**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide services necessary to maintain a sanitary, orderly, and comfortable interior for 5 residents (Residents #10, #217, #226, #324 and #318) of 91 residents reviewed for environment. The findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses including Hypothyroidism, History of Falling and Depression and resided in room [ROOM NUMBER] bed A. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #10 had moderate cognitive impairment. Resident #217 was admitted to the facility on [DATE], with diagnoses including History of Falling, Chronic Obstructive Pulmonary Disease and Type 2 Diabetes Mellitus and resided in room [ROOM NUMBER] bed B. Review of an entry MDS assessment dated [DATE] showed Resident #217 was cognitively intact. During an observation and interview on 9/11/2023 at 11:48 AM, in room [ROOM NUMBER], a portable air conditioning unit was positioned on the floor by the window. The unit had a white, plastic, flexible exhaust pipe attached to the unit, and the pipe extended through an open window. The pipe had a plastic frame to secure it in the window between the sash and sill. The poorly fitting pipe frame resulted in cracks, through which the outdoors could be seen, and the cracks were filled with bath towels. The towels were yellowed and soiled. The privacy curtain was open and both residents, Residents #10 and #217 could see the portable unit. Resident #217 stated it had been like that since she was admitted (12 days previous), and the towels had not been changed. Resident #226 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease, Pneumonitis and Chronic Kidney Disease and resided in room [ROOM NUMBER] bed B. Review of an admission MDS dated [DATE] showed Resident #226 was cognitively intact. During an observation on 9/11/2023 at 3:30 PM, in room [ROOM NUMBER], a portable air conditioning unit was positioned on the floor by the window, and it had a flexible exhaust pipe extending out through the window. Bath towels were crumpled up in the void between the plastic frame holding the exhaust pipe and the window sash. The towels were dirty, yellowed and damp. The resident stated she wasn't aware of how long the unit had been there. The privacy curtain was closed, and the roommate stated she never saw the portable unit. During an observation on 9/13/2023 at 9:40 AM, in room [ROOM NUMBER], the portable air conditioning unit and towels were still in place, and the privacy curtain was closed. Resident #324 was admitted to the facility on [DATE] with diagnoses including Acute Embolism and Thrombosis of the Right Popliteal Vein and Glaucoma and resided in room [ROOM NUMBER]. Review of an admission MDS assessment dated [DATE] showed Resident #324 was cognitively intact. During an observation and interview on 9/11/2023 at 1:50 PM, room [ROOM NUMBER] had a portable heating and air unit beside the window that had an exhaust pipe attached to an exterior window. There were towels placed around the exhaust pipe that were damp and had brownish yellow stains. The resident stated the portable heating and air unit had been there since she admitted to the facility (3 days previous), and the staff had placed towels around the exhaust pipe to absorb condensation. During an observation on 9/12/2023 at 9:35 AM, in room [ROOM NUMBER], towels were still around the exhaust pipe that were damp with brownish yellow stains present. During an observation and interview on 9/12/2023 at 1:56 PM, with the Maintenance Director in rooms 355, 361 and 413, the Director stated the facility was forced to provide portable heating and air units because the air conditioning system in those rooms was not working properly. The towels were used to fill the cracks around the frame to keep water and insects out. The Maintenance Director observed the towels pushed in the cracks to be yellowed and dirty and confirmed the towels filling the cracks around the exhaust pipe in rooms 355, 361 and 413 were unsanitary and did not maintain an orderly and homelike environment. Resident #318 was admitted to the facility on [DATE] with diagnoses including Rheumatoid Arthritis, Immunodeficiency, and Obesity and resided in room [ROOM NUMBER]. Review of an admission MDS assessment dated [DATE] showed Resident #318 was cognitively intact. During an observation on 9/11/2023 at 1:35 PM, room [ROOM NUMBER] had a foul odor, and there were 2 large dark-brown stains, approximately 12 inches in diameter, on the carpet at the bottom right side of the resident's bed. During an interview on 9/11/2023 at 1:38 PM, Resident #318 stated there was a strong smell in her room (room [ROOM NUMBER]) which had been present during her entire stay at the facility. The resident stated when her family or guests came to visit her, they would complain about the smell to her. The resident stated in her opinion, the