**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (Resident #1) of 8 residents reviewed for unnecessary drugs.The facility failed to discontinue 4 medications (mirtazapine, escitalopram, tizanidine, and tramadol) as documented in the physician orders in Resident #1's hospital discharge records dated 08/01/25.This failure could place residents at risk of harm due to medication side effects and/or medication interactions.Findings Included:Record review of Resident #1's admission record dated 09/09/25 revealed a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. She had diagnoses that included, but were not limited to, metabolic encephalopathy (problems in the brain from chemicals in the blood), acute pancreatitis (sudden inflammation of the pancreas resulting in severe abdominal pain), acute kidney failure (sudden episode of kidney failure that happens in hours or days), and unspecified depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).Record review of Resident #1's admission MDS completed on 08/14/25 revealed a BIMS score of 00 which indicated severely impaired cognition. Section N Medications of the MDS revealed Resident #1 was receiving antidepressant and opioid medication.Record review of Resident #1's care plan initiated on 08/02/25 revealed she had impaired cognitive function due to her diagnosis of metabolic encephalopathy and was at risk for depression. She was noted to be receiving escitalopram and mirtazapine to address this risk. One of the interventions was to Administer medications as ordered. Resident #1 was noted to have chronic pain. Tramadol and tizanidine were listed as the medications to address her pain.Record review of Resident #1's discontinued, struck out, and completed orders revealed mirtazapine, escitalopram, tizanidine, and tramadol were all discontinued on 08/25/25.Record review of Resident #1's active order summary revealed the following orders with corresponding start dates:08/25/25 Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for Severe Pain .08/25/25 Sertraline HCI Oral Tablet 25 MG (Sertraline HCI) Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED .Record review of Resident #1's MAR for August 2025 revealed she had the following orders: . tiZANidine HCl Oral Tablet 2 MG (Tizanidine HCl) Give 2 mg by mouth every 8 hours as needed for pain related to OTHER CHRONIC PAIN (G89.29) -Order Date- 08/01/2025 1410 -D/C Date- 08/25/2025 0508 .Mirtazapine Tablet 45 MG Give 1 tablet by mouth at bedtime related to DEPRESSION, UNSPECIFIED (F32.A) -Order Date- 08/01/2025 1410 (02:10 PM) -D/C Date- 08/25/2025 0506 .Escitalopram Oxalate Tablet 10 MG Give 1 tablet by mouth one time a day for Depression related to DEPRESSION, UNSPECIFIED (F32.A) -Order Date- 08/01/2025 1410 -D/C Date-08/25/2025 0510 .traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 50 mg by mouth every 8 hours as needed for pain related to OTHER CHRONIC PAIN (G89.29) -Order Date- 08/01/2025 1410 -D/C Date- 08/25/2025 0509 .The MAR for August 2025 further revealed Resident #1 did not receive tizanidine during the month of August 2025. She received mirtazapine 45 mg tablet every day from 08/01/25 to 08/24/25. Resident #1 received escitalopram 10 mg tablet every day from 08/03/25 to 08/24/25. She received tramadol 50 mg tablet 16 total times from 08/01/25 to 08/24/25. Resident #1 received tramadol on the following dates: 08/01/25, 08/02/25, 08/05/25, 08/07/25, 08/11/25 (Resident #1 received tramadol twice on this date), 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/18/25, 08/19/25, 08/21/25, 08/22/25, 08/23/25, and 08/24/25.Record review of Resident #1's hospital records in her EHR revealed an AFTER VISIT SUMMARY dated 08/01/25 with the following instructions: . Your medications have changed START taking: . sertraline ([brand name of sertraline]) Start taking on: August 2, 2025. STOP taking: escitalopram 10 mg tablet ([brand name of escitalopram]) mirtazapine 45 mg tablet ([brand name of mirtazapine]) tiZANidine 2 mg tablet ([brand name of tizanidine]) tramadol 50 mg tablet ([brand name of tramadol]) .Record review of a progress note with date of service of 08/21/25 and signed by NP A on 08/24/25 revealed under the Admit History section Resident #1 was on mirtazapine and escitalopram, but they were discontinued and replaced with sertraline per psych. The note further indicated due to her (Resident #1's) AMS tizanidine and tramadol were discontinued.Record review of a progress note with date of service of 08/25/25 and signed by NP A on 08/26/25 revealed under the Admit History section Resident #1 was on mirtazapine and escitalopram, but they were discontinued and replaced with sertraline per psych. The note further indicated due to her (Resident #1's) AMS tizanidine and tramadol were discontinued. NP A noted she spoke with Resident #1's family member and explained to [Resident #1's family member] the Tramadol, Tizanidine, Mirtazapine, and escitalopram. NP A explained to Resident #1's family member sertraline was started and was for Resident #1's mood.During an interview on 09/09/25 at 09:58 AM DON stated charge nurses, and MDS nurses were responsible to enter orders into the EHR when a new resident was admitted to the facility. She stated the two ADONs used to help with admissions, but both of them quit last week. DON stated the MDS nurses checked back over the admissions to ensure accuracy.During an observation and interview on 09/09/25 at 11:18 AM Resident #1 stated she had no concerns with the medications she had been receiving since her admission to the facility.During an interview on 09/09/25 at 01:56 AM MDS RN stated MDS LVN entered diagnoses codes for new admissions, and she (MDS RN) entered orders, medications, diets, code status, allergies, and completed the baseline care plan. She looked at Resident #1's admission and stated ADON was the one who entered orders for Resident #1. MDS RN stated a resident could be negatively affected if given medications that were supposed to be discontinued. She stated it would depend on the type of medication. MDS RN stated it can have serious negative outcomes. She gave an example of a resident continuing to receive a blood thinner when it was supposed to be discontinued. She stated in that case the resident would be at risk of bleeding out. When asked about antidepressant and pain medications she stated psychotropic medications sometimes had the opposite effect than expected. MDS RN stated Resident #1's diagnosis of kidney disease could lead to AMS.During an interview on 09/09/25 at 01:58 PM MDS LVN stated Resident #1's diagnosis of metabolic encephalopathy could lead to AMS.During an interview on 09/09/25 at 03:01 PM NP B stated she started working for the facility last week. She stated she did not know about Resident #1 receiving medications that were supposed to be discontinued. Regarding a possible negative outcome to Resident #1, NP B stated, I feel like it is hard for me to say because I don't know what her baseline was before.During an interview on 09/09/25 at 03:07 PM NP A stated she was on vacation at the beginning of August 2025 and her first day back in the facility was 08/11/25. She stated she saw Resident #1 on 08/11/25 and that evening she noticed the medications were not discontinued. NP A stated, I reviewed all the records and found she (Resident #1) was supposed to be off those 4 meds tramadol, tizanidine, mirtazapine and escitalopram. NP A stated she called to let staff know the medications should be discontinued. She stated she made the call on 08/24/25. She stated she did not know which staff member she talked to. She explained the delay from the time she found the medications had not been discontinued to the time she notified facility staff by saying she was behind in her charting and was playing catch up from her vacation. NP A stated she did not think Resident #1 would have been negatively impacted by taking the discontinued medications for 24 days because it was just a transcription error. NP A said, I dug and dug to try to find out why they (hospital) discontinued them (the four medications in question). NP A stated she could not find the reason the medications were discontinued.During an interview on 09/09/25 at 03:30 PM LVN C stated a resident could be negatively impacted by taking medications that were supposed to be discontinued. She stated, I mean surely a doctor said discontinue this for a reason.During an interview on 09/09/25 at 03:46 PM Resident #1's family member stated when NP A called to speak to her about Resident #1's care she (NP A) mentioned four medications were not discontinued as they were supposed to have been. She stated, It was a short conversation, she (NP A) didn't go into it. Resident #1's family member stated Resident #1 was taking mirtazapine and escitalopram prior to entering the hospital on [DATE].During an interview on 09/09/25 at 04:08 PM DON stated a resident could be negatively impacted by receiving medications that were supposed to be discontinued. She stated the negative impact would depend on the medication. DON stated she asked for a different NP than NP A due to concerns about NP A not getting her charting into the EHR timely. When asked why she though ADON did not catch the fact the four medications were to be discontinued, she stated she demoted ADON to a floor nurse when it became evident she did not have the necessary skills to be an ADON. DON did not answer what a specific negative outcome could be for taking discontinued antidepressant and/or pain medications. DON was asked for an unnecessary medication policy during this interview.During an interview on 09/09/25 at 04:16 PM RN D stated a resident could be negatively impacted if they received a medication that was supposed to be discontinued. She stated, If they no longer need it and it was discontinued at the hospital it can put the patient at risk.During an interview on 09/10/25 at 01:20 PM ADON stated she did not remember entering orders for Resident #1. She stated she did not remember Resident #1. ADON stated she only worked for the facility for a short time, and she entered admission orders for one, maybe two residents the whole time I was there. She stated she had an admission checklist and when she was finished the other ADON, DON, or MDS RN would look over her work and sign off on it to indicate it was correct.Record review of facility policy titled Care and Treatment Psychotropic Drug Use revealed the following: . 2. On admission, the admitting nurses will review the transfer orders for any psychotropic medications. Any information obtained will be documented in the resident's clinical record.Record review of facility policy titled Pharmacy Services Physician Orders revealed the following: . it is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs.Record review of the facility policy titled Continuum of Care Admission, General revealed no mention of transcribing orders from the hospital into the facilities EHR.An unnecessary medication policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, the facility failed to report an alleged violation of abuse/neglect immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation resulted in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for one (Resident #1) of 9 residents reviewed for abuse/neglect. The facility failed to report that Resident #1 alleged that she had been raped on 1-22-2025. The noncompliance was found to be Past Non-Compliance (PNC). The noncompliance began on 1-22-2024 and ended on 2-2-2024. The facility corrected the noncompliance before the investigation began. This failure could result in delayed identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent serious bodily harm, or lasting physical impairment. Findings include: Record review of Resident #1's face sheet dated 2-4-2025 revealed a [AGE] year-old female resident admitted to the facility originally on 10-21-2022 and readmitted on [DATE] with diagnoses to include drug induced subacute dyskinesia (a movement disorder that can develop over days or weeks after exposure to certain medications), muscle weakness (a lack of muscle strength), difficulty walking, diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), paranoid schizophrenia (a disease that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), mild intellectual disabilities (a condition that affects a person's intellectual functioning and adaptive skills), and alcohol dependence. Record review of Resident #1's last MDS was a quarterly completed 11-26-2024 with a BIMS of 11 indicating she was moderately cognitively impaired, and she had a functionality of requiring set-up/clean up to supervision/touching assistance with most activities. Record review of Resident #1's care plan with admission date of 1-9-2025 revealed the following: Focus: Resident is at risk for delusions or an acute confusional episode r/t paranoid schizophrenia. - Date Initiated: 02-09-2024. Focus: Resident is at risk for impaired cognitive function/dementia or impaired thought processes r/t DX: Cancer, PARANOID SCHIZOPHRENIA. - Date Initiated: 10-21-2022. Focus: Resident has potential for a psychosocial well-being problem r/t hallucination, delusions, paranoia all that occur intermittently due to DX: Paranoid Schizophrenia. - Date Initiated: 01-22-2025. Record review of Resident #1's Progress Notes revealed the following note completed by LVN A on 1-22-2025: Note Text: Late Entry. Resident stated to this nurse during medication pass, A man comes in my room and rapes me while I'm sleeping. He makes my roommate get out and he rapes me. This nurse told resident that I have been here all night and the aids have been here as well and there has not been a man in her room. This nurse asked resident if she was having hallucinations or delusions and if she could have dreamt this happening. Resident denied hallucinations, delusions or dreaming that she had been raped. Resident stated, It happens while I'm asleep. This nurse told resident that the only resident in the room was the roommate, and she had been in there the whole night. Also let resident know that this nurse has been at the nurses' station all night and that no one has been in her room other than the roommate and aide to help. Resident stated, That makes me feel better. Maybe I did dream it. Left resident in room with equal rise and fall in chest and call light in reach. No further needs. Plan of care continues. Record review of the Provider Investigation Report dated 1-31-2025 revealed the following: Incident Date: 1-22-2025 Date Reported to HHSC: 1-26-2025. Description of Allegation: Resident stated to the nurse a man came into her room and raped her while she was asleep. During an interview on 2-4-2025 at 08:18 AM the ADM reported that the nurse who took the original report from Resident #1 when Resident #1 made her alleged rape on 1-22-2025 did not report this to management until 4 days later and then back dated her note. The ADM reported that LVN A had already been written up for the incident and reeducated. During an interview on 2-4-2025 at 10:23 AM PO B reported that he was early into the investigation with Resident #1 and was reluctant to give any opinion. PO B reported that he did not feel the allegation did occur, but he still needed to get records and interview staff before he would make an official finding. PO B was also waiting on records from another facility were apparently Resident #1 made similar allegations. PO B gave a case #25501238 for this incident. During an interview on 2-4-2025 at 10:32 AM LVN A reported that Resident #1 had reported to her on 1-22-2025 that a man was coming into her room every night while she was sleeping and raping her. LVN A reported that she waited 4 days to report the incident due to Resident #1's history of false allegation, that Resident #1 reported that night that the man involved made her roommate leave the room, and that he was the man from the couple that was always arguing across the hall. LVN A reported that only ladies lived across the hall, there were no males capable of assaulting Resident #1, that she (LVN A) was always up on the unit, and that at least one CNA was always working at the kiosk across from Resident #1's room. LVN A reported that they would have noticed a strange male on the unit, anyone entering or leaving the Resident #1's room to include Resident #1's roommate, so she (LVN A) did not feel the allegation was legitimate. LVN A stated, I didn't think it happened at all with all the false allegations Resident #1 makes. Resident #1's is always accusing someone of stealing or something of that nature. LVN A verified that she had been trained several times on ANE when the facility provides handouts and that she just finished her yearly computer training on 1-29-2025. During an interview on 2-4-2025 at 1:07 PM OM C reported that if an allegation of abuse or neglect was not reported immediately a resident could suffer and something could happen to that resident that we do not want them to have happen. During an interview on 2-4-2025 at 1:47 PM Per the ADM reported that he was aware that the facility was out of compliance with the reporting requirements and that he was aware that they would be cited for the noncompliance. He reported that was why he implemented their policy of a written reprimand for the employee involved and reeducation to include reeducation for all staff so that the noncompliance would not occur again, and resident safety would be maintained. Record review of the facility provided policy titled Nursing Administration revised 10-2013, revealed the following: Subject: Abuse Prevention Policy: It is the policy of this facility that each resident has the right to be free from abuse . D, Identification of Abuse All alleged violations, including injuries of unknow source and misappropriation of resident property are reported immediately to the administrator of the facility and to the officials in accordance with State law through established procedures. Record review of facility provided documents revealed a written warning given to LVN A Date of Notice - 1-27-2025 for failure to report abuse in a timely manner. Record review noted LVN A completed her required assigned retraining for Abuse: Preventing, Recognizing, and Reporting on 2-2-2025. Record review noted all staff completed a facility provided training for Abuse/Neglect and when to report Abuse/Neglect started 1-26-2025 with last date of staff signature 1-28-2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 21 residents (Resident #94) reviewed for resident's rights. -CNA A was standing next to Resident #94's Geri-chair while feeding resident his lunch time meal. This failure could cause residents to feel humiliated and disrespected. Findings include: Record Review of Resident #94's clinical records revealed a [AGE] year-old male resident who was admitted to the facility on [DATE]. Resident #94 had the following diagnosis of personal history of transient ischemic attack (TIA), and cerebral infarction (stroke) without residual deficits, Hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles) and Hemiparesis (a nervous system disorder that causes a person to have a relatively mild loss of strength on one side of their body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose) without complications, unspecified convulsions (seizures), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), chronic, anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), unspecified, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), unspecified, hemiplegia unspecified affecting right dominant side, generalized anxiety disorder, essential (primary) hypertension (a condition in which the force of the blood against the artery walls is too high), hypomagnesemia (low magnesium, acute kidney failure (sudden onset disease of the kidneys leading to kidney failure),, unspecified, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), unspecified, other specified disorders of brain. Record review of Resident #94's MDS, dated [DATE] revealed a BIMS score that was blank and had functionality of complete dependency upon staff with every ADL. Record review of Resident #94's care plan dated 05/03/2024, revealed the following: Focus: [Resident #94] has ADL Self Care Performance Deficit r/t DX: CVA & encephalomalacia (the softening or loss of brain tissue after cerebral infarction, cerebral ischemia infection, craniocerebral trauma or other injury) of bilateral cerebrum (the principal and most anterior part or the brain) & cerebellum (the part of the brain at the back of the skull). Date Initiated: 05/03/2024 . .Interventions: o EATING: requires 1 person assistance to eat. Date Initiated: 05/03/2024 Observation on 06/07/24 at 1:10 PM revealed CNA A standing next to Resident #94's Geri-chair feeding Resident #94 in the dining room of facility. Once CNA A spotted surveyor she promptly got a chair and sat down next to Resident #94 and continued to feed him his lunch. During an interview on 06/07/24 at 1:16 PM, CNA A stated that she did not sit down next to resident due to so many residents being in the dining room. CNA A stated that once the smokers went out to smoke she would be able to find a chair more easily. CNA A stated that a negative outcome for not sitting next to the resident to feed him was there just weren't any chairs available. Record review of facility provided admission pack revealed the following policy Federal Resident Rights undated, revealed the following: As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 25 residents (Resident #21) reviewed for self-determination. The facility failed to ensure Resident #21 was allowed to choose the type of foods he preferred when he expressed he would like all the foods the other residents were served. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and a decrease in their quality of life. Findings include: Record review of Resident #21's face sheet revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses to include dementia (defective memory), dysphagia (difficulty swallowing), diabetes (a disease that results in too much sugar in the blood) and pain. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #21 was usually understood. The MDS revealed Resident # 21 had a BIMS of 3 out of 15 which indicated the resident's cognition was severely impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 05/9/24 for Resident # 21 revealed the following: Category: Nutritional Status Resident has a potential for nutritional problem. Record review of Resident # 21's order summary report dated 6/7/24 revealed the following orders: Diet ordered 10/16/23: LCS, Pureed texture, nectar thick liquids consistency. Record review of Resident #21's diet card dated Wednesday 6/5/24 for the lunch meal revealed Resident # 21 should have received cream pie and sweet potato casserole with his meal. An observation was made on 6/5/24 at 12:03 pm of Resident #21's lunch tray revealed he got pudding instead of a cream pie. There was no sweet potato casserole on his plate. Record Review of the tray ticket for 6/6/24 for the lunch meal revealed Resident # 21 should have received a dessert empanada with his meal. An observation was made on 6/6/24 at 12:00pm of Resident #21's lunch tray revealed he got pudding instead of a dessert empanada on the plate. Record Review of the tray ticket for 6/7/24 for the lunch meal revealed Resident # 21 should have received mixed berry cake with his meal. An observation was made on 6/7/24 at 12:00 pm of Resident #21's lunch tray revealed he got Jell-O, instead of a mixed berry cake. Record view of Resident # 21's weight log, March-May 2024, indicated there was no significant weight loss at the time of survey. During a confidential interview on 6/6/24 at 12:20 pm an employee stated Resident's #21 got pudding for the lunch meal on 6/5/24 instead of pie and pudding again for the supper dessert on 6/5/24 which listed a chocolate chip cookie. She stated most residents in the unit got a chocolate chip cookie on 6/5/24. The employee stated the residents with a pureed meal always got pudding instead of the listed dessert. The employee stated some of the other residents in the unit with a regular meal often get pudding instead of the scheduled dessert. The employee stated Resident # 21 was able to express his wants and he always asks for a dessert instead of pudding. The employee stated Resident #21 always looked sad when he did not get the same foods as other residents. The employee stated Residents # 21 will eat everything he was given and enjoyed eating different foods. During an interview on 6//7/24 at 11:00 am the RD stated she was not aware the menu for residents with purees were not being followed. She stated she expects residents to get what is listed on the menu in the correct form. She stated she trains the staff in policies and how to complete tasks in the kitchen. The Rd stated the consequences of not getting all menu items at meals could be a difference in the caloric intake and lost nutrients. During an interview on 6/7/24 at 12: 55 pm, Resident #21 stated loved the desserts and got tired of puddings all the time. He stated he was sad when he did not get the same foods as he saw on everyone else's plate. During an interview on 6/7/24 at 1:45 pm, the DM stated she was not aware residents on a pureed diet were not receiving pureed items as the menu listed. She stated the banana cream pie, the empananda and the chocolate chip cookie should have been pureed. The DM stated she was not aware residents with pureed diets were receiving pudding at multiple meals. She stated she could not say why residents received so much pudding for meals. She stated she had been short in the kitchen, and she only had one cook. She stated the sweet potatoes for the meal on Wednesday lunch was not pureed. The DM stated she did not have any polices for the kitchen. She stated she trains staff by telling employees how to do a task. She stated the consequences of not providing all the menu items for meals would be not getting enough nutrition. Record review of the facility's undated policy titled, Quality of Care with the subject Therapeutic Diets revealed: It is the policy of this facility that therapeutic diets shall be prescribed by the attending physician. A tray identification system is established to ensure each resident receives his diet as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #5) of 21 residents reviewed for respiratory care. The facility failed to change Resident #5's nebulizer tubing and mask as per his physician orders. This failure could affect residents on respiratory therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings include: Record review of Resident #5's face sheet revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include unspecified intracranial injury (brain dysfunction usually caused by an outside force, usually a violent blow to the head), chronic obstructive pulmonary disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), chronic pain (persistent pain that can last years), osteoarthritis (break down of joints causing pain related to age/wear and tear) or (degeneration of joint cartilage) malnutrition (lack of proper nutrition), coronary artery disease (damage or disease in the hearts major blood vessels), anxiety (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. Record review of Resident #5's clinical record revealed his last MDS was a quarterly completed 3-20-2024 listing him with a BIMS score of 12 indicating he was moderately cognitively impaired, and he had a functionality of requiring partial to moderate assistance with most of his activities of daily living. Record review of Resident #5's Order Summary Report with Active Orders as of: 6-5-2024 revealed the following order: - CHANGE NEBULIZER TUBING/MASK/MOUTHPIECE every night shift every Sun - Verbal Active 12/18/2023 - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally four times a day . Verbal Active 07/18/2023 Record review of Resident #5's clinical record revealed a care plan with the admission date of 7-18-2023, with the following: Focus-Resident has COPD (Chronic Obstructive Pulmonary Disease): med Ipratropium-Albuterol Inhalation Solution . Intervention-Give aerosol or bronchodilators as orders. (There was no intervention documented to address the nebulizer equipment care.) Focus-Resident has oxygen therapy r/t Dx of COPD: (date initiated 7-19-2023) Intervention-Change O2 tubing and humidifier bottle q week per physician orders. (Date initiated 7-19-2023) (There were no intervention documented to address the nebulizer equipment care.) During an interview on 06-05-2024 at 08:09 AM the Administrator reported that the previous DON resigned without notice and the new DON started last week and was currently at training and would be unavailable during the survey. During an observation and interview on 06-05-2024 at 09:27 AM Resident #5 was in his room sitting at the side of his bed eating his breakfast wearing his O2. Noted on Resident #5's bedside dresser was a nebulize with his mask that was noted to have particles in the mask and the mask was noted to have been used frequently. Noted at the base of the mask was tubing that was dated 4-21-2024 with no date noted on the mask. Resident #5 reported that he receives his nebulizer treatments 3 times a day. During an observation on 06-06-2024 at 08:42 AM of Resident #5's nebulizer equipment revealed the mask continued to have particulates in it from continued use (the mask looked dirty). Noted was a second date of 6-2-2024 written over the original date of 4-21-2-24. During an interview on 06-06-2024 at 09:21 AM LVN A (the nurse responsible for Resident #5 this shift) reviewed a photo of Resident #5's nebulizer tubing (taken 6-5-2024) and verified that it was dated 4-21-2024 and that Resident #5's nebulizer mask looked a little dirty. LVN A reported that the nebulizer equipment is usually changed once a month. LVN A was asked to verify Resident #5's orders and LVN A noted that the nebulizer equipment to include tubing was to be changed weekly on Sunday per physician orders. LVN A reported that he would get the mask and tubing changed immediately. LVN A was asked to verify physically that the mask was marked 4-21-2024 and that the mask was dirty. LVN A noted that the nebulizer tubing was marked 6-2-2024 and stated, its marked 6-2-2024 but it looks liked its marked over the 4-21-2024 and that is just lazy. LVN A reported that if the equipment is not changed as it should then the resident could get an infection. During an interview on 06-06-2024 at 09:25 AM the CRN verified that Resident #5's nebulizer tubing was dated 4-21-2024 and that the mask did look dirty. The CRN was asked to physically observe the mask and tubing and upon inspection the CRN again verified that the mask did look dirty and that the tubing was marked 4-21-2024 and someone wrote over the date with 6-2-2024. The CRN reported that if the nebulizer equipment is not changed and maintained then a resident can get an infection. Record review of the facility provided policy titled Oxygen Equipment undated revealed the following: Policy: It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner for resident receiving oxygen. Procedures: A. Pre-filled humidifier, when used, are to be dated and replaced every seven to ten days . 1. Tubing should be replaced every week. 2. Masks should be replaced ever week. C. Nebulizer Equipment Procedures 2. Store, clean, and dry until next use.

Based on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 2 of 3 medication carts (2C-1 and 100 Skilled medication carts) observed. -1 loose pill (Meloxicam)discovered in 2C-1 medication cart. -2 loose pills (Flexeril and unidentified pill) and a packet of 50 (Methadone) pills not double locked. These failures could result in residents' medications not being properly stored and maintained at their best therapeutic level. Findings include: Observation on 06/05/24 at 08:41 AM of Medication cart 2C-1, 1 loose pill was discovered, and MA D was able to identify medication as Meloxicam (an anti-inflammatory medication to help with arthritic pain). Interview on 06/05/24 at 08:49 MA D stated that a negative outcome for having loose pills in the medication cart. MA D stated that it could lead to a missed medication dose for the resident. Observation on 06/04/24 at 11:59 AM of medication cart for 100 skilled Hall revealed 2 pills and a small packet of 50 pills identified as methadone for Resident # 252. 1 lose pill was identified as Flexeril and the 2nd pill was unidentifiable by LVN B. During an interview on 06/05/24 at 12:03 PM LVN B revealed that the negative outcome for having lose pills in medication drawers could lead to the resident not getting the medication, because the medication didn't get into the cup. LVN B stated that the negative outcome for not double locking-controlled substances could lead to drug diversion, that is my fault so sorry. During an interview on 06/05/24 at 04:09 PM LVN B revealed that the previous ADON would package excess medications in small packages in counts of 50 to make narcotic counts easier on staff. During an interview on 06/06/24 at 08:26 AM ADON stated that the previous ADON would take medications from residents' stock and place in a pill crusher pouch and then either staple or tape shut to send medication home with residents. Record review on 06/06/24 at 09:02 AM revealed statements were received from ADON and LVN E along with in-service to reeducate the staff and facility policy regarding medication storage. Record review of facility policy titled, Medication Access and Storage, undated, revealed the following: Policy: It is the policy of this facility to sore all drugs and biological in locked compartments. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications: Procedures: 1. The provider pharmacy dispenses medications in containers that meet legal requirements. Medications are kept and stored in these containers. .4. Schedule II, III, IV, V controlled medications are stored in a separate area under double locked from other medications in a locked drawer or compartment designated for that purpose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the menu was followed, for 2 out of 5 residents that received pureed food (Resident # 19 and 21), and one resident (#16) who had a mechanical soft diet in the Alzheimer's unit in that: 1. The facility failed to ensure Resident # 19 received a pureed pancake for breakfast on 6/5/24. 2. The facility failed to ensure Resident #16 received toast with her breakfast on 6/5/24. 3. Residents #16, 19 and # 21 received pudding for the lunch dessert instead of cream pie and pudding for the supper meal instead of the chocolate chip cookie the other residents received for 6/5/24. Residents #16,19 and 21 did not receive sweet potato casserole for lunch. 4. Residents #16, 19 and #21 received pudding for the lunch meal on 6/6/24 instead of the dessert empanada. 5. Residents #16, 19 and #21 received jello for the lunch meal on 6/6/24 instead of the mixed berry cake. These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. The findings include: Resident # 16 Record review of Resident # 16's face sheet revealed an [AGE] year-old-female admitted to the facility on [DATE] with diagnoses to include dementia (defective memory), dysphagia (difficulty swallowing), diabetes (a disease that results in too much sugar in the blood) and anxiety. Record review of comprehensive MDS assessment dated [DATE] revealed Resident # 16 was rarely understood. The MDS revealed Resident # 16 had a BIMS of 3 out of 15 which indicated the resident's cognition was severely impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 5/12/24 for Resident # 16 revealed the following: Category: Nutritional Status Resident has a potential for nutritional problem. Record review of Resident #16's order summary report dated 6/7/24 revealed the following orders: Diet ordered 01/26/24: LCS diet, Mechanical Soft Pureed bread and cakes, thin liquids consistency. Record review of Resident #16's diet card dated Wednesday 6/5/24 revealed under Special Notes: House Shake Sugar Free, Diabetic Snack, 2 bowls of cereal and toast for breakfast every day, Bread and cakes puree. An observation was made on 16/5/24 at 8:25 am of Resident #16's breakfast tray revealed there was no toast. Record review of Resident # 16's diet card dated Wednesday 6/5/24 revealed she should have received toast with her cereal. Record Review of the tray ticket for 6/5/24 for the lunch meal revealed Resident # 16 should have received cream pie and sweet potato casserole with her meal. An observation was made on 6/5/24 at 12:00 pm of Resident #16's lunch tray revealed she got pudding instead of a cream pie and there was no pureed bread or sweet potato casserole on the plate. Record Review of the tray ticket for 6/6/24 for the lunch meal revealed Resident # 16 should have received a dessert empanada with her meal. An observation was made on 6/6/24 at 12:00 pm of Resident #16's lunch tray revealed she got pudding instead of a dessert empanada on the plate. Record Review of the tray ticket for 6/7/24 for the lunch meal revealed Resident # 16 should have received mixed berry cake with her meal. An observation was made on 6/7/24 at 12:00 pm of Resident #16's lunch tray revealed she got jello instead of a mixed berry cake. Resident # 19 Record review of Resident #19's face sheet revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses to include Huntington's disease (a breakdown in the nerve cells in the brain), dysphagia (difficulty swallowing), and anxiety. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #19 was rarely or never understood. The MDS revealed Resident # 19 had a BIMS of 0 out of 15 which indicated the resident's cognition was severely impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 05/31/24 for Resident # 19 revealed the following: Category: Nutritional Status Resident has a potential for nutritional problem. Record review of Resident # 19's order summary report dated 6/7/24 revealed the following orders: Diet ordered 02/07/24: Regular diet, Pureed texture, thin liquids consistency. Record review of Resident #19's diet card dated Wednesday 6/5/24 revealed Resident #19 should have received a pancake, sausage and oatmeal for breakfast. An observation was made on 6/5/24 at 8:26 am of Resident #19's breakfast tray revealed there was no pancake. Record Review of the tray ticket for 6/5/24 for the lunch meal revealed Resident # 19 should have received cream pie and sweet potato casserole with her meal. An observation was made on 6/5/24 at 12:03 pm of Resident #19's lunch tray revealed she got pudding instead of a cream pie and there was no sweet potato casserole on the plate. Record Review of the tray ticket for 6/6/24 for the lunch meal revealed Resident # 19 should have received a dessert empanada with her meal. An observation was made on 6/6/24 at 12:00pm of Resident #19's lunch tray revealed she got pudding instead of a dessert empanada on the plate. Record Review of the tray ticket for 6/7/24 for the lunch meal revealed Resident # 19 should have received mixed berry cake with her meal. An observation was made on 6/7/24 at 12:00pm of Resident #19's lunch tray revealed she got Jell-O, instead of a mixed berry cake. Resident #21 Record review of Resident #21's face sheet revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses to include dementia (defective memory), dysphagia (difficulty swallowing), diabetes (a disease that results in too much sugar in the blood) and pain. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #21 was usually understood. The MDS revealed Resident # 21 had a BIMS of 3 out of 15 which indicated the resident's cognition was severely impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 05/9/24 for Resident # 21 revealed the following: Category: Nutritional Status Resident has a potential for nutritional problem. Record review of Resident # 21's order summary report dated 6/7/24 revealed the following orders: Diet ordered 10/16/23: LCS, Pureed texture, nectar thick liquids consistency. Record review of Resident #21's diet card dated Wednesday 6/5/24 for the lunch meal revealed Resident # 21 should have received cream pie and sweet potato casserole with his meal. An observation was made on 6/5/24 at 12:03 pm of Resident #21's lunch tray revealed he got pudding instead of a cream pie and no sweet potato casserole. Record Review of the tray ticket for 6/6/24 for the lunch meal revealed Resident # 21 should have received a dessert empanada with his meal. An observation was made on 6/6/24 at 12:00pm of Resident #21's lunch tray revealed he got pudding instead of a dessert empanada on the plate. Record Review of the tray ticket for 6/7/24 for the lunch meal revealed Resident # 21 should have received mixed berry cake with his meal. An observation was made on 6/7/24 at 12:00 pm of Resident #21's lunch tray revealed he got Jell-O, instead of a mixed berry cake. During a confidential interview on 6/6/24 at 12:20 pm an employee stated Resident's #16 #19 and #21 got pudding for the lunch meal on 6/5/24 instead of pie and pudding again for the supper dessert on 6/5/24 which listed a chocolate chip cookie. She stated most residents in the unit got a chocolate chip cookie on 6/5/24. The employee stated the residents with a pureed meal always got pudding instead of the listed dessert. The employee stated some of the other residents in the unit with a regular meal often get pudding instead of the scheduled dessert. The employee stated Resident # 21 was able to express his wants and he always asks for a dessert instead of pudding. The employee stated Resident #21 always looked sad when he did not get the same foods as other residents. The employee stated Residents #16 , 19 and 21 will eat everything they are given and enjoy eating different foods. During an interview on 6//7/24 at 11:00 am the RD stated she was not aware the menu for residents with purees were not being followed. She stated she expects residents to get what is listed on the menu in the correct form. She stated she trains the staff in policies and how to complete tasks in the kitchen. The Rd stated the consequences of not getting all menu items at meals could be a difference in the caloric intake and lost nutrients. During an interview on 6/7/24 at 12: 55 pm, Resident #21 stated loved the desserts and got tired of puddings all the time. He stated he was sad when he did not get the same foods as he saw on everyone else's plate. During an interview on 6/7/24 at 1:45 pm, the DM stated she was not aware residents on a pureed diet were not receiving pureed items as the menu listed. She stated the banana cream pie, the empanada and the chocolate chip cookie should have been pureed. The DM stated she was not aware residents with pureed diets were receiving pudding at multiple meals. She stated she could not say why residents received so much pudding for meals. She stated she had been short staffed in the kitchen, and she only had one cook. She stated the sweet potatoes for the meal on Wednesday lunch were not pureed. The DM stated she did not have any polices for the kitchen. She stated she trains staff by telling employees how to do a task. She stated the consequences of not providing all the menu items for meals would be not getting enough nutrition. Record review of the facility's undated policy titled, Quality of Care with the subject Therapeutic Diets revealed: It is the policy of this facility that therapeutic diets shall be prescribed by the attending physician. A tray identification system is established to ensure each resident receives his diet as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents had the right to reasonable access to the use of a telephone, and a place in the facility where calls can be made without being overheard for 9 of 99 (Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9) residents reviewed for Resident Rights. Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9 stated they did not have access to a telephone to make private calls. This failure could place residents at risk of increased social isolation and decreased psychosocial well-being. Findings Included: Resident #1 In an interview on 5/17/24 at 8:49AM Resident #1 stated he had been at the facility about a year and when he arrived, he had a personal cell phone to use to communicate with friends and family outside of the facility. The cell phone would not hold a charge and he was without cellular communication, beginning in August of 2023. Resident #1 had spoken to the SW regarding his cell phone and was told that documents indicating his financial need to purchase a new cell phone had been submitted to an outside entity who provides provided cell phones for those in need, but the request had been denied. Since August of 2023, Resident #1 has been without a communication device to make a private call. He stated if he wanted to make a personal call, he had to go to the Nurse's Station or to one of the offices of facility staff. He stated there are always nurses at the Nurse's Station, so no call made from there was completely private. He stated that he could use the phone in a staff member's office between the hours of 8AM and 5PM, but after those hours, there was no way for him to place a private call outside of the facility. Record review of Resident #1's admission Record on 5/17/24 at 8:54AM revealed a [AGE] year-old male with a BIMS of 12, indicating moderate cognitive impairment, who was admitted to the facility on [DATE] with a diagnosis of, but not limited to Unspecified Symbolic Dysfunctions (social impairment); Cognitive Communication Deficit (trouble participating in conversations); Limitation of Activities Due to Disability; Depression, Unspecified; Other Specified Anxiety Disorders and Unspecified Sequelae of Cerebral Infarction (psychological distress and neuropsychiatric disturbance after a Stroke). An interview on 5/17/24 at 9:19AM with the Ombudsman revealed residents had complained to her about the lack of a portable phone in the facility, which they could use for personal communication. She stated she had tried to call Resident #1 on 5/16/24 and had spoken with the receptionist, who transferred her to the phone at the Nurse's Station on Resident #1's hall. The phone at the Nurse's Station had rung for about 10 minutes and had not been answered. She instead drove to the facility to speak with Resident #1 face-to-face. Resident #2 In an interview on 5/17/24 at 9:57AM Resident #2 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He would like to have a cell phone of his own but cannot afford one. Record Review of Resident #2's admission Record on 5/17/24 at 10:00AM revealed a [AGE] year-old male with a BIMS of 15, indicating he was cognitively intact, who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Dysphagia (difficulty swallowing); Cognitive Communication Deficit (trouble participating in conversations); Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety (a mental disorder in which a person loses the ability of think, remember, learn, make decisions, and solve problems); Personal History of Transient Ischemic Attack, and Cerebral Infarction without Residual Deficits (a short period of symptoms similar to those of a stroke). Resident #7 In an interview on 5/17/24 at 10:02AM Resident #7 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call, which was difficult due to her declining eyesight. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record Review of Resident #7's admission Record on 5/17/24 at 10:07AM revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS of 11, indicating moderate impairment and a diagnosis of, but not limited to Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure (a combination of the ventricles of the heart not producing enough pressure to push blood circulation and no relaxing enough to fill with blood), Presence of a Cardiac Pacemaker, and Legal Blindness as Defined in the United States of America. Resident #3 In an interview on 5/17/24 at 10:27AM Resident #3 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He stated he would like to have a cell phone of his own but cannot afford one. Record Review of Resident #3's admission Record on 5/17/24 at 10:30AM revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS of 12, indicating moderate impairment and a diagnosis of, but not limited to Otitis Externa (inflammation, either infectious or non-infectious, of the external auditory canal); Limitation of Activities due to Disability; Other Specified Anxiety Disorders; Cognitive Communication Deficit (trouble participating in conversations); Unspecified Sequelae of Cerebral Infarction (psychological distress and neuropsychiatric disturbance after a Stroke) and Unspecified Symbolic Dysfunctions (social impairment). Resident #5 In an interview on 5/17/24 at 1:08PM Resident #5 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He would like to have a cell phone of his own but cannot afford one. Record review of Resident #5's admission Record 0n 5/17/24 at 1:12PM revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS of 15, indicating he was cognitively intact and a diagnosis of, but not limited to Other Voice and Resonance Disorders (hoarseness, strained, breathy or raspy voice quality); Hypovolemia (a state of low extracellular fluid volume, combined with sodium and water loss); Schizoaffective Disorder, Bipolar Type (episodes of mania and sometimes depression), and Cognitive Communication Deficit (trouble participating in conversations). Resident #6 In an interview on 5/17/24 at 1:13PM Resident #6 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record review of Resident #6's admission Record on 5/17/24 at 1:17PM revealed an [AGE] year-old female with a BIMS of 04, indicating severe impairment who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Major Depressive Disorder, Recurrent, Severe Without Psychotic Features (Persistently low or depressed mood); Cognitive Communication Deficit (trouble participating in conversations); Other Reduced Mobility (limitation of independent, personal movement); Other Abnormalities of Gait and Mobility (difficulty walking), and Anxiety Disorder, Unspecified (significant anxiety or phobias without the exact criteria for any other anxiety disorders). Resident #8 In an interview on 5/17/24 at 1:34PM Resident #8 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record review of Resident #8's admission Record on 5/17/24 at 1:39PM revealed an [AGE] year-old female with a BIMS of 15, indicating she was cognitively intact and a diagnosis of, but not limited to, Dysphagia (difficulty swallowing); Cognitive Communication Deficit (trouble participating in conversations); Anxiety Disorder, Unspecified (significant anxiety or phobias without the exact criteria for any other anxiety disorders); Other Reduced Mobility (may require the use of a cane, walker, or wheelchair to ambulate), and Major Depressive Disorder, recurrent, severe with Psychotic Symptoms (persistently low or depressed mood with delusions, hallucinations, or both). Resident #9 In an interview on 5/17/24 at 2:47PM Resident #9 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record review of Resident #9's admission Record on 5/17/24 at 2:51PM revealed a [AGE] year-old female with a BIMS of 12, indicating moderate impairment who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Drug-Induced, Subacute Dyskinesia (sudden, uncontrollable movements of the face and body, caused by long-term use of anti-psychosis drugs); Acquired Stenosis of the External Ear Canal (stenosis caused by infections, inflammation, trauma and radiation therapy); Major Depressive Disorder (persistently low or depressed mood); Anxiety Disorder (response of fear and dread in certain situations), Localized Swelling, Mass and Lump (signs, symptoms and abnormal laboratory findings) and Acquired Absence of Right Breast and Nipple (the absence of one or more breasts, the cause of which is not present at birth). Resident #4 In an interview on 5/17/24 at 3:31PM Resident #4 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He would like to have a cell phone of his own but cannot afford one. Record review of Resident #4's admission Record on 5/17/24 at 3:36PM revealed a [AGE] year-old male with a BIMS of 15 (indicating cognitively intact) who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Acquired Absence of Left Leg (the absence of the left leg, the cause of which is not present at birth); Acquired Absence of Left Upper Limb Above Elbow (the absence of the left arm, above the elbow, which was not present at birth); Cognitive Communication Deficit (trouble participating in conversations), and Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy Without Gangrene (narrowing of the arteries which results in the undersupply of blood and oxygen to different organs). An interview on 5/17/24 at 9:08AM with the Social Worker revealed residents could use her office phone between the hours of 8AM and 5PM, to call outside of the facility, if they do not have a cell phone of their own. She stated if her office was closed, residents had to use the phone at the Nurse's Station. She stated she knew that the Nurse's Station was usually always occupied, so a phone call would not be completely private. An interview with LVN D on 5/17/24 at 1:19PM revealed residents came to the nurse's station to use the phone, but it was not a private place to have a conversation. An observation of Maintenance Supervisor E on 5/17/24 at 1:24PM revealed he received a cell phone call from Administrator C, asking him to purchase cordless phones for the facility, for resident use. When asked if a cordless phone was being bought for resident use, he stated he will be installing 2 cordless phones in the facility, for resident use. Residents will be able to take the phone to their room or to the parlor for more privacy when making a personal phone call. An interview with Medication Aide F on 5/17/24 at 1:29PM revealed residents came to the nurse's station to use the phone, but it was not a private place to have a conversation. An interview with the Administrator on 5/17/24 at 10:07AM revealed residents could use the receptionist's phone or the phone in a staff member's office if they wanted to make a personal call outside of the facility. He stated that after 5PM, residents would have to use the phone at the Nurse's Station, since there was no portable phone, which could be taken to a resident's room. He stated he was not aware of any problems with residents without personal cell phones, wanting to make a personal call. Record Review of the undated facility policy, Federal Residents Rights stated: Privacy and Confidentiality: You have the right to personal privacy and confidentiality, including accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. Information and Communication: You have the right to: have reasonable access to the use of a telephone, including TTY (Tele-typewriters) and TDD (Tele-communication devices for the deaf) services, and a place in the facility where calls can be made without being overheard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 or 10 residents (Resident #1) reviewed for care plans . The facility failed to ensure that Resident #1's care plan was implemented correctly according to her needs. This failure could place residents at risk for not receiving the necessary care or receiving inappropriate care for their condition and diagnosis. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included urinary tract infection, bipolar disorder, unspecified psychosis not due to a substance or known, physiological condition, mild protein-calorie malnutrition, mixed hyperlipidemia, history of falling, other dysphagia, oropharyngeal phase other dysphagia, unspecified other difficulty in walking, not elsewhere classified, depression, other dementia in other diseases classified elsewhere, mild, without other behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other lack of coordination, other specified symptoms and signs involving the circulatory and other respiratory systems, cognitive communication deficit, vitamin deficiency, unspecified delusional disorders, other chronic pain, other conductive hearing loss, unspecified muscle weakness (generalized), other unsteadiness on feet, other abnormalities of gait and mobility, other reduced mobility, other need for assistance with personal care and Alzheimer's disease, unspecified Record review of Resident #1's Care Plan, dated 8/21/23, documented the resident was incontinent, was at risk for falls, required 2-person assistance for ADLs . The Care Plan reflected that Resident #1 requires to be in the locked unit. Record review of Resident #1's Quarterly MDS, dated [DATE], documented a BIMS score of 0 out of 15, indicating severe cognitive function. Record review of Resident #1's care plan reflected Resident #1 required the locked dementia unit, dated 11/14/2022. Record review of Resident #1's Progress Notes reflected no meetings or progress notes were documented for Resident #1 which stated the resident was being moved from the locked unit. During an interview on 9/6/2023 at 9:08 AM with Charge LVN , Charge LVN stated Resident #1 did not have a room on the locked unit. During an interview on 9/6/2023 at 9:19 AM with Charge LVN, Charge LVN stated the nurses assessed residents every day for changes in condition and if there was a change, they notified the physician as well as the DON so changes could be made to the care plan. Charge LVN stated they were told Resident #1 didn't meet the criteria to be in the locked unit anymore as she didn't wander, have behaviors or any issues . During an interview on 9/6/2023 at 9:46 AM with the Admin , the Admin stated Resident #1 was going to be moved back to the locked unit today since a new room opened up for them. The Admin stated Resident #1 did better in the group setting. During an interview on 9/6/2023 at 9:58AM with the DON, the DON stated staff on the LTC side got Resident #1 up in the morning and gave the resident their medications, then took them to the locked unit where Resident #1 spent the whole day until after dinner. The DON stated after dinner, staff brought Resident #1 back to the LTC side and they went to sleep in their room. The DON stated Resident #1 didn't meet the criteria to be in the locked unit anymore because they were not exit seeking . The DON stated Resident #1 did not try to elope. The DON stated changes like this needed to be evaluated and care planned. During an interview on 9/6/2023 at 1:50 PM with Family #1, Family #1 stated Resident #1 was moved out of the locked unit on 7/17/2023. Family #1 stated they had a meeting with the ADON, and their questions about why Resident #1 was moved were answered. Family #1 stated it wasn't a care plan meeting. During an interview on 9/6/2023 at 2:26 PM with FNP , the FNP stated they talked with the facility, and everyone agreed Resident #1 was a low elopement risk and not exit seeking so they thought they would do ok on the LTC unit. The FNP stated they talked about it, but an order was not written for the change. During an interview on 9/6/2023 at 2:34 PM with the SW , the SW stated Resident #1 was moved out of the locked unit without a meeting with the family. The SW asked if Resident #1 could be moved back to the locked unit as they were not doing as well in the LTC side. The SW stated the team said there were no rooms available for Resident #1 and they didn't meet the criteria to be on the locked unit. During an interview on 9/6/2023 at 2:50 PM with the DON , the DON stated the meeting with the family was not a care plan meeting and the ADON met with the family to answer any questions they had. The DON stated they couldn't tell why the care plan didn't reflect the change as the care plan still stated Resident #1 required a locked unit and that it was a system breakdown. The DON stated the DON and the MDS Coordinator were responsible for completing the care plans. During an interview on 9/6/2023 at 2:59 PM with the Admin, the Admin stated they looked at the care plan for Resident #1 earlier today and Resident #1's care plan shouldn't have said they required the locked facility and that it was a mistake. The Admin stated that the facility fixed the care plan a little bit ago. Record review of the facility policy for Comprehensive Person-Centered Care Planning, dated 2022, reflected the IDT shall develop a comprehensive person-center care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in a comprehensive assessment, and that the baseline care plan includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by failing to assure dignity and respect were provided for 2 of 2 residents (Resident #11 and Resident #67) reviewed for privacy and dignity issues. Resident #11 and Resident #67's abdomens were exposed in the multi-purpose room of the locked unit during their subcutaneous injection of insulin, that was administered by LVN D. This failure could cause residents to feel uncomfortable and disrespected. Findings include: Record Review of Resident #67's clinical records reveal an [AGE] year-old female resident admitted to facility 03/07/2021 with diagnosis, but not limited to include: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL 01/20/2021 Primary DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS 01/20/2021 Other MILD COGNITIVE IMPAIRMENT OF UNCERTAIN OR UNKNOWN ETIOLOGY LONG TERM (CURRENT) USE OF INSULIN Record review of Resident #67's physician order revealed the following: Novolog Pen (Insulin Aspart Flexpen) per sliding scale for hyperglycemia (elevated blood glucose), and MDS shows a BIMS score of 5. 04/12/23 11:08 AM-During observation, Resident #67 received insulin in the multi-purpose room of the locked unit in front of family member and multiple other residents. Insulin was given in the LLQ of abdomen. LVN D lifted shirt for this medication to be administered. 04/13/2023-During an interview, Resident #67 was unable to answer any questions regarding how it made her feel to have medication administered in the multi-purpose room of the locked unit. Record review of Resident #11's clinical records reveal a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses, but not limited to include: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL 01/20/2021 Primary DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY ALTERED MENTAL STATUS, UNSPECIFIED 04/12/2022 4 TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS 01/20/2021 Other MILD COGNITIVE IMPAIRMENT OF UNCERTAIN OR UNKNOWN ETIOLOGY 01/20/2021 Other LONG TERM (CURRENT) USE OF INSULIN Record review of Resident #11's physician order dated 1-13-2020 revealed the following: HumaLOG Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451+ notify provider, subcutaneously before meals for Diabetes /hyperglycemia MDS shows a BIMS score of 3 for resident #11. During observation: 04/12/23 11:19 AM -observed resident #11 receiving insulin in the LLQ in the multi-purpose room of the locked unit in front of multiple other residents in the room. Resident's shirt had to be lifted for this medication to be administered. This medication was administered by LVN D. 04/13/23 09:13 AM -Interviewed resident #11 and she was unable to answer questions regarding receiving insulin in front of other residents. Record review of facility provided admission pack revealed the following policy Federal Resident Rights undated, revealed the following: You have the right to personal privacy and confidentiality of your personal medical records. You have the right to: personal privacy, including accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 2 (Resident #34, and #67) of 23 residents reviewed for advanced directives. Resident #34 and Resident #67 had a DNRs in their records that were incomplete, missing information and signatures. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings include: Resident #34 Record review of the face sheet dated 4-13-2023 in the clinical record for Resident #34 revealed a [AGE] year-old female resident admitted to the facility originally on 3-1-2019 and readmitted on [DATE] with diagnoses to include type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), dementia (a group of thinking and social symptoms that interferes with daily functioning), aphasia (loss of the ability to understand or express speech caused by brain damage), dysphasia (difficulty swallowing food or liquids arising from the throat or esophagus), pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder), and dyskinesia (abnormality or impairment of voluntary movement). Under the section Advanced Directives Resident #34 was listed as a DNR. Record review of the clinical record for Resident #34 revealed the last MDS completed was a quarterly dated 4-4-2023 with a BIMS that could not be evaluated because she is rarely/never understood, and she had a functionality of requiring one to two-person assistance with all activities. Record review of the clinical record for Resident #34 revealed a care plan with admission date of 3-28-2023 with the following: Focus: Resident has elected DNR status-Date initiated 3-30-2023 Record review of the clinical record for Resident #34 revealed an Order Summary with active orders as of 1-1-2023 with the following order: DNR-Do Not Resuscitate-Order date 11-20-2019 Record review of the clinical record for Resident #34 revealed a DNR dated 7-28-2016 (by Resident #34's legal guardian) with the following: Section-Physician Statement-there was no physicians signature, no printed physician name, no date of signature, and no printed license number. There was no information in the Directive by Two Physicians section. Section-All person who have signed above must sign below, acknowledging that this document has been properly completed-there were no secondary signatures in this section. Resident #67 Record review of the face sheet dated 4-13-2023 in the clinical record for Resident #67 revealed a [AGE] year-old female resident admitted to the facility originally on 3-7-2021 and readmitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), malnutrition (lack of proper nutrition), and dysphasia (difficulty swallowing food or liquids arising from the throat or esophagus). Under the section Advanced Directives Resident #67 was listed as a DNR. Record review of the clinical record for Resident #67 revealed the last MDS completed was a quarterly dated 2-4-2023 with a BIMS of 5 indicating she was severely cognitively impaired and she and had a functionality of requiring one to two-person assistance with all activities. Section O-Special Treatment, Procedures, and Programs Resident #67 was listed as having hospice care while a resident. Record review of the clinical record for Resident #67 revealed a care plan with admission date of 8-14-2021 with the following: Focus: Resident has elected DNR status-Date initiated 12-5-2022 Focus: Resident wishes to remain in the facility long term care. Resident is a DNR. Resident is under the care of hospice. Record review of the clinical record for Resident #67 revealed an Order Summary with active orders as of 4-13-2023 with the following order: DNR-Do Not Attempt Resuscitation-Order date 12-2-2022 Record review of the clinical record for Resident #67 revealed a DNR dated 12-2-2022 (by both witnesses) with the following: Section-Declaration of the legal guardian, agent, or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication-there is no date of when the legal guardian signed the DNR form. Section-Physician's Statement-there is no date of when the physician signed the DNR form. During an interview on 04-13-2023 at 02:26 PM LVN D confirmed she was responsible for Resident #34 and #67 during the shift. LVN D reported that she had been employed for this facility for awhile and she was aware that both Resident #34 and #67 were currently a DNR status. LVN D reported that Resident #67 was on hospice and was a DNR, that if Resident #67 coded she would not start CPR, and she would notify Hospice. She reported that Resident #34 was a DNR and if Resident #34 coded she would not start CPR, she would notify the DON or ADON, notify family, and call the funeral home. LVN D pulled up both residents DNR forms on the computer system. She verified by their face sheet that Residents #34 and #67 were listed as a DNR. LVN D then reviewed each resident's DNR form. LVN D reported that Resident #67's physician and legal guardian did not date the DNR form. Resident #34's did not have any physician's information to include the signature, date, printed signature, and license number, and there were no secondary signatures for any persons who signed the DNR form. When questioned LVN D reported that both Resident #34 and #67's forms were not correct and therefore invalid and that if Resident #34 and/or #67 coded then she would start CPR. LVN D reported that if the DNR forms are not correct the resident's wishes will not be followed. During an interview on 04-13-2023 at 02:39 PM the DON and RN A (Resource Nurse) reviewed Resident #34 and #67's DNR forms and verified that Resident #67 was missing the date of when the physician and legal guardian signed the forms and Resident #34 was missing the physician information and all the secondary signatures. They verified that the DNR forms were invalid. The DON reported that the Social Worker was responsible for ensuring DNR accuracy and that the Social Worker was a new employee and had not had time to be trained on the DNR process. The DON reported that if the DNR's were not filled out correctly then staff will not fallow the DNR process correctly and the residents wishes would not be followed. Both the DON and RN A reported that they would immediately start an in-service with staff and ensure that the two DNR's were corrected. The DON and RN A reported that at all Case Conference meetings each resident was asked if they wished to continue to be a DNR, but the DNR form was not reviewed. The DON reported that they will start pulling the DNR form and review the form at the Case Conference to ensure that it is complete and accurate. Record review of facility provided policy titled Advanced Directive Documentation, revised 12-2019, revealed the following: Documentation: Policy: 4. Ensure compliance with OBRA and State Law respecting Advance Directives. Record review of OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following: -The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to conduct a comprehensive and accurate assessment of each resident using the resident assessment instrument (RAI) specified by CMS for 2 (Resident #58 and #79) of 23 residents whose records were reviewed for assessments. Resident #58 and Resident #79 did not have section C completed on their last MDS assessment. This failure to ensure comprehensive and accurate assessments could affect all residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding include: Resident #58 Record review of Resident #58's face sheet dated 4-13-2023 revealed a [AGE] year-old male resident admitted to the facility originally on 5-19-2020 and readmitted on [DATE] with diagnoses to include end stage renal disease (a medical condition in which persons kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), malnutrition (lack of proper nutrition), congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), and hypertension (a condition in which the foresee of the blood against the artery walls is too high). Record review of Resident #58's clinical record revealed he had an annual MDS completed 2-23-2023, a Medicare 5-day MDS completed 2-23-2023, and a Modification of MDS completed 2-23-2023. All three MDS's did not list Resident #58 with a BIMS score due to the entire section was completed with dash's indicating no information was available (for the 7-day look back period required by the RAI manual). All three MDS's listed Resident #58 with a functionality of requiring one person assistance with his activities (for the 7-day look back period required by the RAI manual). Resident #79 Record review of Resident #79's face sheet dated 4-13-2023 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include unspecified intellectual disabilities (a diagnoses assessed due to multiple factors, such as physical disability or co-occurring mental illness), dysphasia (difficulty swallowing food or liquids arising from the throat or esophagus), hypertension (a condition in which the foresee of the blood against the artery walls is too high), gastrostomy (an opening into the stomach from the abdominal wall), and cognitive communication deficit (difficulty with thinking and how someone uses language), Record review of Resident #79's clinical record revealed he had a quarterly MDS completed 3-10-2023. The MDS did not list Resident #79 with a BIMS score due to the entire section with completed with dash's indicating no information was available (for the 7-day look back period required by the RAI manual). Resident #79 was listed with a functionality of requiring set-up assistance with activities (for the 7-day look back period required by the RAI manual). During an interview on 04-13-2023 at 1:55 pm MDS Coordinator B stated that the last MDS for Resident #58 and #79 was completed during a time when the facility did not have a social worker and the MDS BIMS score for each one was just missed. MDS Coordinator B stated that the social worker is the person who is responsible for completion of the BIMS information on the MDS. During an interview on 4-13-2023 at 2:00 pm MDS Coordinator B and MDS Coordinator C both stated that the previous social worker had just quit, and the facility was in between getting a new social worker (the new social worker started on 3-8-2023) and that the BIMS score for Resident #58 and #79 was missed. MDS Coordinator B reported that there was no reason for the BIMS to not have been completed. During an interview on 04/13/23 at 02:20 PM the Social Worker confirmed that she was responsible for completing the BIMS section of the MDS assessment and that she was hired on 3-8-2023 and was not present for Resident #58 and #79's MDS assessment. The Social Worker reported that if the MDS is not completed correctly then staff will not be aware of a resident's cognitive function and care may be affected. During an interview on 04-14-2023 at 08:16 AM MDS Coordinator B reported that the facility follows the RAI Manual for MDS accuracy. MDS Coordinator B reported that if the MDS is not accurate if can affect facility reimbursement but usually not affect resident care. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17, dated October 2019 revealed the following: Section C Cognitive Patterns- SECTION C: COGNITIVE PATTERNS Intent: The items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information. These items are crucial factors in many care-planning decisions. Coding Tips o If the resident interview was not conducted within the look-back period (preferably the day before or the day of) the ARD, item C0100 must be coded 1, Yes, and the standard no information code (a dash -) entered in the resident interview items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed, based on a resident's comprehensive assessment, to ensure that a resident is offered a therapeutic diet when there is a nutritional problem, and the health care provider orders a therapeutic diet for 2 (Resident #23 and Resident #208) of 23 residents reviewed for nutrition. Residents #23 and #208 had physician's orders for therapeutic diets, but the dietary staff did not have them listed as receiving therapeutic diets. This failure could place residents who are to receive therapeutic diets at risk of not receiving the diets as ordered and could result in health complications such as increased sugar, waste and build up in the blood stream due to inappropriate nutrition. Findings included: Record review of Resident #23's face sheet, dated 04/14/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with an initial admission date of 06/20/22. She was admitted with diagnoses that included, but were not limited to, type 2 diabetes, bipolar disorder, major depressive disorder, borderline personality disorder, Parkinson's disease, and morbid obesity. Record review of Resident #23's quarterly MDS, dated [DATE], revealed a BIMS of 15 indicating her cognition was intact. She required supervision and no set up or physical help from staff in bed mobility, walking and locomotion, and toilet use. She required supervision and set up help with eating and limited to extensive one-person assistance with transfer, dressing, and personal hygiene. She was on a therapeutic diet while a resident. Record review of Resident #23's current physician's orders, dated 04/14/23, revealed an order for a CC/RCS (controlled carbs/reduced concentrated sugar) diet dated 11/08/22. Record review of Resident #208's face sheet, dated 04/13/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, end stage renal disease (last stage of kidney failure), type 2 diabetes, fluid overload, morbid obesity, and hypertension (high blood pressure). Record review of Resident #208's admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. He required limited to extensive, one- to two-person assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. He was independent with eating. He was on a therapeutic diet while a resident. Record review of Resident #208's care plan, dated 03/22/23, revealed he had a potential nutritional problem related to diagnosis of fluid overload and end stage renal disease. One of the interventions listed to address the issue was diet as ordered by physician. Record review of Resident #208's current physician's orders dated 04/13/23 revealed an order for LCS Diet (low concentrated sugar) dated 03/22/23 and an order for CCHO (consistent carbohydrate for diabetes) Renal diet dated 03/29/23. During an observation and interview on 04/13/23 at 08:27 AM Resident #208 was lying in bed on his back in a hospital gown with a blanket over his left leg and his right leg outside the blanket. He stated he needed to eat less carbohydrates because they had been causing problems with the function of his legs. He stated the facility had not been helping him with his diet. He stated, Every supper plate is ¾ potato. He stated he had been taking care of his diet on his own because if I wasn't this stay here would have been pointless. He stated he has spoken to nurses and CNA's about his diet and asked often for substitutions but he did not know which ones he had spoken to. During an observation on 04/13/23 at 12:03 PM Resident #208 was lying in bed on his back asleep. His lunch tray was next to the bed and his plate was made up of mixed carrots and peas, cheesy tater tot casserole, a slice of white bread, and a piece of cake-the regular lunch menu of the day. During an interview on 04/13/23 at 04:12 PM DS K stated the only therapeutic diet the facility did was low concentrated sugar. She stated that is the same thing as a diabetic diet. She stated some residents on special diets prefered to eat regular diets and they must honor the resident's wishes. When asked about a renal diet DS K stated the facility uses a liberal renal diet and that means not so many potatoes or carbohydrates. DS K and Dietary L produced the menu for the week and showed that the regular lunch for 04/13/23 was beefy tater tot casserole and the alternative was a turkey sandwich with tomato soup. DS K stated if a resident was on a renal diet, they would have had the sandwich and soup option. She stated the nurses gave her a communication form that reflected diet orders, and she filled out the tray cards for dietary staff to see and comply with. DS K and Dietary L provided a diet type report for all residents on special diets. Record review of the diet type report, provided by DS K and Dietary L, dated 04/13/23 for all residents on a therapeutic diet revealed no entry for Resident #23 or Resident #208. During an observation and interview on 04/14/23 at 01:18 PM Resident #23 was sitting in her wheelchair outside in the smoking courtyard having a cigarette with several other residents. She stated she got a regular diet and was not on a special diet despite being a diabetic. She stated it made it harder for her to make good choices in what to eat. She stated she has told nurses and CNA's about her diet but she did not know which nurses and CNA's she had spoken to. During an interview on 04/14/23 at 01:28 PM ADON E stated a possible negative outcome of a resident not receiving a special diet as ordered was, obviously a risk of high glucose and insulin. He stated the diets for residents are in our system (the facility's EHR). He stated the facility was working to reeducate staff on accessing that information. During an interview on 04/14/23 at 02:28 PM LVN H stated a possible negative outcome of a resident not getting the ordered special diet would be, They would have higher sugar. She stated, Our protocol with diet change is fill out a communication form and give it to the kitchen. Then we follow up for 72 hours to be sure they get it. During an interview on 04/14/23 at 02:36 PM the DON stated residents who were not following a renal diet order might get too much protein in their diet and diabetic residents not following a diabetic diet might get too much sugar in their diet. During an interview on 04/14/23 at 02:54 PM the DON and RN A stated the nurses were responsible for filling out the dietary communication form and turning it into the kitchen. Record review of an undated facility policy titled; Therapeutic Diets revealed the following: Policy: When necessary, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of a patient/resident to achieve outcomes/goals of care. Procedure: . 3. Diets will be offered as ordered by the physician or designee. 8. An individual's medical record and diet on file in the food and nutrition service office's system must be reviewed on a regular basis to assure that they agree.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences, for 1 (Resident #208) of 23 residents reviewed for respiratory care. Resident #208 had orders for oxygen at 2 liters per minute and was receiving oxygen at higher concentrations. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings included: Record review of Resident #208's face sheet, dated 04/13/23 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, end stage renal disease (last stage of kidney failure), type 2 diabetes, and hypertension (high blood pressure). Record review of Resident #208's admission MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. He required limited to extensive, one- to two-person assistance with bed mobility, transfer, locomotion, dressing, toilet use and personal hygiene. He was independent with eating. The MDS documented a need for oxygen while not a resident and as a resident. Record review of Resident #208's care plan, dated 03/22/23, revealed he had oxygen therapy related to congestive heart failure at 2 liters per minute continuously by nasal cannula. One of the interventions listed on the care plan was to give medications as ordered by physician. Record review of Resident #208's current physician's orders dated 04/13/23 revealed an order for oxygen at 2 liters per minute continuous per nasal cannula. The order had a start date of 03/23/23. Record review of Resident #208's oxygen saturation summary dated 04/13/23 revealed his oxygen saturation was checked and documented on 04/12/23 at 09:23 AM and 08:34 PM. His oxygen saturation was checked and documented by nursing staff one to two times a day for each day he was in the facility except 03/22/23. During an observation on 04/12/23 at 08:22 AM Resident #208 was lying in bed on his back asleep with oxygen by nasal cannula at 4 liters per minute. During an observation on 04/13/23 at 08:27 AM Resident #208 was lying in bed on his back asleep with oxygen by nasal cannula at 4 liters per minute. During an observation on 04/13/23 at 11:02 AM Resident #208 was lying in bed on his back asleep with oxygen by nasal cannula at 4 liters per minute. During an observation on 04/13/23 at 12:03 PM Resident #208 was lying in bed on his back asleep with oxygen by nasal cannula at 4 liters per minute. During an observation and interview on 04/14/23 at 09:28 AM Resident #208 was sitting in his w/c with his hospital gown on and his oxygen at 3 liters per minute. He stated he took oxygen by nasal cannula all day long. He stated he could not remember when he started taking oxygen. During an observation and interview on 04/14/23 at 09:45 Resident #208 stated he did not turn his own oxygen up. He said, A nurse did that. Resident's oxygen was at 3 liters per minute. During an interview on 04/14/23 at 10:38 AM LVN G stated the nurses knew what level of oxygen a resident needed because it is in the order itself and we get it in report at change of shift. She stated, We review the orders with the provider before putting them in the chart. When asked how she knew a resident's oxygen is set at the correct level she said the nurses look at them every time we go in the room, and when we monitor oxygen levels. She stated if a resident took more oxygen than was ordered it could lead to overloading lungs, lungs can't tolerate that high amount of oxygen. It can be toxic because carbon dioxide can't exchange fast enough. Too much oxygen can be just as bad as not having oxygen. During an interview on 04/14/23 at 11:00 AM LVN G stated she worked on Resident #208's hall. She stated she thought Resident #208's oxygen was supposed to be set at 3-4 liters per minute. She looked up the order and noted it was for 2 liters per minute. During an interview on 04/14/23 at 01:06 PM ADON E stated a negative outcome of using more oxygen than ordered was there is always a danger if not following physicians orders. During an interview on 04/14/23 at 02:28 PM LVN H stated a negative outcome of not using oxygen as ordered was carbon dioxide levels and labs can get messed up. During an interview on 04/14/23 at 02:38 PM the DON stated a negative outcome of not using oxygen as ordered was oxygen dependance, or not enough oxygen or cardiac arrest. During an interview on 04/14/23 at 02:54 PM the DON and RN A stated the nurses were responsible for entering oxygen orders into the electronic health record and for making sure the orders were followed. Record review of facility policy titled, Policy/Procedure - Nursing Clinical and dated 05/2007 revealed the following: Subject: Physician Orders . 1. No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 3 medications. Omeprazpole, Vitamin D3 5000IU, and Dronabinol The facility failed to ensure that medications have an expiration date and/or are discarded appropriately and in a timely manner after medication has expired. This failure could place residents at risk for reduced efficacy of the medications administered. Findings include: [DATE] 9:09 AM-Observation and interview with LVN D stated that she had medications to give to Resident #56. Vitamin D3 5000IU was expired and given to Resident #56. LVN D stated that the iron was expired and removed it from the drawer however the iron did not expire until 12/2023. LVN D did not remove iron and or the actual expired medication of Vitamin D3 was crushed and administered to Resident #56. LVN D did perform hand hygiene before and after medication was administered. LVN D proceeded to remove the iron stating that it was expired and would replace it. LVN D stated that she saw this documentation on my medication pass documentation form. However, she did not remove it from the resident #56 medication before crushing the medication and administering it to the Resident #56. The iron is not what is expired, it is the Vitamin D3 5000IU, with an expiration date of [DATE]. [DATE] 10:56 AM-observed medication within the lock box placed in the fridge in station #3 medication room. Medication was for resident #19, medication Dronabinol 2.5mg no expiration date found on label. When LVN D was asked if medication was given today, she confirmed that medication was given before meals to help with appetite. Confirmed a 2nd time with LVN D that medication had been given today, and LVN D stated yes that Resident #19 had received this medication. [DATE] 08:02 AM-observed medication Omeprazole tablet 20mg was given to Resident #3, there is no expiration noted on the over-the-counter medication. The expiration date was removed from the box when box was opened, and no expiration date was found on medication box. Medication was administered by CMA F to Resident #3. [DATE] 09:02 AM -interviewed ADON E what was the protocol on expired meds. He stated that expired medication should be pulled from carts and discarded and destroyed upon discovery. [DATE] 09:07 AM -interviewed MA F what was the protocol on expired meds. She stated that she makes her nurse aware when an expired medication is discovered. Record review of facility provided policy titled, Storing and controlling medications policy stated that Medications that are discontinued, expired, contaminated, or deteriorated, and those that are in containers that are cracked, soiled, or without secure closures are immediately removed from the locked medication storage area and disposed of in accordance with the Facility policies and procedures.

Based on observation, interview, and record review, the facility failed to establish and 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 for 3 of 3 staff (CNA I, CNA J, and MA F) reviewed for infection control. The facility failed to ensure that CNA I, CNA J, and MA F performed hand hygiene appropriately during overall care of residents, this including medication pass. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene. The findings include: 04/12/23 10:03 AM-observed incontinent performed by CNA I and CNA J proceeded to performed incontinent care on resident #61. CNA J performed hand hygiene and donned clean gloves. CNA I did not perform hand hygiene before donning gloves. Resident #61 was seating in a chair in the shower room removing clothing. Resident #61 could do this alone and needed not assistance. Resident #61 was asked if she would like to take a shower and she refused. CNA I asked if resident would sign a refusal sheet. Resident #61 stated that she would sign the document. Resident #61 was then asked if she could stand so that peri-care could be performed. CNA J performed peri-care while standing behind the resident. CNA J wiped from front to back of resident. Wipe was discarded, another wipe was obtained and applied from front to back on resident. No peri-care was performed to the front of the resident's genital area. Resident sat on a towel that had been laid in the chair, a clean brief, and clean pants by CNA J without hand hygiene performed or removing of dirty gloves were provided to resident to put on. Hand hygiene was encouraged to resident by CNA I, who assisted resident with hand hygiene. 04/12/23 10:11 AM-observed incontinent care performed by CNA I with Resident #45. No hand hygiene was performed before starting peri-care. Soiled clothing and brief were removed by CNA I. There was no hand hygiene or glove change before peri-care was performed. CNA I performed peri-care starting at the back of the resident and performing peri-care to genitals last. No hand hygiene or glove change was performed before clean brief or clothing was placed on Resident #45. 04/12/23 10:19 AM- observed incontinent care performed by CNA I and CAN J. Resident #19. Resident #19 was wheeled into the shower room; CNA I did not perform hand hygiene before donning gloves to place a gait belt around resident. Resident #19 was assisted to a standing position form her chair. CNA J did not perform hand hygiene before donning gloves. CNA J proceeded to remove residents' pants and brief, while CNA I helped resident to stand. Peri-care was performed with peri wipes, buttocks and rectal area cleaned with wipes. No observation of female genital area being cleansed. No hand hygiene or glove change was performed before clean brief or clothing was placed on resident, by either CNA I or CNA J. 04/12/23 11:22 AM -Interview with CNA J was asked what the protocol for incontinent care for resident is, CNA J stated that she would wash hands before and after incontinent care. However, there was no mention of hand hygiene or change of gloves in between performing removal of soiled clothes or brief and placing clean brief and clean clothes. CNA J stated that any new skin issues or bruises are placed on a shower sheet and reported to LVN. 04/12/23 11:32 AM -Interview with CNA I stated all new bruises or skin issues are documented on shower sheets and reported to LVN on duty. CNA I was asked what the protocol was for incontinent care. CNA I stated that dirty soiled clothing and briefs will be discarded in dirty laundry. Doffing of dirty gloves, and hand hygiene performed before new gloves will be put on before perineal care is performed. When surveyor asked CNA I why she did not perform hand hygiene, CNA I stated that she did not have an answer. When asked what the negative outcome from lack of clean gloves and proper hand hygiene could be, CNA I stated, it is a break in infections control. 