**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 medications were properly stored and secured for 1 of 1 sampled residents (Resident #277) when medications were found unattended and unsecured in the Resident's room. The findings include: Review of the facility policy titled, Medication Administration: Medication, Controlled and Biological Storage, Night/ Emergency Box and Backup Pharmacy Storage, dated 9/25/2024, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored .in locked compartments .medications must be under the direct observation of the person administering medications of locked in the medication storage area/cart . Review of the medical record revealed Resident #277 was admitted to the facility on [DATE], with diagnoses including Osteomyelitis, Diabetes, and Anemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #277 was cognitively intact and assessed for special treatments that included intravenous (IV) medications. Observation in Resident #277's room on 10/28/2024 at 9:35 AM, revealed 2 syringes filled with Heparin (a medication used to keep IV catheters open and prevent blood clots) on the chair next to the bed, unsecured and unattended. During an interview on 10/28/2024 at 9:46 AM, RN A confirmed that the medications should not be left at bedside unattended. During an interview on 10/30/2024 at 5:02 PM, the Director of Nursing confirmed that Heparin should not be left at the Resident's bedside unattended.

Based on policy review, observation, and interview, the facility failed to ensure appropriate infection control prevention and practices during medication administration when 1 of 2 nurses Registered Nurse (RN) C observed failed to perform hand hygiene between changing gloves during medication pass, and 1 of 1 Certified Nurses Assistant (CNA) B failed to properly handle and transport a soiled brief. The findings include: 1. Review of the facility policy titled, Infection Control, dated 11/20/2023, revealed . It is a policy of this facility to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary .environment .to help prevent the development and transmission of communicable diseases and infections .direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection .All staff shall demonstrate competence in relevant infection control practices . Review of the facility policy titled, Hand Hygiene, dated 3/28/2024, revealed .Staff involved in direct resident contact shall perform proper hand hygiene procedures to prevent the spread of infection .the use of gloves does not replace hand hygiene. Perform hand hygiene after removing gloves .before applying and after removing personal protective equipment .including gloves . 2. During an observation on 10/30/2024 at 7:35 AM, revealed RN C entered Resident #29 ' s room to administer medications, sanitized, donned gloves, administered eye drops, removed gloves, did not perform hand hygiene, and donned another pair of gloves to administer oral medications. Upon completion of administering oral medications, RN C removed her gloves, did not perform hand hygiene, donned another pair of gloves to administer the second ordered eyedrops. 3. During an observation on 10/30/2024 at 8:04 AM, RN C entered Resident #227 ' s room to administer medications and performed hand hygiene before donning gloves. RN C helped the resident unbutton his shirt to gain access to the Peripherally inserted central catheter (PICC) (a thin flexible tube inserted into a vein in the arm and threaded into a large vein in the chest) line, removed her gloves, and did not perform hand hygiene before donning a new pair of gloves. RN C failed to perform hand hygiene after removing gloves during medication administration. 4. A random observation and interview on the 400 Hall on 10/30/2024 at 9:23 AM, revealed CNA B walked out of a resident ' s room with a dirty brief in her bare hand, walked to the other side of the hallway and placed the brief in a trash barrel. CNA B confirmed it was a dirty brief in her hand. CNA B confirmed the dirty brief should have been in a plastic bag before she walked out of the room. 5. During an interview on 10/30/2024 at 9:37 AM, the Director of Nursing (DON) was asked how should staff handle dirty briefs when exiting a resident ' s room. The DON stated, Put it in a bag and then it goes into a barrel in the hallway. During an interview on 10/31/24 at 7:15 AM, the DON confirmed that hand sanitization should always be performed after removing gloves.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when the ice machine was found with black slimy residue on the inside trim of the ice machine and white residue running down the inside of the door. The facility had a census of 74 residents with 74 of those residents receiving a tray from the kitchen. The findings include: Review of the facility policy titled, Dietary: Ice Storage, dated 11/30/2022, revealed .Ice is to be maintained and served to patients in a sanitary manner . Review of the Named Company's invoice dated 4/15/2024, revealed the last time the ice machine was clean/sanitized was on 4/15/2024. Observation in the Clean Utility Room on the 300 Hall on 10/30/2024 at 8:09 AM, revealed a black, slimy substance on the inside trim and inside edge of the ice machine and white residue running down the inside of the door. During an interview on 10/30/2024 at 8:13 AM, the Dietary Supervisor (DS) stated that Maintenance is responsible for cleaning the ice machine. The DS confirmed there should not have been any black slimy substance or white residue on the ice machine. During an interview on 10/30/2024 at 8:21 AM, the Maintenance Director (MD) was asked how often the ice machine should be cleaned. The MD stated, .should be cleaned monthly through a contractor . The MD was asked should there be black slimy and white residue on the ice machine. The MD stated, .Probably not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to accurately assess residents for antipsychotic medication use and Dialysis for 5 of 21 sampled residents (Resident #3, #9, #21, #33, and #64) reviewed for accuracy of Minimum Data Set (MDS) assessments. The findings include: Review of the facility's policy titled, Dialysis, dated 10/18/21, revealed .Residents who have End Stage Renal Disease (ESRD) and receive dialysis will be .identified in assessments . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Chron's Disease, Malignant Neoplasm of Rectum, Anus, and Anal Canal, Diabetes, and Anxiety. Review of the Physician Order Sheet dated 2/2022, revealed Resident #3 did not have an order to receive Antipsychotic medication. Review of the Medication Administration Record (MAR) dated 2/2022, revealed Resident #3 did not receive Antipsychotic medications. Review of the quarterly MDS dated [DATE], revealed Resident #3 was assessed as having received Antipsychotic medications on a routine basis. Review of the Physician Order Sheet dated 5/2022, revealed Resident #3 did not have an order to receive Antipsychotic medication. Review of the Medication MAR dated 5/2022, revealed Resident #3 did not receive Antipsychotic medications. Review of the quarterly MDS dated [DATE], revealed Resident #3 was assessed as having received Antipsychotic medications on a routine basis. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Hypertension, Diabetes, Cerebral Infarction, and Protein Calorie Malnutrition. Review of the Physician Order Sheet dated 5/2022, revealed Resident #9 did not have an order to receive Antipsychotic medication. Review of the MAR dated 5/2022, revealed Resident #9 did not receive Antipsychotic medications. Review of the quarterly MDS dated [DATE], revealed Resident #9 was assessed as having received Antipsychotic medications on a routine basis. During an interview on 8/17/2022 at 4:44 PM, MDS Coordinator #1 stated she coded Resident #9 as receiving Antipsychotic medications because she was receiving some type of psychotropic medication. Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses of Hypertension, Renal Insufficiency, and End-Stage Renal Disease. Review of a Treatment/Order Update/Change in Condition sheet dated 12/15/2021, revealed .Verbal Order Begin Date 12/15/2021 .3 Times Weekly .Dialysis on M [Monday]-W [Wednesday]-F [Friday] . Review of the Treatment Sheet dated 6/2022, revealed Resident #21 received dialysis on 6/13/2022, 6/15/2022, and 6/17/2022. Review of the quarterly MDS assessment dated [DATE], revealed Resident #21 was assessed as having a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact, with diagnoses of End-Stage Renal Disease and Dependence on Renal Dialysis, and Resident #21 was not coded as receiving dialysis services. During an interview on 8/17/2022 at 7:43 PM, MDS Coordinator #1 confirmed Resident #21 received dialysis and should have been assessed for dialysis services on the 6/19/2022 quarterly MDS assessment. Review of the medical record, revealed Resident #33 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Chronic Kidney Disease, Myocardial Infarction, Atrial Fibrillation, Diabetes, and Failure to Thrive. Review of the Physician Order Sheet dated 6/2022, revealed Resident #33 did not have an order to receive Antipsychotic medication. Review of the MAR dated 6/2022, revealed Resident #33 did not receive Antipsychotic medication. Review of the quarterly MDS dated [DATE], revealed Resident #33 was assessed as having received Antipsychotic medications on a routine basis. Review of the medical record, revealed Resident #64 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Cerebral Infarction, Malnutrition, and Dysphagia. Review of the Physician Order Sheet dated 7/2022, revealed Resident #64 did not have an order to receive Antipsychotic medication. Review of the MAR dated 7/2022, revealed Resident #64 did not receive Antipsychotic medications. Review of the annual MDS dated [DATE], revealed Resident #64 was assessed as having received Antipsychotic medications on a routine basis. Review of the Physician Order Sheet dated 8/2022, revealed Resident #64 did not have an order to receive Antipsychotic medication. Review of the MAR dated 8/2022, revealed Resident #64 did not receive Antipsychotic medication. Review of the quarterly MDS dated [DATE], revealed Resident #64 was assessed as having received Antipsychotic medications on a routine basis. During an interview on 8/17/2022 at 5:21 PM, MDS Coordinator #1 and MDS Coordinator #2 confirmed the MDS assessments were coded incorrectly for receiving Antipsychotic medications.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when expired, opened, and undated food items were found in the dry food storage area. The facility had a census of 70, with 68 of those residents receiving a meal tray from the Kitchen. The findings include: Review of the facility's policy titled, Dietary: Food Storage, dated 8/5/2021, revealed .Product will be used or discarded within the appropriate time frame .spices should be dated with the delivery date and discarded after one year . Observation in the Kitchen on 8/15/22 beginning at 8:52 AM, revealed the following: a. a 16 ounce (oz) plastic container of ground mustard seasoning opened and dated 11/8/2019 b. a 18 oz plastic container of paprika seasoning opened and dated 4/14/2017 c. a 16 oz plastic container of salt free seasoning opened, undated, and no visible use by date During an interview on 8/17/22 at 9:49 AM, the Dietary Manager confirmed that all food and spices should have an open date and spices should be discarded after 1 year.