**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments inaccessible to unauthorized staff, visitors, and residents for 1 (Resident #63) of 40 residents reviewed for medication storage. The facility failed to ensure Resident #63 did not have medications stored at the bedside. This failure could place residents at risk of ingesting unprescribed medications resulting in adverse health consequences. Findings included: Review of Resident #63's face sheet revealed a [AGE] year-old woman admitted on [DATE] with diagnoses of hypertension, muscle weakness, abnormalities of gait and mobility, lack of coordination, need assistance with activities of daily living, and chronic diastolic (congestive) heart failure. Review of Resident #63's annual MDS dated [DATE] reflected she had a brief interview of mental status score of 14, indicating no cognitive impairment. Resident # 63 required supervision or moderate assistance with activities of daily living. Review of Resident #63's physician orders dated 10/02/24 reflected the following medications were not ordered for the resident; Tums Ultra 400 mg calcium (1,000 mg) chewable tablet, Nasal Spray 12 Hour 0.05 % (Oxymetazoline), Cortizone-10 1 % topical gel (Hydrocortisone), Debrox 6.5 % ear drops (Carbamide peroxide), and fiber gummies (chewable). Review of Resident #63's care plan dated 10/03/24 revealed, (Resident #63) wishes to administer some of her own medication. Resident's cognition level BIMS score of 14. Goal, (Resident #63) will successfully name medication and reason for administration within next 90 days.Obtain order for self-medication administration, .Ensure medications can be safely secured from other resident's access within room. Ensure (Resident #63) is able to demonstrate safe handling and storage. Observation on 10/02/24 at 11:45 AM revealed Resident #63 was in bed, awake, and alert. The following medications were noted on the bedside table; bottle of Xylident dry mouth, 1 tube of Hydrocortisone cream which was about half used, 1 bottle of ear wax removal, and 2 bottles of nasal spray. On the shelf wall there was a bottle of fiber chewable gummies. In an interview on 10/02/24 at 11:52 AM with Resident #63, she stated she had been in the facility for about 1 year and reported no concerns. Resident #63 stated she ordered the medications from store and self-administered the medications and at times being assisted by the staff, but she was not able to identify the staff who assisted her. Resident #63 stated she had been using the medication for a while and she did not give a specific timeline she had used the medications. She stated she always stored the medications on the bedside table and the shelf. Resident #63 stated she had not been educated on self-administration of medications. In an interview on 10/02/24 at 01:51 PM with LVN A she stated she was the charge nurse of Resident #63. LVN A stated she was not aware of the medications in the resident's room, but again stated the resident had been assessed for self-medication administration and she was looking for the record in the resident's clinical record. LVN A then stated she was going to get the document from a printer, and she did return. Later, LVN A was noted in Resident #63's room, and she stated she had gone to help the staff who was getting Resident #63 in the wheelchair. LVN A then stated she was not able to find the self-administration assessment or the orders to indicate the resident could administer her own medications. LVN A stated Resident #63 was supposed to have the orders of all the medications she was taking. LVN A stated she saw the medications in the resident's room on the bedside table and on the shelf. LVN A stated the resident was supposed to have orders of the medications and complete a self-medication administration assessment on the resident. The medications were not supposed to be in the resident's room on the bedside table or shelf, they were supposed to be stored in a safe place. Resident #63 self-administering medications without the knowledge of the facility could lead to medication interaction with the ones the resident was prescribed which could lead to side effects. In an interview on 10/02/24 at 03:53 PM with the ADON she stated she was made aware of Resident #63 having medications in her room. The ADON stated the staff were supposed to report to the charge nurse any medications noted in any resident's room. The ADON stated Resident #63 was not supposed to have medications in the room without the physician's order. The ADON stated Resident #63 had not been assessed for self-medication administration prior to the medications being noted in the room. The ADON stated she called the resident's primary care provider and obtained the orders for the medication, and she will complete the self-medication administration assessment. Resident's self-administering medications could lead to medication interactions and even overdose. In an interview on 10/02/24 at 04:20 PM with the DON he stated he had just been notified that