odor reminded her of cooked broccoli and garlic. During an observation on 9/12/2023 at 9:30 AM, room [ROOM NUMBER] continued to have a robust odor consistent with that of cooked vegetables. During an interview on 9/12/2023 at 2:20 PM, in room [ROOM NUMBER], the Housekeeping Director stated there was an unknown odor in room [ROOM NUMBER] which could be related to the dark-brown stains on the carpet. During an interview on 9/12/2023 at 2:23 PM, the Maintenance Director stated Resident #318's room had an .unknown odor with unknown stains . present on the carpet. The Maintenance Director stated he did not know where the odor was coming from but thought it could be from the carpet which needed to be shampooed. The Maintenance Director confirmed Resident #318's room was not consistent with a home-like environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation and interview, the facility failed to provide a summary of the baseline care plan to 1 resident (Resident #218) of 24 residents reviewed for baseline care plans. The findings include: Review of the facility's policy titled, Nursing Services, dated 2/2023, showed .A baseline care plan is developed to address the immediate needs .within 48 hours of .admission .summary of the baseline care plan will be shared with the patient and the representative . Resident #218 was admitted to the facility on [DATE] with diagnoses including Traumatic Subdural Hemorrhage, History of Falling and Depression. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #218 was cognitively intact. During an interview on 9/12/2023 at 8:19 AM, Resident #218 stated she did not receive a summary of her baseline care plan. Record review showed no documentation Resident #218 received a summary of her baseline care plan. During an interview on 9/13/2023 at 11:23 AM, the Social Services Coordinator (SSC) stated she interviewed the resident on 8/28/2023 and discussed her medical history and her discharge plan. The SSC stated the RN Unit Manager was responsible for reviewing the baseline care plan with the cognitively intact resident. The SSC confirmed there was no documentation that the resident was given a summary of the baseline care plan and that the Resident was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to implement the comprehensive care plan for 1 resident (Resident #45) related to wounds of 3 residents reviewed for wounds. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses including, Left Femur Fracture, History of Falling, Dementia, and Pressure Induced Deep Tissue Damage of Left Heel. Review of a Physician Order dated 8/15/2023, showed .PATIENT TO HAVE L [LEFT] HEEL PROTECTOR ON WHEN IN BED . Review of Resident #45's comprehensive care plan dated 8/15/2023, showed .PATIENT TO HAVE L HEEL PROTECTOR ON WHEN IN BED . During an observation on 9/13/2023 at 10:25 AM, Resident #45 was lying in bed and the left heel protector was not in place. During an interview on 9/13/2023 at 10:26 AM, the wound care Licensed Practical Nurse confirmed Resident #45 did not have the left heel protector in place I'm not sure why but I will find out. During an interview on 9/13/2023 at 3:30 PM, the Director of Nursing confirmed the facility failed to implement the care plan for Resident #45 related to heel protector in place to the left heel while in bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to update a comprehensive care plan to include an identified need for 1 resident (Resident #9) out of 22 residents reviewed. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, dated 2/2023, showed .Decision making/planning is based on identified needs/problems and builds on patient strengths while taking into account the patient's preferences . Resident #9 was admitted to the facility on [DATE] with diagnoses including Moderate Protein-Malnutrition, Fracture Left Humerus, Mass Upper Right Limb, and Osteoporosis. Review of Resident #9's comprehensive care plan dated 8/16/2023 showed no prompted toileting had been added as an intervention for bladder incontinence due to bladder leakage. Review of Resident #9's admission Minimum Data Set (MDS) assessment dated [DATE] showed resident had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact and was frequently incontinent of bowel and bladder. Review of Resident #9's Bowel and Bladder assessment dated [DATE], showed the resident was not always incontinent of bowel and bladder, a score of 10 indicated resident was a candidate for scheduled/prompted toileting. During an interview on 9/12/2023 at 3:23 PM, Resident #9 revealed the staff do not offer to take me to the bathroom, they just change me when I am wet, I would like to go to the bathroom. During an interview on 9/12/2023 at 3:35 PM, Certified Nurse Aide (CNA) #1, revealed .I have received no instructions to do prompted toileting for the resident . During an interview on 9/12/2023 at 3:45 PM, Registered Nurse Unit Manager #2 confirmed prompted toileting had not been added to the care plan and was not implemented as an intervention for Resident #9.