04/13/23 08:02 AM -observed MA F taking medication from a pill blister pack and dropping medication into her hand and then placing into medication cup. Let MA F know that medication pass observation was going to be performed. No hand hygiene was performed before, during, or after medication administration to Resident #3. Record review of infection control/hand hygiene-policy states that hand hygiene will be performed hand hygiene before preparing or handling medications. Hand hygiene will also be performed before and after the donning and doffing of gloves before moving from a contaminated body site to a clean body site during resident care. After reviewing handwashing check-offs CNA I, CNA J, MA F checkoffs were not found. Record review of a facility provided policy titled, Hand Hygiene, dated 05/2007, revealed, in part, B. Before and after direct contact with resident, C. Before preparing or handling medications .H. Before moving from a contaminated body site to a clean body site during resident care; I. After contact with a resident's intact skin; J. After contact with blood or bodily fluids. Record review of a facility provided policy titled, Infection Prevention and control Program, dated 06/2021, revealed, in part, .3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection . b. Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in the facility kitchen reviewed for dietary services in that: There was unlabeled, undated, and unsealed food in the refrigerators, freezers, and dry storage area; there was expired food in the refrigerators, freezer, and dry storage area; staff's personal food was in one of the service refrigerators; and refrigerator and freezer temperature logs were not updated. These failures placed residents who ate food served by the kitchen at risk for food-borne illness. Findings include: In an observation of the kitchen and refrigerator on 4/12/23 at 8:10 AM the following was observed: 1. The main trash can in the kitchen, had no cover and contained discarded food items. 2. The foods in the main refrigerator(s) were not labeled or dated with the contents of the containers, nor the received on, opened on or expiration dates; signs posted on all refrigerators, freezers, and pantry doors, clearly stated, All foods in walk-in and reach-in need a date in and a date out. 3. 24 individual cartons of Ensure, nutritional supplement drink, with an expiration date of 3/1/23. 4. 2 food service containers of orange juice, with no date. 5. 4 food service containers of apple juice, with no date. 6. 24 individual glasses of fruit punch, covered, with no date. 7. 1 12-pound container of Three Bean Salad, with no date. 8. 1 dozen eggs, with no date. 9. 1 quart of gravy, with no date. 10. 1 food service container of melted butter, with no date. 11. 3 banana cream pies, with no date. 12. Temperature logs on the holding refrigerator, walk-in cooler and the freezer had not been updated since 4/10/23. 13. 1 large zip top bag of tortilla quarters, open to air, with no date. 14. 2 food service packages of tortillas, open to air/, with no date. 15. 8 slices of cooked bacon in a zip top bag, with no date. In an observation of the walk-in freezer on 4/12/23 at 8:29 AM, the following was observed: 1. 24 1-pound rolls of sausage, with an expiration date of 12/9/22. 2. 1 large food service bag of shredded cheddar cheese, open to the air, with no date. In an observation of the walk-in pantry on 4/12/23 at 8:42 AM, the following was observed: 1. 1 28-ounce box of Cream of Wheat, open to air, with no date. 2. 1 large food service container of peanut butter with an expiration date of 10/14/23. 3. 1 large zip top bag of penne pasta, open to air, with no date. 4. 1 10-pound bag of dry spaghetti, open to air, with no date. In an interview on 4/6/23 at 1:30 PM, the Dietary Manager stated all foods were to be labeled and dated and were to be used in a first in, first out manner. She also stated that all foods were to be clearly marked with the contents and date opened. When asked why foods were not sealed properly and were left open to air, she stated that all food items, regardless of whether they are in the pantry, refrigerator or freezer should be sealed tightly to avoid spoilage, contamination and/or freezer burn. When asked how long foods that were opened should be kept in the refrigerator, she stated that their policy was to throw leftovers out after 7 days. In an interview on 4/6/23 at 4:09PM, dietary worker M and dietary worker N were asked what the consequences of serving expired food to the residents would be, Dietary Worker M stated, We could get written up! Dietary Worker N immediately stated that the residents could become sick, and all other workers agreed. A review of the facility's Dietary Services Policy and Procedures book revealed the following: 1. The facility will store, prepare, distribute, and serve food under sanitary conditions. 2. Foods placed in the freezer are to be left in the original wrapping with an identifying label. If an item must be rewrapped, a moisture proof wrapping or closed container should be used to prevent freezer burn. 3. Leftovers will be stored in a container or wrapped carefully and securely. Each item will be clearly marked, labeled, and dated before being refrigerated. Leftover food is to be used within 7 days or discarded. A review of the FDA Food Code 2017 revealed the following: 3_201.11 (C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under §§ 3-202.17 and 3-202.18. Pf A review of the Food Storage Policy and Procedure revealed the following: Refrigerated food storage: 1. TCS food must be maintained at or below 41 degrees F unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 degrees F. Temperatures for refrigerators should be between 35-41 degrees F. Thermometers should be checked at least two times each day. Check for proper functioning of the unit at the same time. 2. All foods should be covered, labeled, and dated. All foods will be checked at assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. 3. Refrigerated food should be stored upon delivery and careful rotation procedures should be followed. Frozen Foods: 1. Frozen foods must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times each day. Check for proper functioning of the unit at the same time. Periodically, check the firmness of foods in the freezer to assure temperatures are maintained to keep food frozen solid. 2. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 3. All food items should be stored upon delivery and careful rotation procedures should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 11 residents (Resident #2) reviewed for significant medication errors. The facility failed to ensure Resident #2 received his diuretic for 7 days after admission to the facility. This failure could place residents at risk of complications from deterioration in health, extended recoveries, hospitalizations. Findings include: Record review of Resident #2's clinical record revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included, encephalopathy (disease that affects brain structure or function causing mental state and confusion), pneumonia (infection of the air sacs in one or both the lungs), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), pain, fluid overload (too much fluid in your body), polyneuropathy (damage to multiple peripheral nerves), heart failure (a progressive heart disease that affects pumping action of the heart muscles causing fatigue and shortness of breath), and hypokalemia (low potassium in lab work) (12/27/22), anxiety disorder (feeling nervous, restless or tense or having a sense of impending danger, panic or doom) (1/2/23), vitamin D deficiency (very little vitamin D in the body causing impairment in bodily functions including bone mineralization) (12/30/22), dysphagia (difficulty in swallowing food or liquid) and cognitive communication deficit (difficulty with thinking or how someone uses language) (12/29/22), obstructive sleep apnea (hoarse or harsh sound from nose or mouth that occurs when breathing is partially obstructed), and muscle weakness (reduction in the power exerted by muscles resulting in an inability to perform a given task on first attempt)(12/28/22). Record review of Resident #2's admission MDS, completed 1/3/23, revealed a BIMS of 15, which indicated he was cognitively intact and required one-person assistance with all activities. Record review of Resident #2's Hospital discharge orders dated 12/23/22 revealed the following: .furosemide 40mg tablet, commonly known as: LASIX 40 mg, oral, Daily. Record review of Resident #2 MAR indicated Furosemide was not in orders from 12/27/22 until 1/2/23. Record review of Resident #2 Nursing Progress Note, dated 1/1/2023 at 17:37 (5:37 PM) revealed the following: .Called on call and spoke with NP. Per NP, verbal over the phone, furosemide 40 mg daily for fluid overload. Resident was taking before coming to the facility .BMP to be drawn on 1/3/23. Family is present and notified as well. Record review of Resident #2's order for Furosemide 40 mg 1 tablet once a day started 1/2/23 and discontinued on 1/4/23. Record review of Resident #2's order for Furosemide 20 mg 3 tablets twice a day started 1/4/23 and discontinued 1/11/23. Record review of Resident #2's order for Furosemide 20 mg 3 tablets once a day started 1/12/23 and discontinued upon resident's discharge 1/28/23. During an interview on 2/24/23 at 08:24 AM, the ADON stated he started working at the facility on 1/12/23. The ADON stated it depended on the time of day but usually the floor nurse who receives the admission, put the orders into the computer for new admissions. The ADON stated If it was Monday through Friday the ADON's or wound care manager would assist with placing admission orders into computer . During an interview on 02/24/23 at 08:34 AM, LVN A stated she has worked at facility for 4 months. LVN A stated the nurses, the ADON and DON helped with placing the orders into the chart for newly admitted residents, but it was primarily the nurse who received the admission to place the orders into the computer system. LVN A stated there should be two people clarifying medication orders. LVN A stated a negative outcome for a resident to not receive his Lasix or potassium for 8 days could be the resident could develop edema (swelling), increase CHF(fatigue and shortness of breath) due to buildup of fluid in his lungs. LVN A stated the resident's lab levels could be off, such as his BUN/Creatinine could be elevated due to fluid overload. During an interview on 2/24/23 at 08:43 AM, LVN B stated he only worked in the facility for 4 days. LVN B stated it was the nurses who put the orders into the computer system for new admissions or the ADON's. During an interview on 2/24/23 at 08:50 AM, the DON stated the nurses put in the orders into the system for a new admission depending upon the time of day, sometimes it's the ADON's and the DON assisted when needed. The DON stated Resident #2's Lasix (Furosemide) was not started upon admission on [DATE] because it was missed. The DON stated all ADON's were new to the facility, and they had clinical meetings every morning to review medications for all new orders and new admissions before the floor nurses put in the orders into the computer. Record review of the facility provided policy titled Wellness Services - Administration of Medications, dated 7/2017, revealed the following: .3. Medications must be administered in accordance with the written orders of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 20 residents (Resident #90) reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #90 for the use of bedrails on his 2-15-2022 admission MDS assessment. This failure to ensure accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Finding include: Record review of Resident #90's face sheet, dated 03/08/22, revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included, but were not limited to, diabetes (metabolic disorder causing high sugar levels), implantable cardiac defibrillator (implanted, battery-powered device placed in chest to detect and stop abnormal heart beats), reduced mobility, muscle weakness, cognitive communication deficit, need for assistance with personal care, and morbid obesity. Record review of Resident #90's admission MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated his cognition was intact. He required extensive two-person assistance with bed mobility, dressing, toilet use and personal hygiene and total two-person dependence with transferring. Section P of the MDS, Restraints and Alarms, indicated that Resident #69 used bed rails daily. Record review of Resident #90's care plan, dated 02/16/22, revealed no mention of bedrails. Record review of Resident #90's physician's orders revealed, in part: Pt was evaluated and assisted for bed mobility and requires Bilateral bedrails in order to improve safety and independence and active pt participation with bed mobility tasks as well as to prepare for EOB activities, ADLs, and transfers. Bed rails are safe and are not restraining pt independence and functional mobility dated 02/11/22. During an observation and interview on 03/07/22 at 10:18 AM, Resident #90 was lying in his bed. No restraints or bedrails observed. Resident #90 stated he had not been restrained while at the facility. He stated he was previously restrained when he was in the hospital due to hallucinating when taking medications. He stated he did not have bed rails on his bed at the facility. He stated he wanted them because it was easier for him to move in bed, but he was told bed rails were not allowed because residents had been injured before. During an interview on 03/09/22 at 10:34 AM, MDSC G stated, from her understanding, the therapy department had evaluated Resident #90 for bedrails and tagged an order for it, but it wasn't really an order. It was a mistake. When asked why the MDS reflected bed rails were used by Resident #90 when bed rails had not been used by Resident #90, MDSC G stated if a resident has an order for something, it would be coded in the MDS. MDSC G stated Resident #90 never had bed rails; we looked it to see if he had them and if they were removed but apparently, he just never had them. MDSC G stated she would have considered the MDS for Resident #90 an inaccurate MDS. She stated it was an error on her part and an error on the therapy department's part. MDSC G stated she should have made sure if Resident #90 had bed rails or not. If an MDS was inaccurate, MDSC G stated it wouldn't change the pay in the MDS, but they would not want to inaccurately code a government document. MDSC G stated if they did not follow up with the bedrails and, it slipped through the cracks, I could see how it could impair his modified independence. MDSC G stated she had MDS training several years ago, she had attended conferences. She stated she had only been at the facility since 01/17/22. During an interview on 03/09/22 at 08:57 AM the DON stated concerning MDS assessments, It will affect the RUG and our payment. If it is an annual it can affect the care planning. When asked if it affects care planning can it affect resident care the DON stated, Yes. It can affect resident care. When questioned what policy the use to complete the MDS assessment the DON stated, We follow the RAI manual. During an interview on 03/09/22 09:03 AM the MDSC H stated concerning MDS policy, We use the RAI manual to complete the MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents reviewed (Resident #91) for pressure ulcer care. The medical record of Resident #91 was not complete and accurate in that there was missing documentation in the resident's wound care administration record to indicate whether or not her wound care was completed on 2 days during the month of February 2022 and on 3 days during the month of March 2022. This failure could place residents at risk of not receiving needed care or treatments by misleading care providers regarding what care or treatments residents have or have not received which could lead to new or worsening pressure ulcers. Findings include: Record review of Resident #91's face sheet, dated 03/08/2022, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, periprosthetic fracture around internal prosthetic right knee joint (fracture associated with an orthopedic implant of the right knee), reduced mobility, muscle weakness, and cognitive communication deficit. Record review of Resident #91's admission MDS, dated [DATE], revealed a BIMS score of 14 out of 15 which indicated her cognition was intact. She required extensive two-person assistance with bed mobility, transferring, and toilet use, and extensive one-person assistance with dressing and personal hygiene. The MDS also indicated that she had one Stage 3 pressure ulcer (skin breakdown that involves full thickness tissue loss) that was present upon admission. Record review of Resident #91's care plan, dated 02/15/2022, revealed in part: [Resident #91] has a stage 3 pressure ulcer to sacrum .Administer treatments as ordered and monitor for effectiveness. Record review of Resident #91's physician's orders, dated 03/08/2022, revealed in part: Clean sacrum area with wound cleanser and apply skin protectant and apply foam dressing. Continue to monitor wound. one time a day, ordered on 02/17/2022. Record review of Resident #91's Wound Administration Record for February 2022 revealed no documentation for sacrum wound care being performed on 02/19/2022, and 02/23/2022. Record review of Resident #91's Wound Administration Record for March 2022 revealed no documentation for sacrum wound care being performed on 03/02/2022, 03/04/2022 and 03/05/2022. During an interview and record review on 03/08/2022 at 2:45 PM with RN E (who performed wound care at the facility) and CRN, the Wound Care Administration Record for Resident #91 was reviewed showing lack of documentation for sacrum wound care for 02/19/2022, 02/23/2022, 03/02/2022, 03/04/2022 and 03/05/2022. CRN stated wound care should have been documented on the Wound Care Administration Record and if it was not documented there, it should have been documented in a progress note. Review of Resident #91's progress notes with RN E and CRN for those days revealed no documentation of sacrum wound care being performed on the days in question. RN E stated there were days that she was unable to perform wound care so she would leave it for the night nurse to complete. CRN stated that the order to perform wound care may not have shown up on the Wound Care Administration Record for the night nurses to complete if it was not done during the day, which is when a progress note should have been made if it was done. When asked what negative resident outcome could have resulted if it was unclear if the sacrum wound care was being performed since it was not documented, RN E stated that the wound could have worsened. RN E stated she recently performed an in-service on documentation and giving report between shifts. During an interview on 03/09/2022 at 11:02 AM, DON stated that CRN was unable to find documentation of the sacrum wound care being performed for Resident #91 on the days in question for February and March 2022. DON stated that the wound care was being performed, the staff is good about doing that. Record review of facility provided policy titled Documentation, dated May 2007, revealed in part: Policy: It is the policy of this facility to provide: All services provided to the resident, or changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Procedure: 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. 