the resident had medications in the room. The DON stated the self-medication administration assessment was being completed today and the orders for the medications would be obtained from the primary care provider. The DON stated the resident was not supposed to have medications in the room and use without the doctor's orders and staff assessment for self-medication administration. The DON stated the staff were supposed to report if there were any mediations in the resident's room to prevent medication interactions, overdose, or side effects. The facility was supposed to be aware of all the medications the resident was taking. Review of the facility policy undated and titled, Medication Storage reflected, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Review of the facility policy revised February 2021 and titled Self - Administration of Medication reflected, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.7. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. 8. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 one (CMA D) of two staff observed during medication pass reviewed for infection control. 1. CMA D failed to disinfect the blood pressure cuff in between use with Resident #1 and Resident #91. These failures could affect all residents by causing cross contamination and placing them at risk for exposure to a contagious disease, infection, and possible hospitalization. Findings included: 1. Record review of Resident #1 face sheet dated 8/31/23.admitted to the facility at 8/19/23 with diagnosis of urinary tract infection, and hypertension (high blood pressure). Observation on 8/30/23 at 8:15AM with CMA D revealed him going into Resident #1 room to take his blood pressure. He placed the blood pressure machine on the bed while receiving a reading. Once CMA D was done, he came out of the room. Placed the blood pressure machine back on his cart without sanitizing the cuff. He then Sanitized his hands to prepare Residents #1 medication. Once he finished given the medication, he washed his hands to prepare to go to the next resident room. Record review of Resident #91 dated 8/31/23 admitted [DATE] with diagnosis of hypertension (high blood pressure), depressive episodes, and muscle weakness. Observation on 8/30/23 at 8:27AM with CMA D went to Resident #91 room and took the non-sanitized blood pressure cuff in the room to take his blood pressure. After that CMA D sanitized his hands to prepare Residents #91's medications and placed the non-sanitized blood pressure cuff on the medication cart. Interview on 8/30/23 at 8:35AM revealed CMA D had been trained to sanitize multi-use devices such as the blood pressure cuff right after using it on a resident and in between residents. He stated they have wipes that were supposed to be used but he forgot to use them. Interview on 8/30/23 at 2:23PM with the Administrator revealed when dealing with multi use devices she expected her staff to disinfect and clean in between residents. The Administrator revealed the risk of not doing so could lead to the spread of infection. She also stated they do infection control once a month and every couple of weeks go around to watch medication passes to make sure staff are following the appropriate protocol. Record Review dated September 2022 of Cleaning and disinfection of resident-care items and equipment policy revealed, Reusable items are cleaned and disinfected or sterilized between residents (eg. Stethoscopes, durable medical equipment Reusable resident care equipment is decontaminated and or sterilized between resident according to manufacturer's instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails and enabler pivot assist bars with the resident or resident representative and obtain informed consent prior to installation for three (Residents #81, #312, #314) of 37 resident rooms observed and reviewed for bed rails/pivot assist bars in that: The facility failed to have consents signed for the pivot assist quarter bed rails for Residents #81, #312, and #314. This failure could affect residents who used bed rails/pivot assist bars at risk of the resident/responsible party not being aware of the risk. Findings included: 1. Record review of Resident #81's face sheet, dated 08/31/2023 revealed resident was originally admitted on [DATE] and current admit on 03/23/2023 with diagnoses of Pneumonia, unspecified organism; Paroxysmal atrial fibrillation; Unspecified dementia, unspecified severity, without behavioral/psych/mood; Hypothyroidism, unspecified; Muscle weakness (generalized); Difficulty in walking, not elsewhere classified; Cognitive communication deficit; Other abnormalities of gait and mobility; Essential (primary) hypertension; Other lack of coordination; Unsteadiness on feet; Need for assistance with personal care; Unspecified lack of coordination. Per the face sheet, Resident #81's responsible party was a family member. Review of Resident #81's MDS, dated [DATE], revealed the resident had issues with forgetfulness. Resident needed assistance with