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to follow a physician's order for a pressure reducing device for 1 resident (Resident #45) of 3 residents reviewed for pressure ulcers. The findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses including Fracture of Left Femur, Presence of a Left Artificial Hip Joint, Dementia, Pressure-Induced Deep Tissue Damage of the Left Heel, and Encounter for Palliative Care. Review of the Braden Scale assessment dated [DATE], showed a score of 16, which indicated Resident #45 was at risk for skin breakdown. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score was 4, which indicated Resident #45 had severe cognitive impairment, required limited one person assistance with bed mobility, had risk of pressure ulcers present, had the presence of an unstageable deep tissue injury (DTI), utilized a pressure reducing device, and had received hospice care. Review of a Weekly Skin Observation dated 8/29/2023, showed Resident #45's wound (left heel) measured 1.5 centimeters (cm) x 2.0 cm and was non-blanchable with purple discoloration. Review of the current physician's orders dated 9/2023, showed Paint DTI [deep tissue injury] to Left (L) Heel with Betadine four times a day. Patient to have L Heel Protector on when in bed. During an observation on 9/12/2023 at 2:05 PM, Resident #45 was lying in bed and the left heel protector was not in place. During an observation on 9/13/2023 at 10:25 AM, Resident #45 was lying in bed and the left heel protector was not in place. During an interview on 9/13/2023 at 10:26 AM, the Wound Care Licensed Practical Nurse (LPN) confirmed Resident #45 did not have the left heel protector in place. The Wound Care LPN stated, .I'm not sure why but I will find out . During an interview on 9/13/2023 at 3:30 PM, the Director of Nursing (DON) confirmed the facility failed to follow the physician orders related to heel protector to the left heel while in bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation and interview, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, for 1 resident (Resident #40) of 3 residents reviewed for wound care. The findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Long Term (current) Use of Anticoagulants, Other Giant Cell Arteritis, Long Term (current) Use of Systemic Steroids, Peripheral Vascular Disease, and Acquired Absence of Other Right Toes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. Further review showed Resident # 40 had a pressure reducing device on the chair and bed and the resident had venous and arterial ulcers. Review of Resident #40's comprehensive care plan dated [DATE], showed .Right lower extremity wounds cleanse right lateral foot with wound cleanser, pat dry, apply Betadine [used as an antiseptic for the treatment of common skin infections], gauze wrap with kerlex secure with paper tape .Cleanse wound to right medial foot with wound cleanser, pat dry, paint with betadine and apply [a type of wound dressing], gauze, [absorbant dressing] and, wrap with kerlex secure with paper tape .Paint right third toe with betadine except for bone, place silver alginate between toes, cover exposed bone with [a specialized product for wound care], cover with gauze, wrap in kerlex, secure with paper tape Monday, Wednesday, and Friday . Review of a Physician Order dated [DATE], showed .TREATMENT TO R [RIGHT] LATERAL AND MEDIAL FOOT .APPLY BETADINE . During an observation of wound care on [DATE] at 9:45 AM, Wound care Licensed Practical Nurse (LPN) gathered the wound care supplies, provided wound care as ordered to include applying betadine to the right foot. Observation of the betadine used by LPN Wound Care showed it had expired on 2/2023. During an interview on [DATE] at 9:55 AM, the Wound Care LPN confirmed the betadine used on Resident #40's right foot was out of date and expired 2/2023. During an interview on [DATE] at 10:33 AM, the Medical Director stated the expired betadine would not delay wound healing. During an interview on [DATE] at 2:01 PM, the Pharmacist stated he researched the manufacturer of the betadine, and found the expiration date was not a firm not use by date. The Pharmacist stated, in his professional opinion, use of the betadine that expired 2/2023 would not cause a delay in wound [NAME]. During an interview on [DATE] at 3:30 PM, the Director of Nursing (DON) confirmed the facility used expired betadine solution to treat Resident #40's right foot wounds and did not meet the facility's expectations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to provide scheduled/prompted toileting, a Bowel and Bladder need identified for 1 resident (Resident #9) out of 22 