN #1, #2, and #3, and Dietary Staff #1. c. 7/12/2021- NA #7, LPN #4 and #5, Dietary Staff #2, and PT Staff #1. d. 7/13/2021- NA #1 and #2, CNA # 3,#4, and #6, LPN #3, #4, and #6, and Housekeeping Staff #2. e. 7/14/2021- NA #1, #2 and #3, CNA #4, LPN #3, #4, #5, and #7, RN #1, and Housekeeping Staff #3. f. 7/15/2021- NA #1, #2, #3 and #4, CNA #1, #3 and #4, LPN # 3, #4, and #8, and Housekeeping Staff #3. g. 7/16/2021- LPN # 4 and #9, PT Staff #3. h. 7/17/2021- NA #2 #3, and #5, CNA #2 and #5, LPN #1, #2, and #3, and Dietary Staff #3. During an interview on 7/29/2021 at 2:45 PM, the Director of Nursing (DON) confirmed all staff should be screened for COVID-19 upon entering the facility.