all ADL care. Resident was not able to move from seated to standing position, move on and off toilet, or perform a surface-to-surface transfer without the assistance of staff. Resident used a wheelchair for mobility. Review of Medical record of Resident #81 revealed no written Physician Order for quarter bed rails (pivot assist bars) for mobility and positioning. Review of Medical Record of Resident #81 revealed no Physical Device Acknowledgement form (bed rail/pivot assist consent) for the pivot assist bars (quarter bed rails) signed by the resident's responsible party. Record review of Resident #81's Care Plan, dated 3/23/2023, revealed no indication of bed rail or pivot assist bar discussion of risks and benefits with Resident or responsible party. Observation on 08/29/2023 at 9:50 AM revealed Resident #81's room revealed the resident's bed with quarter bed rails/pivot assist bars raised on both sides of bed with call light laying on the mattress. Observation on 08/30/2023 at 02:05 PM of Resident #81's room revealed both quarter bed rails/pivot assist bars raised on resident's bed. Observation on 08/31/2023 at 08:42 AM of Resident #81's room revealed both quarter bed rails/pivot assist bars raised on resident's bed. 2. Record review of Resident #312's face sheet dated 08/31/2023 revealed resident's current admit date of 08/24/2023, initial admit date of 08/19/2023, with diagnosis of Stable burst fracture t11-t12 vertebra, subs for fracture with ro; Parkinson's disease; Unspecified fall, subsequent encounter; Hyperlipidemia, unspecified. Per face sheet, the responsible party was the resident, spouse listed as emergency contact. Record review of Resident #312's Care Plan, dated 08/31/2023, revealed resident is a fall risk and has a history of falls. Record review of Resident #312's Physician Orders reveals twice daily medication for dementia. Review of Medical record of Resident #312 revealed no written Physician Order for quarter bed rails (pivot assist bars) for mobility and positioning. Review of Medical record of Resident #312 reveals no Physical Device Acknowledgement form (bed rail/pivot assist bar consent) for the pivot assist bars (quarter bed rails) signed by the resident's responsible party. Record review of Resident #312's Care Plan, dated 08/31/2023, revealed no indication of bed rail or pivot assist bar discussion of risks and benefits with Resident or responsible party. Observation on 08/29/2023 at 09:35 AM revealed Resident #312 sitting in wheelchair in room. Resident #312's bed was equipped with quarter bed rails (pivot assist bars) that were raised. Observation on 08/30/2023 at 2:54 PM revealed Resident #312's bed observed with both quarter bed rails/pivot assist bars raised. Observation on 8/31/2023 at 10:15 AM of Resident #312's empty room revealed both quarter bed rails/pivot assist bars raised. 3. Record review of Resident #314's face sheet dated 08/31/20232 revealed resident was admitted on [DATE], with a current admit date of 2/22/2023, with diagnosis of Encephalopathy, unspecified; Sepsis, unspecified organism; Urinary tract infection, site not specified; Cerebral infarction, unspecified; Type 2 diabetes mellitus without complications; Generalized anxiety disorder; Depression, unspecified; Essential (primary) hypertension; Hyperlipidemia, unspecified; Unsteadiness on feet; Other lack of coordination; Need for assistance with personal care; Difficulty in walking, not elsewhere classified; Muscle weakness(generalized). Per the face sheet, the responsible party was the resident. Review of Medical record of Resident #314 revealed no written Physician Order for half bed rails (pivot assist bars) for mobility and positioning. Review of Medical Record of Resident #314's Care Plan, undated with updates made between 6/22/2023 and 7/27/2023, revealed there was no care plan addressing the use of bilateral half bedrails or pivot assist device on resident's bed. Review of Medical record of Resident #314 reveals no Physical Device Acknowledgement form (bed rail/pivot assist bars consent) for the pivot assist bars (half bed rails) signed by the resident's responsible party. Observation on 08/29/2023 at 10:03 AM revealed Resident #314 sitting in bed watching television with both half bedrails/pivot assist bars raised. Call light was wrapped on the bed rail. Observation on 08/30/2023 at 02:55 AM revealed Resident #314 lying her in bed sleeping with television on. Resident #314's bed was equipped with half bed rails (pivot assist bars) that were raised on each side. Observation on 8/31/2023 at 09:55 AM revealed Resident #314 in bed eating breakfast; both half side rails/pivot assist bars were raised. In an interview with Administrator on 8/31/2023 at 10:35 AM, the facility has used the pivot assist enabler bars on every bed in the facility since 2020 and had not obtained physician orders or signed consent. Administrator A maintains that the pivot assist bars are not bed rails and bases this on the manufacturer's product statement flyer and that the