residents reviewed. The findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses including Moderate Protein-Malnutrition, Fracture Left Humerus, Mass Upper Right Limb, and Osteoporosis. Review of Resident #9's Comprehensive Care Plan dated 8/16/2023, showed no prompted toileting had been added as an intervention for bladder incontinence due to bladder leakage. Review of Resident #9's admission Minimum Data Set (MDS) assessment dated [DATE] showed resident had a Brief Interview for Mental Status score of 15 which indicated the resident was cognitively intact and was frequently incontinent of bowel and bladder. Review of Resident #9's Bowel and Bladder assessment dated [DATE], showed the resident is not always incontinent of bowel and bladder, a score of 10 indicated resident was a candidate for scheduled/prompted toileting. During an interview on 9/12/2023 at 3:23 PM, Resident #9 revealed, the staff do not offer to take me to the bathroom, they just change me when I am wet, I would like to go to the bathroom. During an interview on 9/12/2023 at 3:35 PM, Certified Nurse Aide (CNA) #1 revealed .I have received no instructions to do prompted toileting for the resident . During an interview on 9/12/2023 at 3:45 PM, Registered Nurse Unit Manager #2 confirmed scheduled/prompted toileting had not been added to the care plan and was not implemented as an intervention for Resident #9. During an interview on 9/13/2023, the MDS Coordinator revealed the scheduled/prompted toileting need, identified through the Bowel and Bladder assessment dated [DATE], was used as guidance. The facility was not required to provide the intervention due to the resident had admitted to the facility with bladder leakage and wore briefs at home. Further interview confirmed no formal scheduled/prompted Bowel and Bladder program had been implemented for Resident #9.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Nurse Aide Training (NAT) program, review of work schedules and interview, the facility failed to ensure 1 of 4 Nurse Aides (NA) #1 was removed from the working schedule and not allowed to perform the duties of a Certified Nursing Assistant (CNA) after 120 days of taking the NAT program. The findings include: Review of the facility's working schedule for the months of 8/2023 and 9/2023 showed NA #1 had worked as a NA and performed direct resident care. During an interview on 9/12/2023 at 10:22 AM, NA #1 stated he had worked at the facility for 5 months, continued to provide direct resident care, and took the certification test on 9/12/2023. During an interview on 9/13/2023 at 7:48 AM, the NAT Instructor stated NA #1 had taken the NA certification examination on 9/12/2023 and had passed. The NAT Instructor stated NA #1 had worked at the facility providing direct resident care since 4/3/2023. During an interview on 9/13/2023 at 8:25 AM, the Registered Nurse Unit Manager stated NA #1 had worked on the floor as an NA. Review of NA #1's employee file showed he was hired on 4/3/2023 and is currently employed as a NA. During an interview on 9/13/2023 at 8:15 AM, the Administrator confirmed NA #1 had completed the NAT class at the facility, had worked on the floor as an NA, and had tested on [DATE] for the NA certification. The Administrator confirmed NA #1 had not tested within the 120 day time frame of completing the NAT program.

Based on facility policy review, observation and interview, the facility failed to dispose of garbage and refuse properly in 1 of 2 dumpsters. The findings include: Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, dated 11/2017, showed .WASTE MANAGEMENT .Receptacles and waste handling units shall be kept covered .after they are filled .Dumpsters will be checked routinely for cleanliness .debris .Doors are to be kept closed except during use . An observation of 2 dumpsters on 9/11/2023 at 11:05 AM, with the Dietary Manager and the Regional Dietician, showed the left dumpster was full, contained food containers and was uncovered. Food containers were found on the ground around the dumpster attracting flies and bees. During an interview on 9/11/2023 at 11:10 AM, the Dietary Manager confirmed the area around the dumpster was littered with food containers and the left dumpster was not covered, which allowed pests to enter, and was not a sanitary environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to maintain an accurate medical record for 1 Resident (#6) of 19 residents reviewed. The findings include: Resident #6 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Long Term Current Use of Insulin, Hypertension, Dementia, and Major Depressive Disorder. Review of Resident #6's physicians orders dated 8/17/2023, showed fasting blood sugar before meals and at bedtime and contact the provider (Physician or Nurse Practitioner) for blood sugar less than 70 and greater than 400. Review of the