4. Documentation of Medication Administration, Procedures and Treatments shall include care-specific details and shall include at a minimum: The date and time the procedure/treatment was provided; The name and title of the individual(s) who provided the care; The assessment data and/or any unusual findings obtained during the procedure/treatment; How the resident tolerated the procedure/treatment; Whether the resident refused the procedure/treatment; Notification of family, physician or other staff, if indicated; The signature and title of the individual documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 out of 32 residents (Resident #10) whose medical records were reviewed for medication administration. The medial record of Resident #10 was not accurate in that LVN C and RN D documented giving the resident medications that they did not. This failure could place residents at risk of not receiving needed care or treatments by misleading care providers regarding what care or treatments residents have or have not received. Findings Include: Record review of face sheet for Resident #10, dated 03/07/2022, revealed that Resident #10 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included heart failure and hypertension (high blood pressure). Record review of MDS for Resident #10, dated 12/12/2021, revealed that the resident had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. The MDS indicated that the resident required limited assistance with bed mobility, transfers, dressing, and personal hygiene; and that the resident had active diagnoses of heart failure and hypertension. Record review of active physician orders for Resident #10, dated 03/07/2022, revealed the following: An active order with a start date of 04/02/2021 for the resident to receive 1 tablet of 2.5 milligrams of Amlodipine Besylate (a medication used to treat high blood pressure) one time a day for hypertension that stated to hold the medication if the resident's systolic blood pressure was less than 110 or diastolic blood pressure was less than 70. An active order with a start date of 04/02/2021 for the resident to receive 1 tablet of 5 milligrams of Bisoprolol Fumarate (a medication used to treat high blood pressure) one time a day for hypertension that stated to hold the medication if the resident's systolic blood pressure was less than 110 or diastolic blood pressure was less than 70. An active order with a start date of 04/02/2021 for the resident to receive 1 tablet of 100 milligrams of Losartan Potassium (a medication used to treat high blood pressure) one time a day for hypertension that stated to hold the medication if the resident's systolic blood pressure was less than 110 or diastolic blood pressure was less than 70. Record review of the MAR for Resident #10 for the months of February and March of 2022, dated 03/08/2022, revealed the following: LVN C documented that he administered a dose of Amlodipine Besylate, Bisoprolol Fumarate, and Losartan Potassium to Resident #10 on 03/07/2022 and that, at that time, her diastolic blood pressure was below 70 at 65. LVN C documented that he administered a dose of Amlodipine Besylate, Bisoprolol Fumarate, and Losartan Potassium to Resident #10 on 02/28/2022 and that, at that time, her diastolic blood pressure was below 70 at 68. RN D documented that she administered a dose of Amlodipine Besylate, Bisoprolol Fumarate, and Losartan Potassium to Resident #10 on 02/19/2022 and that, at that time, her diastolic blood pressure was below 70 at 50. RN D documented that she administered a dose of Amlodipine Besylate, Bisoprolol Fumarate, and Losartan Potassium to Resident #10 on 02/10/2022 and that, at that time, her diastolic blood pressure was below 70 at 65. LVN C documented that he administered a dose of Amlodipine Besylate, Bisoprolol Fumarate, and Losartan Potassium to Resident #10 on 02/08/2022 and that, at that time, her diastolic blood pressure was below 70 at 67. RN D documented that she administered a dose of Amlodipine Besylate, Bisoprolol Fumarate, and Losartan Potassium to Resident #10 on 02/06/2022 and that, at that time, her diastolic blood pressure was below 70 at 66. RN D documented that she administered a dose of Amlodipine Besylate, Bisoprolol Fumarate, and Losartan Potassium to Resident #10 on 02/05/2022 and that, at that time, her diastolic blood pressure was below 70 at 68. During an interview on 03/08/2022 at 2:46 PM, LVN C reported that the blood pressure medications for Resident #10 are supposed to be held (not administered) when the resident's systolic blood pressure is below 110 or her diastolic blood pressure is below 70. When asked about his documentation on the MAR of Resident #10 for the dates of 03/07/2022, 02/28/2022, and 02/08/2022, LVN C reported that those documentations were typos and that he administered the medications but entered the wrong blood pressure that was obtained on those dates. LVN C reported that the resident's diastolic blood pressure must have been above 70 on those dates because he would have held her blood pressure medications otherwise. LVN C reported that the resident's medical record was not currently accurate and that the consequences of that include that other providers may misinterpret data that they find or providers may adjust prescriptions incorrectly based on false data. LVN C reported that he documented inaccurately in Resident #10's medical record because she [Resident #10] is always elevated [her blood pressure] and I'm needing to take a second to slow down. During an interview on 03/09/2022 at 8:05 AM, RN D reported that the blood pressure medications for Resident #10 should be held (not administered) when the resident's systolic blood pressure is below 110 or diastolic blood pressure is below 70. RN D confirmed that Resident #10's medical record indicated that she administered the resident's blood pressure medications on 02/05/2022, 02/06/2022, 02/10/2022, and 02/19/2022 while she had a diastolic blood pressure that was below 70. RN D reported that she documented having given those medications, but that she held the medications on those days. RN D reported that Resident #10's medical record was not accurate and that she would correct the inaccurate entries in the resident's MAR. RN D reported that she documented inaccurately in the resident's medical record because she was not familiar the medical record software at the facility and was not certain how to document a medication as having been held. RN D reported that inaccuracies in a resident's medical record could lead to trouble or give doctors and providers an inaccurate picture of the resident's status. During an interview on 03/09/2022 at 10:02 AM, DON reported that nurses should not be documenting inaccurately in residents' medical records because it could paint a false picture of the resident's status. DON reported that doctors and nurses could assume that a resident received a medication when they did not. DON reported that she recently became aware that at least one nurse documented in a resident's medical record inaccurately because the nurse did not know how to document held medications. DON reported that nurses are trained to document in the medical records by other nurses that they follow while they are newly hired, which typically occurs over 3 days. Record review of facility provided policy titled Documentation, dated May 2007, revealed in part: Policy: It is the policy of this facility to provide: All services provided to the resident, or changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Procedure: 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. 4. Documentation of Medication Administration, Procedures and Treatments shall include care-specific details and shall include at a minimum: The date and time the procedure/treatment was provided; The name and title of the individual(s) who provided the care; The assessment data and/or any unusual findings obtained during the procedure/treatment; How the resident tolerated the procedure/treatment; Whether the resident refused the procedure/treatment; Notification of family, physician or other staff, if indicated; The signature and title of the individual documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure their medication error rate was not five percent or greater. The medication error rate was 7.69% with four errors out of 52 opportunities and involved one of two staff members (LVN A) and two of five residents (Resident #52 and Resident #298) reviewed for medication administration. LVN A attempted to administer isosorbide mononitrate ER 30 mg 1 tablet (used to prevent chest pain), lisinopril 10 mg 1 tablet (used to treat high blood pressure) and metoprolol tartrate 25mg 1 tablet (used to treat chest pain, heart failure and high blood pressure) to Resident #52 when Resident #52's vital signs were outside of the physician ordered medication administration parameters. LVN A administered Aspirin 81 mg (prevents platelets from sticking together and forming a clot) to Resident #298 when his physician's orders were for Aspirin 325 mg. These failures could place residents at risk of their medications not being administered in accordance with physician's orders, which could place residents at an increased risk of experiencing adverse effects such as low blood pressure, low heart rate, dizziness, or fainting. Findings include: Errors #1, #2 and #3 Record review of Resident #52's face sheet, dated 03/09/22, revealed a [AGE] year-old female admitted on [DATE], readmitted on [DATE], with diagnoses that included, but were not limited to, chronic respiratory failure, cognitive communication deficit, need for assistance with personal care, muscle weakness, lack of coordination, history of falling, difficulty walking, abnormalities of gait and mobility, and chronic combined systolic and diastolic heart failure (inability of the heart to pump blood efficiently or properly fill with blood during the resting phase between each heart beat). Record review of Resident #52's admission MDS, dated [DATE], revealed a BIMS score of 04 out of 15 which indicated she was severely cognitively impaired. She required limited one-person assistance with bed mobility, transferring, dressing and toilet use and extensive one-person assistance with personal hygiene. Record review of Resident #52's physician's orders revealed, in part: Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth one time a day for hypertension [high blood pressure] HOLD if systolic [top number of blood pressure reading] less than 100; diastolic [bottom number of blood pressure reading]/HR under 60 dated 02/02/22. Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic under 100; diastolic/HR under 60 dated 02/02/22. Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for hypertension. HOLD for systolic under 100; diastolic/HR under 60 dated 02/02/22. During an observation and interview on 03/08/22 at 8:14 AM, LVA A obtained a right wrist cuff blood pressure on Resident #52 of 116/55 with a heart rate of 70. Observed LVN A dispense isosorbide mononitrate 30 mg 1 tablet, lisinopril 10 mg 1 tablet and metoprolol tartrate 25 mg 1 tablet from their respective blister packs into a medication administration cup, along with seven other medications. Observed LVN A pour a cup of water to take to the resident and begin to take the cup of water and cup of medications into Resident #52's room. Surveyor intervened and questioned LVN A what the medication administration parameters were for Resident #52's isosorbide mononitrate, lisinopril and metoprolol tartrate. LVN A reviewed the medication orders and stated the parameters for all three medications were hold for a systolic blood pressure under 100 and a diastolic blood pressure under 60 and a heart rate under 60. Observed LVN A remove all three medications from the medication cup and wasted in the sharps container. During an interview on 03/08/22 at 8:55 AM, LVN A stated if she had given Resident #52 the isosorbide mononitrate, lisinopril, and metoprolol tartrate, it could have dropped Resident #52's heart rate. She stated she was trained for three days on medication administration by her Unit Supervisor when she first started at the facility. During an interview on 03/09/22 at 8:52 AM, LVN A stated she was not aware that there was a diastolic parameter for the isosorbide mononitrate, lisinopril or metoprolol tartrate medication orders, and it was not a typical parameter for residents. Error #4 Record review of Resident #298's face sheet, dated 03/09/22, revealed an [AGE] year-old male admitted on [DATE] with diagnoses that included, but were not limited to, chronic systolic heart failure (inability of the heart to pump blood efficiently), hypertension (high blood pressure) and hyperlipidemia (high lipids, or fats, in the blood). Record review of Resident #298's admission MDS, started 03/01/22, revealed it was still in progress. Record review of Resident #298's physician's orders revealed, in part: Aspirin Tablet 325 MG Give 1 tablet by mouth one time a day for CHF dated 02/22/22. During an observation on 03/08/22 at 8:32 AM, LVN A administered Enteric Coated Aspirin 81 mg 1 tablet orally to Resident #298. During an interview and record review on 03/09/22 at 8:52 AM, when asked which dose of Aspirin LVN A gave Resident #298 on 03/08/22, she opened her medication cart and obtained a bottle of Enteric Coated Aspirin 81 mg. When asked to look in Resident #298's chart for the medication order, LVN A reviewed the order for Aspirin 325 mg and stated Resident #298 should have been given the Aspirin 325 mg dose. When asked why she gave the Aspirin 81 mg tablet instead of the Aspirin 325 mg tablet, LVN A stated 81 mg was the dose they gave most of the residents. When asked what negative consequence could have occurred from administering Aspirin 81 mg instead of Aspirin 325 mg, LVN A stated Resident #298 would not be getting enough [medication]. During an interview on 03/09/22 at 10:07 AM with DON and CRN, regarding a staff member attempting to administer the isosorbide mononitrate, lisinopril and metoprolol tartrate with a resident's vital signs outside of the medication administration parameters, DON stated as a nurse, I would not give them; I would expect staff to hold them and notify the physician. When asked why the three medications were almost given, DON stated, I can't answer that, I don't know that. They get very nervous when you're here. DON stated new staff went through new hire orientation in the classroom and then would normally follow behind a training nurse, observing the electronic charting system during medication administration before they did anything on the electronic system themselves. DON stated the next day, the orientee would access the electronic system themselves and the training nurse would follow the orientee during medication administration. DON stated she would normally schedule orientees to orient for three 12-hour shifts. Regarding administering Aspirin 81 mg instead of Aspirin 325 mg, DON stated it was considered a medication error. She stated a medication error, is the five rights: right patient, right med, right route, right dose . DON stated, I would guess the regulation goes to the more gray area that it is an error. It's the five rights, I would expect her [nurse] to give [medications] within the 5 rights. DON stated that Aspirin was usually administered for blood thinning and giving a lower dose may have caused thickening of the blood. CRN stated they would have to factor in the reasoning for why the resident was receiving the Aspirin to determine if it was a medication error; if it was a prophylactic or was it for a specific diagnosis. Record review of facility provided policy titled, Policy/Procedure-Nursing Clinical .Subject: Medication Administration-Oral, dated 05/2007, revealed, in part: POLICY: It is the policy of this facility to accurately prepare. Administer and document oral medications. [sic] PROCEDURES: .2. Read resident's electronic medication administration record and select appropriate drugs 3. Take vital signs if required. Hold drugs if indicated.