beds are custom. Administrator A stated the pivot assist bars can swing out to aid in standing if an individual is sitting on the edge of the bed. Administrator A, in an email dated 8/31/2023 at 11:17 AM, when asked for consents for bed rail/pivot assist bars stated however we will not have consent forms for the assistive devices as they are not side rails and therefore not required. In an interview on 08/31/2023 at 8:58 AM, DON reviewed facility process and policy for bed rail and grab bars/pivot assist bars use. DON stated the bed rails and grab bars/pivot assist devices are used for residents for positioning and comfort. DON stated that on admission residents are informed about the facility use and evaluated for extent of need for bed rails and grab bars/ pivot assist bars; Residents were also reviewed quarterly or when care is plan updated. DON stated this facility did not call them bed rails rather they called them supportive devices. DON stated that the grab bars/pivot assist bars were also used to anchor the call light cable to make sure it did not fall on ground and was more available for resident use. DON stated that when a family member or resident did not want the grab bars/pivot assist bars to be used, the facility would put them in a down position or have them removed. DON stated that electronic health records should be updated with resident evaluations for safe use of bed rails and grab bars/pivot assist bars and that staff should be reviewing and familiar with resident status in their care areas. Interview with LVN A on 8/30/23 at 1:36 PM about bed rail or grab bar/pivot assist bar use in the facility. LVN A stated she would check orders for new residents for information on need for bed rails or grab bars/pivot assist bars being used or if a change in use or position of the bars is noticed. LVN A stated that bed rails can be a hazard as a resident could be hurt by choking on a cord anchored on the rail, having limb caught in the open spaces of the bar resulting in fractures or injury. Interview with LVN B on 8/30/23 at 2:10 PM about bed rail or grab bar/pivot assist bar use in the facility. LVN B stated she checks the electronic chart of residents she was not familiar with for the reasoning for use of bed rails or grab bars/pivot assist bars. LVN B stated that bed rails or grab bars/pivot assist bars can be dangerous due to the potential of injury to a resident getting caught in the bars and because the bars may be seen as a restraint. Interview with CNA C on 8/30/23 at 1:55 PM about bed rail or grab bar/pivot assist bar use in the facility. CNA C states that she would verify with a floor nurse if she saw a change in use of bed rails or grab bars/pivot assist bars for a resident and verified what the need for the bars or change in use. CNA C stated that bed rails and grab bars/pivot assist bars can be a danger as they can be a restraint and limit mobility of a resident. Facility provided product statement flyer, undated, by [Company Name], the manufacturer of the bed rails/grab pivot assist bars in use by facility. The statement states that the product is not a bed rail but a three position pivoting assist device . and does not fulfill all the criteria indicated in CMS F604 §483.10 Euro Respect and Dignity. Facility Administrator states that as the manufacturer Product Statement is specific that these pivot assist bars are not side rails that the facility does not care plan their use, obtain consent or physician orders. Record review of the facility's provided Proper Use of Side Rails, ©2001 [Company Name] (Revised December 2016), revealed the purpose To ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guideline item #2 states Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. General Guideline #3 states An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. General Guideline #4 states The use of side rails as an assistive device will be addressed in the resident care plan. General Guideline #5 states Consent for using restrictive devices will be obtained from resident or legal representative per facility protocol. General Guideline #7 states Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. No General Guideline item indicated need for a physician order before side rails or pivot assist bars can be used or installed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that 3 of 10 residents (Resident # 2, Resident #3, Resident #4) reviewed for pressure ulcers and wounds received the necessary treatment and services, consistent with professional standards of practice, to provide wound healing. 1) The facility failed to implement interventions of providing wound care as needed on Resident #2's left heel. 2) The facility failed to ensure Resident #4's sacral wound was covered with a dressing. 