medication administration record (MAR) for [DATE] showed an entry on 8/18/2023, .Blood Sugar .424 .called [Nurse Practitioner] .and order received to give 12 units lispro insulin .and retest in 2 hr [hour] . Continued review showed no documentation the 12 units of insulin had been administered or the retest of the blood sugar (BS) had been documented on the MAR. During an interview on 9/13/2023 at 4:43 PM, the Director of Nursing (DON) stated she had contacted Registered Nurse #1, the RN had administered 12 units of insulin to Resident #6, rechecked the BS 2 hours later as ordered, and the BS was within normal range. During an interview on 9/13/2023 at 4:55 PM, the DON confirmed the facility failed to maintain an accurate medical record related to insulin administration and rechecks of a BS level for Resident #6.

Based on facility policy review, observation, and interview, the facility failed to maintain a sanitary kitchen environment by failing to properly store opened food items that were observed in 1 of 1 dry storage room and 1 of 1 reach in freezer with the potential to affect 89 of 91 residents. The findings include: Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, dated 11/2017, showed .REFRIGERATOR AND FREEZER STORAGE .Foods will be stored .Clearly labeled with the contents and the use by date .DRY STORAGE .if opened .should be clearly labeled . During a tour of the kitchen on 9/11/2023 at 10:47 AM, with the Dietary Manager and the Regional Dietician, the following items were found. In the dry storage: 1- 3.9 liter bottle of olive oil, 1/8 full, opened, and unlabeled 1- 16-ounce jar of low sodium chicken base, full, opened, and unlabeled In the reach-in freezer: 1- 5 pound bag sweet potato fries, 1/2 full, opened, and unlabeled During an interview on 9/11/2023 at 11:03 AM, the Dietary Manager confirmed the olive oil, chicken base and sweet potato fries were stored incorrectly and available for resident use.

**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 medications were administered in a timely manner and in accordance to professional nursing standards for 6 of 10 residents (Resident #56, #63, #72, #3, and #349, #191) reviewed for unnecessary medications. The findings include: Review of the facility policy titled, PREPARATION AND GENERAL GUIDELINES, dated 6/2016, showed Medications are administered as prescribed in accordance with good nursing principles and practices .Medications are administered within 60 minutes before or after scheduled time. Unless otherwise specified by the prescriber . Resident #56 was admitted to the facility on [DATE] with diagnosis of Acute Respiratory Failure with Hypoxia, Chronic Kidney Disease Stage 3, Anxiety Disorder, Congestive Heart Failure, Paroxysmal Atrial Fibrillation, and Rheumatoid Arthritis. Review of Resident Orders dated 1/1/2020 - 1/29/2020 showed Resident #56 was ordered the following: *Buspirone (an anti-anxiety medication) tablet 10 mg (milligrams) twice a day at 9:00 AM and 9:00 PM. *Carvedilol (heart medication) tablet 25 mg twice a day at 9:00 AM and 9:00 PM. *Furosemide (diuretic) tablet 40 mg twice a day at 9:00 AM and 9:00 PM. Review of Resident #56's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Buspirone tablet 10 mg was documented administered late as follows: *1/17/2020 at 11:32 AM (1 hour and 32 minutes late) resident was unavailable. *1/19/2020 at 11:12 PM (1 hour 12 minutes late) resident was unavailable. *1/22/2020 at 11:11 AM (1 hour and 11 minutes late) resident was unavailable. *1/29/2020 at 11:01 AM (1 hour and 1 minutes late) resident was unavailable. Review of Resident #56's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Carvedilol tablet 10 mg was documented administered late as follows: *1/4/2020 at 11:14 AM (1 hour and 14 minutes late) resident unavailable. *1/17/2020 at 11:32 AM (1 hour and 32 minutes late) resident unavailable. *1/18/2020 at 10:52 AM (59 minutes late) resident unavailable. Review of Resident #56's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Furosemide tablet 40 mg was documented administered late as follows: *1/22/2020 at 11:11 AM (1 hour and 11 minutes late) resident unavailable. *1/24/2020 at 11:05 AM (1 hour and 5 minutes late) resident unavailable. *1/26/2020 at 10:36 AM (36 minutes late) resident unavailable. During an interview on 1/30/2020 at 9:07 AM, Registered Nurse (RN) #3 confirmed she was assigned to Resident #56 several times in January. She confirmed Resident #56's medications were administered late several times in January. Resident #63 was admitted to the facility on [DATE] with diagnosis of Diabetes, Atrial Fibrillation, Anxiety, Hypertensive Heart, and Chronic Kidney Disease with Heart Failure. Review of Resident #63's Orders dated 1/9/2020 - 1/29/2020 showed Resident #63 was ordered the following: *Amiodarone (antiarrhythmic medication) tablet 200 mg once a day at 8:00 AM. *Amlodipine (blood pressure medication) tablet 5 mg once a day at 8:00 AM. *Bisoprolo-Hydrochlorothiazide (high blood pressure medication) tablet 5-6.25 mg once a day at 8:00 AM. *Clonazepam (anti-anxiety medication) tablet 0.5 mg twice a day at 8:00 AM and 8:00 PM. *Levothyroxine (thyroid medication) 137 mcg (micrograms) once a day at 8:00 AM *Methocarbamol (muscle relaxer) tablet 500 mg twice a day at 8:00 AM and 8:00 PM. *Allopurinol (Gout medication) 100 mg once a day at 8:00 AM. *Furosemide (diuretic medication) 40 mg twice a day at 8:00 AM and 8:00 PM. *Augmentin (antibiotic medication) 500/125 mg every 12 hours at 8:00 AM and 8:00 PM. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Amiodarone 200 mg was documented administered late as follows: *1/4/2020 at 9:38 AM (38 minutes late) resident was unavailable. *1/11/2020 at 9:25 AM (25 minutes late) resident was unavailable. *1/18/2020 at 1:30 PM (4 hour and 30 minutes late) resident was unavailable. *1/22/2020 at 9:39 AM (39 minutes late) resident was unavailable. *1/25/2020 at 9:27 AM (27 minutes late) patient care. *1/26/2020 at 9:55 AM (55 minutes late) patient care. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Amlodipine 5 mg was documented administered late as follows: *1/17/2020 at 1:30 PM (4 hours and 30 minutes late) resident was unavailable. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Bisoprolo-Hydrochlorothiazide tablet 5-6.25 mg was documented administered late as follows: *1/28/2020 at 1:30 PM (4 hours and 30 minutes late) resident was unavailable. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Clonazepam 0.5 mg was documented administered late as follows: *1/18/2020 at 1:30 PM (4 hours and 30 minutes late) resident was unavailable. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Levothyroxine 137 mcg was documented administered late as follows: *1/18/2020 at 1:30 PM (4 hour and 30 minutes late) resident was unavailable. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Methocarbamol 500 mg was documented administered late as follows: *1/25/2020 at 9:27 AM (27 minutes late) patient care. *1/26/2020 at 9:55 AM (55 minutes late) patient care. *1/28/2020 at 9:44 AM (44 minutes late) patient care. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Allopurinol 100 mg was documented administered late as follows: *1/4/2020 at 9:38 AM (38 minutes late) resident unavailable. *1/18/2020 at 1:30 PM (4 hours 30 minutes late) resident unavailable. *1/26/2020 at 9:55 AM (55 minutes late) patient care. Review of Resident #63's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Furosemide 40 mg documented administered late as follows: *1/4/2020 at 9:38 AM (38 minutes late) resident unavailable. *1/5/2020 at 10:14 PM (1 hour and 14 minutes late) patient care. *1/10/2020 at 10:10 PM (1 hour and 10 minutes late) patient care. Review of Resident #63's Medication Administration History dated 1/1/2020-1/29/2020 showed Augmentin 500-125 mg was documented administered late as follows: *1/18/2020 at 1:30 PM (4 hours and 30 minutes late) resident unavailable. During an interview conducted on 1/29/2020 at 4:55 PM, RN #4 confirmed she was assigned to Resident #63 several times in January. RN #4 confirmed the facility failed to administer Resident #4's medications within the 1 hour before or 1 hour after the scheduled medication times. During an interview on 1/29/2020 from 9:36 PM - 10:13 PM, the Director of Nursing (DON) stated medications should be given 1 hour before or 1 hour after the scheduled time. The DON confirmed the facility failed to ensure Residents #56 and #63 received medications in a timely manner. Resident #72 was admitted to the facility on [DATE] with diagnoses including Fracture of Right Femur, Right Artificial Hip Joint, History of Falling, Type 2 Diabetes, Chronic Kidney Disease, Dementia, and Heart Disease. Review of Resident Orders dated 12/31/2019 - 1/29/2020 and Medications Administration History dated 1/1/2020 - 1/28/2020 revealed Resident #72 was ordered: *Admelog SoloStar U-100 insulin pen (a medication to regulate the blood sugar level) sliding scale (number of units administered based on the blood sugar reading) before meals and at bedtime at 8:30 AM, 12:30 PM, 4:30 PM, and 8:00 PM. *Brilinta (prevents platelets from sticking together and forming clots) twice a day at 9:00 AM and 9:00 PM. *Enoxaparin (blood thinner) once a day at 9:00 AM for 21 days. *Glimepiride (medication to treat high blood sugar) once a day at 9:00 AM. Review of Resident #72's Medication Administration History dated 1/1/2020 - 1/28/2020 showed Admelog SoloStar U-100 insulin was documented administered late as follows: * 1/3/2020 at 9:13 PM (13 minutes late) patient care * 1/8/2020 at 2:08 PM (38 minutes late) patient care * 1/13/2020 at 11:15 AM (1 hour and 45 minutes late) patient