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in 2 of 3 medication carts (unit 2 medication cart and unit 1 medications cart) reviewed. The unit 1 medication cart contained a vial of insulin that was beyond its expiration/use-by date. The unit 2 medication cart contained loose medication tablets. This failure could place residents at risk of drug diversion or exposure to medications and/or biologicals that are expired and/or contaminated. Findings include: During an observation and interview on 03/07/2022 at 8:35 AM, there were 4 medication tablets loose in the second drawer and 1 medication tablet loose in the third drawer of the unit 2 medication cart. The medication tablets were not in any type of packaging and did not contain any labeling. LVN C reported that there were loose medication tablets in the unit 2 medication cart and that he was currently responsible for that cart. LVN C reported that there should not be loose medication tablets in the medication cart and that he did not know why the loose tablets were in the cart. LVN C reported that loose medication tablets should be kept out of medication carts to prevent mix ups and LVN C that loose medication tablets could indicate that a resident did not receive doses of medications. LVN C was asked to identify the 5 medication tablets found loose in his medication cart and reported that he believed four of them to be bisoprolol (a medication used to treat high blood pressure), sertraline (a medication used to treat depression), furosemide (a medication used to reduce excess body fluid), and a statin (a term used for a group of medications used to treat high cholesterol). LVN C reported that he did not know what the fifth medication tablet was. During an interview on 03/08/2022 at 1:23 PM, DON reported that she did not consider it acceptable for medication tablets to be loose in medication carts. DON reported that night shift nurses are supposed to clean out medication carts each night. DON reported that the consequences of medication tablets being in medication carts include infection control or not having the med for the patient because you run out. DON reported that she did not know why there were loose medication tablets found in a facility medication cart. During an observation and interview on 03/07/2022 at 9:14 AM with LVN A, the Unit 1 Medication Cart contained an opened bottle of Lantus insulin for Resident #30 that had a handwritten date indicating it was opened on 02/02/2022. When asked what the discard date should have been for the bottle of Lantus since it was dated as being opened on 02/02/2022, LVN A stated that she was unsure. During an interview on 03/09/2022 at 8:24 AM, LVN A stated she had asked another staff member when insulin expired after being opened because she was not 100% sure. LVN A stated she was told that insulin expired 28 days after it was opened. When asked if an insulin bottle that was opened on 02/02/2022 and was observed in the medication cart on 03/07/2022 would have been expired, LVN A reported it would have been expired. LVN A stated that she knew that she was supposed to check the insulin expiration dates in the medication cart. LVN A reported that a consequence of administering an expired insulin to a resident was that the insulin could have lost its potency. During an interview on 03/09/2022 at 10:07 AM, DON confirmed that if a bottle of Lantus insulin was dated as being opened on 02/02/2022 and was observed in the medication cart on 03/07/2022, the insulin would have been in there for 33 days and it should have been replaced. DON stated most insulins expire 30 days after being opened, that is what the pharmacist told them. DON stated the pharmacist checked their medication carts once per month. DON stated staff should have been checking the medication carts every day and it was the responsibility of the staff member who was administering the insulin to check it for the expiration date. DON stated the night shift nurses should have been going through the medication cart and checking for expired medications. DON stated, they probably just didn't pay attention to the date. When asked what consequences could have resulted if a resident received an expired insulin, she stated with that little of expiration, I wouldn't know without having to talk to my pharmacist. She stated, I know those parameters are set for a reason, it [insulin] may not have the efficacy to do its job. I'm sure there is education [staff training]. Record review of facility provided policy titled Medication Access and Storage, dated May 2007, revealed in part: Procedures: 1. The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. Transfer of medications from one container to another is done only by a pharmacist. 13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from pharmacy, if a current order exists. 14. Medication storage areas are kept clean, well lit, and free of clutter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free of any significant mediation errors for one out of five residents (Resident #52) reviewed for medication administration. LVN A attempted to administer isosorbide mononitrate ER 30 mg 1 tablet (used to prevent chest pain), lisinopril 10 mg 1 tablet (used to treat high blood pressure) and metoprolol tartrate 25mg 1 tablet (used to treat chest pain, heart failure and high blood pressure) to Resident #52 when Resident #52's vital signs were outside of the ordered medication administration parameters. RN B, RN N, LVN J, LVN L, LVN K, and LVN M documented on the MAR that isosorbide mononitrate ER 30 mg 1 tablet, lisinopril 10 mg 1 tablet and metoprolol tartrate 25 mg 1 tablet were administered for five days in February 2022 and one day in March 2022 to Resident #52 when Resident #52's vital signs were outside of the ordered medication administration parameters. These failures could place residents at risk of their medications not being administered in accordance with physician's orders, which could place residents at an increased risk of experiencing adverse effects such as low blood pressure, low heart rate, dizziness, or fainting. Findings include: Record review of Resident #52's face sheet, dated 03/09/22, revealed a [AGE] year-old female admitted on [DATE], readmitted on [DATE], with diagnoses that included, but were not limited to, chronic respiratory failure, cognitive communication deficit, need for assistance with personal care, muscle weakness, lack of coordination, history of falling, difficulty walking, abnormalities of gait and mobility, and chronic combined systolic and diastolic heart failure (inability of the heart to pump blood efficiently or properly fill with blood during the resting phase between each heart beat). Record review of Resident #52's admission MDS, dated [DATE], revealed a BIMS score of 04 out of 15 which indicated she was severely cognitively impaired. She required limited one-person assistance with bed mobility, transferring, dressing and toilet use and extensive one-person assistance with personal hygiene. Record review of Resident #52's physician's orders revealed, in part: Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth one time a day for hypertension [high blood pressure] HOLD if systolic [top number of blood pressure reading] less than 100; diastolic [bottom number of blood pressure reading]/HR under 60 dated 02/02/22. Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic under 100; diastolic/HR under 60 dated 02/02/22. Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for hypertension. HOLD for systolic under 100; diastolic/HR under 60 dated 02/02/22. During an interview on 03/09/22 at 10:07 AM, DON and CRN confirmed that a checkmark on the MAR indicated a medication was given. Record review of Resident #52's MAR for February 2022 revealed, in part: 02/07/22-Resident #52's blood pressure was documented as 112/50 and heart rate 62. There was a checkmark indicating the medication was given by RN B on the lines for Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic less than 100; diastolic/HR under 60, Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic under 100; diastolic/HR under 60 and Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for hypertension. HOLD for systolic under 100; diastolic/HR under 60. 02/08/22-Resident #52's blood pressure was documented as 131/65 and heart rate 53. There was a checkmark indicating the medication was given by RN B on the lines for Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic less than 100; diastolic/HR under 60, Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic under 100; diastolic/HR under 60 and Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for hypertension. HOLD for systolic under 100; diastolic/HR under 60. 02/11/22-Resident #52's blood pressure was documented as 156/100 and heart rate 53. There was a checkmark indicating the medication was given by RN N on the lines for Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic under 100; diastolic/HR under 60 and Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for hypertension. HOLD for systolic under 100; diastolic/HR under 60. 02/20/22-Resident #52's blood pressure was documented as 115/56 and heart rate 60. There was a checkmark indicating the medication was given by LVN J on the lines for Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic less than 100; diastolic/HR under 60, Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic under 100; diastolic/HR under 60 and Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for hypertension. HOLD for systolic under 100; diastolic/HR under 60. 02/23/22-Resident #52's blood pressure was documented as 117/56 and heart rate 81. There was a checkmark indicating the medication was given by LVN L on the lines for Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic less than 100; diastolic/HR under 60, Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic under 100; diastolic/HR under 60 and Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for hypertension. HOLD for systolic under 100; diastolic/HR under 60. Record review of Resident #52's MAR for March 2022 revealed, in part: 03/04/22-Resident #52's blood pressure was documented as 78/58 and heart rate of 114. There was a checkmark indicating the medication was given by LVN K on the lines for Isosorbide Mononitrate ER Tablet Extended Release 24 Hour 30 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic less than 100; diastolic/HR under 60 and Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for hypertension. HOLD for systolic under 100; diastolic/HR under 60. There was a checkmark indicating the mediation was given by LVN M on the line Lisinopril Tablet 10 MG Give 1 tablet by mouth one time a day for hypertension HOLD if systolic under 100; diastolic/HR under 60. During an observation and interview on 03/08/22 at 8:14 AM, LVA A obtained a right wrist cuff blood pressure on Resident #52 of 116/55 with a heart rate of 70. Observed LVN A dispense isosorbide mononitrate 30 mg 1 tablet, lisinopril 10 mg 1 tablet and metoprolol tartrate 25 mg 1 tablet from their respective blister packs into a medication administration cup, along with seven other medications. Observed LVN A pour a cup of water to take to the resident and begin to take the cup of water and cup of medications into Resident #52's room. Surveyor intervened and questioned LVN A what the medication administration parameters were for Resident #52's isosorbide mononitrate, lisinopril and metoprolol tartrate. LVN A reviewed the medication orders and stated the parameters for all three medications were hold for a systolic blood pressure under 100 and a diastolic blood pressure under 60 and a heart rate under 60. Observed LVN A remove all three medications from the medication cup and wasted in the sharps container. During an interview on 03/08/22 at 8:55 AM, LVN A stated if she had given Resident #52 the isosorbide mononitrate, lisinopril, and metoprolol tartrate, it could have dropped Resident #52's heart rate. LVN A stated she would have considered it a significant medication error. She stated she was trained for three days on medication administration by her Unit Supervisor when she first started at the facility. During an interview on 03/08/22 at 3:33 PM, RN B confirmed a checkmark on the MAR indicated a medication was given. Regarding Resident #52's isosorbide mononitrate, lisinopril and metoprolol tartrate that had a checkmark on 02/07/22 and 02/08/22 with vital signs outside of the ordered medication administration parameters, RN B stated the medications should not have been given and they could have bottomed out her heart rate. She stated that she was a new nurse and at the time, the acuity of the residents coming into the facility was high and she was more worried about respiratory issues, such as low oxygen saturation, due to working in the COVID-19 unit. She stated that she obtained minimal training upon hire; she stated it was not a specific trainer she was with, the facility did not have a nurse educator, it was a nurse working on the floor. During an interview on 03/09/22 at 8:52 AM, LVN A stated she was not aware that there was a diastolic parameter for the isosorbide mononitrate, lisinopril or metoprolol tartrate medication orders, and it was not a typical parameter for residents. During an interview on 03/09/22 at 10:07 AM with DON and CRN, DON and CRN confirmed that a checkmark on the MAR indicated a medication was given. When asked if administering isosorbide mononitrate, lisinopril and metoprolol tartrate outside of ordered parameters was a significant medication error, CRN stated it would depend on the what the resident's actual vital signs were at the time, what their history was, and what their baseline vital signs were; we would have to look into it for sure. When asked if the three medications should have been given when the resident's vital signs were outside of ordered administering parameters, DON stated they should not have been given without notifying the physician. DON stated consequences included the adverse effect of the medication; if they have low blood pressure and they are given a blood pressure medication, they could become hypotensive [low blood pressure]. When asked why these three mediations were given, DON stated, I can't answer that. There are parameters for a reason, that is nursing 101. DON stated CRN observed two medications passes last week. Regarding the observation of the nurse attempting to administer isosorbide mononitrate, lisinopril and metoprolol tartrate, DON stated as a nurse, I would not give them; I would expect staff to hold them and notify the physician, regarding staff attempting to administer the isosorbide mononitrate, lisinopril and metoprolol tartrate outside of their administering parameters. When asked why the three medications were almost given, DON stated, I can't answer that, I don't know that. They get very nervous when you're here. DON stated new staff went through new hire orientation in the classroom and then would normally follow behind a training nurse, observing the electronic charting system during medication administration, before they did anything on the electronic system themselves. DON stated the next day, the orientee would access the electronic system themselves and the training nurse would follow the orientee during medication administration. DON stated she would normally schedule orientees to orient for three 12-hour shifts. Record review of facility provided document titled, IN-SERVICE/TRAINING DATE: 09/12/-09/13/21 .TOPIC: Medication Administration, revealed, in part: .Never fill in that a med was given unless you gave the medication .DOCUMENTATION: .2. eMAR-medications should be administered timely and documented immediately after each medication administration. Signatures on in-service included RN B and LVN J. Record review of facility provided policy titled, Policy/Procedure-Nursing Clinical .Subject: Medication Administration-Oral, dated 05/2007, revealed, in part: POLICY: It is the policy of this facility to accurately prepare. Administer and document oral medications. [sic] PROCEDURES: .2. Read resident's electronic medication administration record and select appropriate drugs 3. Take vital signs if required. Hold drugs if indicated.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: Ensure foods were stored, prepared and served under sanitary conditions. These failures may increase the risk for foodborne illness. Findings include: In an observation on 03/07/22 at 08:30 AM the following issues in the pantry were observed: 1. Crumbs and dirt on top of buckets holding flour, sugar, brown sugar and rice. 2. Bucket of sugar on floor in storage In an observation on 03/07/22 at 08:30 AM the following issues in the kitchen were observed: 1. Crumbs on toaster 2. Crumbs behind toaster 3. Crumbs behind microwave 4. Crumbs on stove 5. Crumbs on plate holder In an observation on 03/07/22 at 08:30 AM the following issues in the freezer were observed: 1. Crumbs, trash, and dirt on floor of freezer In an observation on 03/08/22 at 08:15 AM the following issues in the pantry were observed and unchanged: 1. Crumbs and dirt on top of buckets holding flour, sugar, brown sugar and rice. 2. One chocolate pudding snackpak on the floor In an observation on 03/08/22 at 08:15 AM the following issues in the kitchen were observed and unchanged: 1. Crumbs on toaster 2. Crumbs behind toaster 3. Crumbs behind microwave 4. Crumbs on stove 5. Crumbs on plate holder In an observation on 03/08/22 at 08:15 AM the following issues in the freezer were observed and unchanged: 1. Crumbs, trash, and dirt on floor of freezer In an observation on 03/09/22 at 9:30 AM the following issues in the pantry were observed: 1. Crumbs and dirt on top of buckets holding flour, sugar, brown sugar and rice. 2. An opened bowl of dry cereal open to air on a tray In an observation on 03/09/22 at 9:30 AM the following issues in the kitchen were observed and unchanged: 1. Crumbs on toaster 2. Crumbs behind toaster 3. Crumbs behind microwave 4. Crumbs on stove 5. Crumbs on plate holder In an observation on 03/09/22 at 9:30 AM the following issues in the freezer were observed and unchanged: 1. Crumbs, trash, and dirt on floor of freezer In an observation on 03/09/22 at AM the following issues in the refrigerator were observed: 1. Two unlabeled containers In an interview and a walk through with the Dietary Manager on 03/09/22 at 9:35 AM, DM acknowledged a bowl of dry cereal open to air on a tray in the pantry. DM stated, She probably missed it this morning and discarded the contents into a trash. DM acknowledged the crumbs on top of the buckets and asked DC 1 to clean them. DM acknowledged the crumbs, trash, and dirt on floor of the freezer and said, If I see something you see wrong, I'm going to fix it. DM acknowledged the crumbs on counter behind the toaster, behind the microwave, on the toaster and on the stove. DM asked DC 1 to clean the bins. DM acknowledged the two unlabeled containers in the refrigerator and said Those were from last night. It's key lime pie. She forgot to label them. When asked the consequences of DM said, Foodborne illness. Record review of an undated Cleaning Schedule Policy submitted by DM revealed: After Each Use: all small equipment, utensils, and appliances counters toasters Record review of an undated Food Storage Policy submitted by DM revealed: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination b. Food should be dated as it is placed on the shelves if required by state regulation. c. Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS food should be consumed, sold, or discarded. 7. Plastic containers with tight-fitting covers must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. 11. Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 7 days or discarded as per the 2017 Federal Food Code. Check state regulations as some states may allow shorter time frames for use of leftovers. 12. Refrigerated food storage: a. All refrigerator units will be kept clean and in good working condition at all times. f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. i. All foods will be stored off the floor. 13. Frozen Foods: a. All freezer units will be kept clean and in working condition at all times. Record review of an undated Cleaning Instructions: Counter Space Policy: Counter space will be cleaned and sanitized prior to and following food preparation and meal service, and as needed. Record review of the USDA Food Code, dated 2017, revealed: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Record review of the USDA Food Code, dated 2017, revealed: 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Record review of the USDA Food Code, dated 2017, revealed: Preventing Contamination from the Premises 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under § 4-204.122.