3) The facility failed to implement wound care on 08/25/23 for Resident #3's right great toe. These failures could place residents with pressure ulcers and wounds at risk for worsening of pressure injuries and wounds. Findings included: 1) Record review of Resident #2's MDS assessment dated [DATE], reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's diagnoses included Unspecified fracture of left femur, unspecified fall, essential (primary) hypertension, peripheral vascular disease, pain in left hand, lack of coordination, muscle weakness, unsteadiness on feet, difficulty walking, pain in left hip. The resident's health conditions included repair of fractures of the pelvis, hip, leg, knee, or ankle. The resident skin conditions include 3 unstageable deep tissue injury. The resident had a BIMS score of 14, indicating the resident is cognitively intact. She required limited assistance of one person with ADL's and was incontinent of both bowel and bladder. She had limited mobility in one lower extremity and required the assistance of one person with transfers to her walker. Record review of Resident #2's Skin Evaluation Form dated 08/22/23 reflected the resident had a unstageable pressure injury to the left heel of the foot. The size of the pressure injury included a length (L) x 3.6cm width (W) x 3.6cm and depth (D) x 0.4cm. The wound was described 40% granulation (new connective tissue), and 30% necrotic (dead tissue), 30% slough (a form of dead tissue) with Tissue type 4 necrotic/eschar and serosanguineous (pink/brown) drainage. Record review of Resident #2's Care Plan dated 08/03/23 reflected she had unstageable pressure wound to the left heel and will show signs of healing by the next review date. The care plan stated, treatment as follows: clean with ns, pat dry, apply calcium alginate with AG, cover with dry dressing every Tuesday and Friday and PRN if becomes soiled/dislodged. Review of Resident #2's Physician's Orders dated 08/04/23 and 08/16/23 (respectively) revealed wound care orders for the following; 1. Start Date: 08/04/23 wound care- twice a week cleanse unstageable pressure wound to left heel with NS, pat dry, apply calcium alginate with Ag, cover with dry dressing 2 times a week on Tuesday and Friday and PRN if becomes soiled/dislodged. 2. Start Date: 08/16/23 PRN wound care- as needed cleanse unstageable pressure wound to left heel with NS, pat dry, apply calcium alginate with Ag, cover with dry dressing 2 times a week on Tuesday and Friday and PRN if becomes soiled/dislodged Review of Resident #2's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated August 2023 revealed when the wound care treatment was performed the nurse would indicate this with her initials. According to the eTAR wound care start date was 08/04/23 and was provided on 08/18/23, 08/22/23, and 8/25/23 for the left heel. When the procedure was not performed an X would take the place of the nurses' initials. The as needed wound care order was not listed on the eTAR until the day of surveyor entry on 08/26/23. The eTAR revealed 08/26/23 was the only day Resident #2 had received as needed wound care. Review of nurse's notes revealed Resident #2 did not refuse wound care in August 2023. Interview on 08/26/23 at 12:18 PM with the Resident #2 family member revealed the Resident #2 only spoke Spanish. The Family member stated Resident #2 had been at the facility for 3 weeks. The Family member stated the resident was getting wound care on the left heel and there was a large blister that had been drained by the wound care doctor. She stated the resident had walked a lot which caused the heel to drain to the point of Resident #2's sheets would often get changed. The Family member stated wound care was provided only upon request. The Family member stated Initially the staff would do the resident's wound care often and the wound was getting worse because it was a open wound. The Family member stated Resident #2's left heel drained so much the facility had left a small kit in the resident's room for the family to change the dressing. The Family member stated she had changed the resident dressing last night. Record review revealed Resident #2 had muscle tissue debridement performed by surgical excision of devitalized subcutaneous muscle on 08/15/23. Observation on 08/26/23 at approximately 12:30 PM revealed Resident #2 had no date on the left heel dressing. Observation revealed the family member had removed Resident #2's dressing because the bottom of the dressing was saturated with pink/brown fluid. The family member had check the bag of supplies given to her by Resident #2's left heel pressure ulcers had shown the top two layers of the skin was absent and draining clear fluid towards the bottom of the heel, and black necrotic (dead) tissue on top. The pressure ulcer was approximately (L)3cm x (W)3cm x (D) 0.5cm. Interview on 08/26/23 at 1:17 PM with Wound Care Nurse revealed Resident #2 was to receive wound care for her left heel twice weekly on Tuesdays and Fridays and as needed if the dressing become dislodged. She stated she would be responsible for Resident #2's scheduled dressing changes and the floor nurses were responsible for as needed and weekend dressing changes. She stated the left heel was unstable (there may been [NAME]/ dead tissue, but you need to see the bed to accurately stage it). She stated family was not allowed to provide wound care to residents because it can delay healing and she was not aware that family was providing wound care for Resident #2. The Wound Care Nurse stated she did complete in-services on wound care in the last month. Interview on 08/26/23 at 1:56 PM with LVN A revealed Resident #2's left foot has an unstageable ulcer with the bottom edges open with drainage. He stated the family was usually good at keeping up with the wound care. He stated the family was not supposed to provide wound care because the resident would pose the risk of infection. LVN A stated he had completed in-services on wound care in the last month. Interview on 08/27/23 at 3:57 PM with the Wound Care Physician revealed Resident #2 was admitted with a left heel pressure ulcer. She stated Resident #2 was seen on 08/08/23, 08/15/23, and 08/22/23 was admitted with a deep tissue injury ulcer of the left heel and was a blood blister which meant the wound was at a muscular level. She stated the wound on the left heel was unstageable (will be at the muscular or the bone level). She stated unstageable was somewhere between stage 3 or 4. The Wound Care Physician stated the Left heel was at the 50% slough and granulation Unstageable. She stated the dressing changes was on Tuesday and Friday and prn if dislodged. She stated she was not aware that family was providing wound care and given supplies to complete the intervention. The Wound Care Physician stated Resident #2's left heel was to be always covered because it had sanguineous drainage coming from the wound. She stated the risks of the family members performing wound care for Resident #2 could cause an infection and delayed wound healing. Interview on 08/27/23 at 6:38 PM with the DON (Director of Nursing) revealed Resident #2 was being treated for wound care on the left heel. He stated the family was not allowed to provide wound care to Resident #2. He stated he was not aware that family was providing wound care to Resident #2. The DON stated, the nurses are the only employees allowed to do wound care for the residents. He stated the treatment nurse was responsible for wounds during the week and the floor nurses were responsible for wound care on the weekends. He stated the wounds were supposed to be covered all times. The DON stated the risks of allowing a family member provide dressing changes could delay healing. 2) Record review of Resident #3's MDS assessment dated [DATE], reflected she was an [AGE] year-old male, who had a current admit date to the facility on [DATE]. The resident's diagnoses included presence of left artificial hip joint, post covid-19, anemia, fall, peripheral vascular disease, cutaneous abscess of the right limb, chronic kidney disease, heart failure, presence of cardiac pacemaker, sinus syndrome, and need for assistance with personal care. The resident had a BIMS score of 15, he was cognitively intact. He required limited assistance of one person with ADL's and was incontinent of both bowel and bladder. He had limited mobility in the lower extremities and required partial/ moderate assistance. Record review of Resident #3's Care Plan dated 07/27/23 revealed he had peripheral vascular disease- right 1st metacarpal joint and treatment should be followed per doctor orders. Review of Resident #3's Physician's Orders dated 07/10/23 and 07/19/23 (respectively) revealed wound care orders for the following. 1. Start Date: 08/02/23 wound care- once daily cleanse right 1st metatarsal joint with normal saline, pat dry, apply Santyl, apply derma blue foam, cover with dry dressing 3 times on Monday, Wednesday, and Friday and as needed if became dislodge. 2. Start Date: 08/02/23 PRN wound care- cleanse right 1st metatarsal joint with normal saline, pat dry, apply Santyl, apply derma blue foam, cover with dry dressing 3 times on Monday, Wednesday, and Friday and as needed if became dislodge. Review of Resident #3's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated August 2023 revealed when the wound care treatment was performed the nurse would indicate this with her initials. According to the eTAR wound care start date was 08/02/23 and was provided on the right 1st metatarsal joint. The eTAR revealed wound care had not been completed on 08/25/23. Review of nurse's notes revealed Resident #3 did not refuse wound care in August 2023. Observation on 08/26/23 at 9:13 PM with the Wound Care Nurse revealed Resident #3's dressing on his right 1st metatarsal joint was dated for 8/24. The wound dressing appeared to look old and the edges were pulled up. She had cleaned the wound with normal saline and had applied a dressing dated for 8/27. The wound had shown signs of healing with approximated edges, skin around the wound was yellow and pink. Interview on 08/26/23 at 1:17 PM with the Wound Care Nurse revealed Resident #3's Right toe dressing was to be changed three times a week on Monday, Wednesday, and