care * 1/15/2020 at 10:04 AM (34 minutes late) patient care * 1/23/2020 at 2:14 PM (44 minutes late) patient care * 1/24/2020 at 6:27 PM (57 minutes late) patient care Review of Resident #72's Medication Administration History dated 1/1/2020 - 1/28/2020 showed Brilinta was documented administered late as follows: *1/2/2020 at 11:05 AM (1 hour and 5 minutes late) patient care *1/8/2020 at 10:52 PM (52 minutes late) patient care *1/17/2020 at 10:12 AM (12 minutes late) resident unavailable Review of Resident #72's Medication Administration History dated 1/1/2020 - 1/28/2020 showed enoxaparin was documented administered late as follows: * 1/2/2020 at 11:05 AM (1 hours and 5 minutes late) patient care *1/17/2020 at 10:12 AM (12 minutes late) resident unavailable Review of Resident #72's Medication Administration History dated 1/1/2020 - 1/28/2020 showed Glimepiride was documented administered late as follows: *1/2/2020 at 11:05 AM (1 hours and 5 minutes late) patient care *1/17/2020 at 10:12 AM (12 minutes late) resident unavailable During an interview on 1/29/2020 at 8:10 PM, Licensed Practical Nurse (LPN) #2 stated sometimes medications were given late and it was documented on the Medication Administration History. When patient care was documented, it could mean the resident was being toileted, put to bed, etc., and .this can cause giving meds [medications] to take a while . During an interview on 1/30/2020 at 9:20 AM, LPN #1 stated nurses had one hour before and one hour after a medication was due to administer the medication timely.The reasons meds are given late is situational. The residents move around; they go to dining, go to therapy . LPN #1 confirmed if the Medication Administration History read resident unavailable it meant the resident wasn't able to be located by the nurse and received the medication late. During an interview on 1/30/2020 at 9:45 AM, RN #1 stated the expectation was for medications to be administered 1 hour before or 1 hour after the scheduled time and the charted administration time was the time the medication was given. During review of RN #1's documentation on Resident #72's January Medication Administration History, RN #1 stated .it is what it looks like [medications were charted as given late] . Resident #3 was admitted to the facility on [DATE] with diagnoses including Rhabdomyolysis, Major Depressive Disorder, Single-episode, and Anxiety Disorder. Review of the Resident Orders dated 1/9/2020 - 1/29/2020 showed Resident #3 was ordered the following: *Diclofenac Sodium Gel (Analgesic Gel) 1% topical four times a day 9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM *Fluoxetine (Antidepressant) capsule 80 mg once a day 9:00 AM *Guaifenesin (Mucus thinning agent) 400 mg four times a day 9:00 AM, 1:00 PM, 5:00 PM, 9:00 PM *Risperidone (antipsychotic) 2 mg at bedtime 9:00 PM Review of Resident #3's Medication Administration History dated 1/9/2020 - 1/29/2020 showed Diclofenac Sodium Gel 1% was documented administered late as follows: * 1/11/2020 at 10:53 AM (53 minutes late) resident was unavailable. * 1/11/2020 at 6:14 PM (14 minutes late) resident was unavailable. * 1/12/2020 at 6:37 PM (37 minutes late) resident was unavailable. * 1/15/2020 at 12:13 PM (2 hours, 13 minutes late) resident was unavailable. * 1/15/2020 at 6:48 PM (48 minutes late) resident was unavailable. * 1/15/2020 at 10:28 PM (28 minutes late) patient care * 1/16/2020 at 11:14 AM (1 hour, 14 minutes late) resident was unavailable. * 1/16/2020 at 6:34 PM (34 minutes late) resident was unavailable. * 1/16/2020 at 10:30 PM (30 minutes late) patient care. * 1/17/2020 at 2:35 PM (35 minutes late) resident was unavailable. * 1/17/2020 at 6:30 PM (30 minutes late) resident was unavailable. * 1/18/2020 at 12:43 AM (2 hour, 43 minutes late) patient care. * 1/19/2020 at 10:37 PM (37 minutes late) charted late. * 1/20/2020 at 10:20 PM (37 minutes late) charted late. * 1/21/2020 at 2:32 PM (32 minutes late) administered late * 1/22/2020 at 10:17 AM (17 minutes late) patient care * 1/25/2020 at 3:37 PM (1 hour, 37 minutes late) resident was unavailable. * 1/26/2020 at 2:44 PM (44 minutes late) resident was unavailable. * 1/26/2020 at 6:51 PM (51 minutes late) resident was unavailable. * 1/26/2020 at 10:13 PM (13 minutes late) patient care. Fluoxetine 80 mg was documented administered late as follows: * 1/11/2020 at 10:53 AM (53 minutes late) resident was unavailable. * 1/15/2020 at 12:13 PM (2 hours, 13 minutes late) resident was unavailable. * 1/16/2020 at 11:14 AM (1 hour, 14 minutes late) resident was unavailable. * 1/22/2020 at 10:17 AM (17 minutes late) patient care. Guaifenesin 400 mg tablet was documented administered late as follows: * 1/21/2020 at 2:32 PM (32 minutes late) administered late. * 1/22/2020 at 10:17 AM (17 minutes late) patient care. * 1/25/2020 at 3:37 PM (1 hour 37 minutes late) resident was unavailable. * 1/25/2020 at 6:54 PM (54 minutes late) resident was unavailable. * 1/26/2020 at 2:44 PM (44 minutes late) resident was unavailable. * 1/26/2020 at 6:51 PM (51 minutes late) resident was unavailable. * 1/26/2020 at 10:13 PM (13 minutes late) patient care. Risperidone 2 mg tablet was documented administered late as follows: * 1/15/2020 at 10:28 PM (28 minutes late) patient care. * 1/16/2020 at 10:30 PM (30 minutes late) patient care. * 1/17/2020 at 12:43 AM (2 hours, 43 minutes late) patient care. * 1/20/2020 at 10:20 PM (20 minutes late) charted late. * 1/26/2020 at 10:13 PM (13 minutes late) patient care. During an interview conducted on 1/29/2020 at 4:50 PM, RN #1 stated .Resident may have been in therapy when documentation showed resident unavailable .I do the best I can to get to residents for medication pass .medications are to be administered 1 hour before or 1 hour after scheduled time . During an interview conducted on 1/30/2020 at 9:05 AM, RN #1 confirmed the medications for Resident #3 on the January electronic medication administration record were given late, .Yes the medications were given late. That's why I documented them [the medications] that way .they were given late . Resident #349 was admitted to the facility on [DATE] with diagnoses including Presence of Left Artificial Knee Joint, Hypertension, Atrial Fibrillation (irregular heart rhythm), Chronic Pain, and Osteoarthritis. Review of the Resident's Orders dated 1/28/2020 - 1/29/2020 showed Resident #349 was ordered the following: Amlodipine 5 mg once a day at 8:00 AM Ferrous Sulfate (iron supplement) 325 mg twice a day at 8:00 AM and 8:00 PM Gabapentin (nerve pain medication) 300 mg twice a day at 8:00 AM and 8:00 PM Gabapentin 600 mg twice a day at 8:00 AM and 8:00 PM Lisinopril (high blood pressure medication) 20 mg once a day at 8:00 AM Metoprolol Tartrate (high blood pressure medication) 25 mg twice a day at 8:00 AM and 8:00 PM MS Contin ER (pain medication) 30 mg twice a day at 8:00 AM and 8:00 PM Review of the Medication Administration History dated 1/1/2020 - 1/29/2020 showed Resident #349's medications were documented as administered late as follows: *Amlodipine 5 mg on 1/27/2020 at 9:19 AM (19 minutes late) patient just returned from breakfast. *Ferrous Sulfate 325 mg on 1/27/2020 at 9:19 AM (19 minutes late) patient just returned from breakfast. *Gabapentin 300 mg and Gabapentin 600 mg (total dose of 900 mg) on 1/27/2020 at 9:22 AM (22 minutes late) patient just returned from breakfast. *Lisinopril 20 mg on 1/27/2020 at 9:19 AM (19 minutes late) patient just returned from breakfast. *Metoprolol Tartrate 25 mg on 1/27/2020 at 9:27 AM (27 minutes late) patient just returned from breakfast. *MS Contin 30 mg on 1/27/2020 at 9:24 AM (24 minutes late) patient just returned from breakfast. During an interview conducted on 1/30/2020 at 9:45 AM, RN #5 confirmed that medications were to be given one hour before or one hour after the scheduled time and the medications for Resident #349 were administered late. Resident #191 was admitted to the facility on [DATE] with diagnosis of Myocardial Infarction, Long term use of Aspirin, Atrial Fibrillation, Alzheimer's Disease, and Bipolar Disorder. Review of the Resident Orders dated 1/28/2020 - 1/29/2020 showed Resident #191 was ordered the following: *Metoprolol Tartrate 12.5 mg twice a day 9:00 AM and 9:00 PM. Review of Resident #191's Medication Administration History dated 1/1/2020 - 1/29/2020 showed Metoprolol Tartrate was documented administered late as follows: *1/28/2020 at 10:24 AM (1 hour and 24 minutes late) resident unavailable. During an interview conducted on 1/29/2020 at 4:55 PM, LPN #3 confirmed that if a medication was scheduled for 9:00 AM, administration time could range from 8:00 AM (1 hour before) to 10:00 AM (1 hour after). During an interview conducted on 1/29/20 at 5:00 PM, RN #2 confirmed medications could be administered 1 hour before or 1 hour after the scheduled time. During an interview conducted on 1/29/2020 at 9:30 PM, the DON confirmed that the medications were documented as given late and the administration times did not comply with the facility's medication administration policy. During an interview conducted on 1/29/2020 at 7:00 PM, the Consultant Pharmacist stated during monthly chart reviews, a trend was noted for with 8AM and 9 AM scheduled medications being administered late. This trend was discussed with the Director of Nursing and the Medical Director at the quarterly medication error meeting. The standard of practice was to administer medications within a 1 hour window before or after the scheduled time a medication was due. During an interview on 1/30/2020 at 10:21 AM, the Medical Director stated the expectation was for nurses to administer medications within 1 hour before or 1 hour after the scheduled time.