Friday. She stated Resident #3 should have had wound care done on 08/25/23 and because the wound dressing was labeled 08/24/23 then wound care was not done on the 08/25/23 as ordered. Wound Care Nurse stated she was responsible for providing wound care Monday- Friday and floor nurses was responsible Saturday and Sunday and in her absence during the week. Wound Care Nurse did confirm she was at work on 8/25/23. She stated the risk were delayed wound healing. The Wound Care Nurse stated she had received an Inservice on medication administration in the last month. Interview on 08/27/23 at 3:57 PM with the Wound Care Physician revealed Resident #3 was seen on 08/08/23, 08/15/23, and 08/22/23. She stated, Resident #3 has a right 1st metatarsal joint wound due to peripheral vascular disease. Order for ointment Monday, Wednesday, and Friday and prn if the dressings dislodged or soiled. The Wound Care Physician stated the risks of not receiving wound care on ordered days would delay wound healing. Interview on 08/27/23 at approximately 6:38 PM with DON (Director of Nursing) revealed Resident #3 was seen for wound care. He stated the resident was ordered to receive wound care on right 1st metatarsal joint on Mondays, Wednesdays, Friday, and as needed when dressing had become dislodged. He stated the expectation for staff was to use the correct date for dressing every time the dressing was changed. The DON stated the date was applied to a wound dressing was to ensure wound care had been provided for that day. He stated the nurses were responsible for ensuring the dressing change was completed. He stated the risks of not performing wound care for the resident as ordered could lead to delayed wound healing. The DON stated the staff had received an Inservice on wound care in the last month. Interview on 08/27/23 at approximately 6:45 PM with the Administrator revealed she had spoken with the Wound Care Nurse and 08/25/23 was a missed date on eTAR for Resident #3. Interview on 08/27/23 at approximately 6:46 PM with the DON revealed missed dates that were not documented on the eTAR would put Resident #3 at risk for delayed healing. 3) Record review of Resident #4's MDS assessment dated [DATE], reflected she was an [AGE] year-old female, who had a current admit date to the facility on [DATE]. The resident's diagnoses included benign neoplasm, history of venous thrombosis, type 2 diabetes, depression, hypothyroidism, hyperlipidemia, aortic valve stenosis, and anxiety disorder. The resident had a BIMS score of 6, indicating severe cognitive impairment. She had required extensive assistance of one person with ADL's and was incontinent of both bowel and bladder. Record review of Resident #4's Care Plan dated 07/27/23 revealed she had a potential for skin breakdown due to: cognitive deficit, urinary in continence, and bowel incontinence. Staff were to minimize exposure to moisture and assist with toileting or provide incontinence care. Review of Resident #4's Physician's Orders dated 08/22/23 revealed wound care orders for the following; 1. Start Date: 08/22/23 wound care- once daily cleanse right upper buttocks with NS, pat dry, apply collagen powder, cover with dry dressing daily and as needed if became soiled/dislodge. 2. Start Date: 08/02/23 as needed wound care- as needed cleanse right upper buttocks with NS, pat dry, apply collagen powder, cover with dry dressing daily and as needed if became soiled/dislodge. Review of Resident #4's electronic Treatment Administration Record (eTAR) and eTAR Notes, dated August 2023 revealed when the wound care treatment was performed the nurse would indicate this with her initials. According to the eTAR wound care start date was 08/22/23 and was provided on the right upper buttocks. The eTAR revealed as needed wound care had not been added or completed on 08/27/23. Review of nurse's notes revealed Resident #4 did not refuse wound care in August 2023. Interview and observation on 08/27/23 at 9:42 AM with Resident #4 stated she was in pain on her bottom. The Wound Care Nurse had asked Resident #4 if she wanted pain medication. The resident had refused at that time, but as the nurse was turning the resident the resident yelled ouch, ouch and stated she was in pain on her bottom, and she could not be turned no further. The resident requested her pain medications. The Wound care nurse stopped and informed the floor nurse resident need for pain medication. Observation on 08/27/23 at 9:53 AM of Wound Care Nurse and CNA C revealed Resident #4 tolerated the body turn but complained of pain on her bottom. Resident #4 was given pain medication. There were no dressing on the resident's right upper buttocks. The nursed had opened the brief to look for the dressing, but there were no dressing in the brief or on the resident's bed. The Wound was open and red with underlying tissue exposed at approximately (L) 2cm x (W) 3cm. The resident had asked, is that what hurt so bad and Wound Care Nurse responded by saying, you have an open sore on your bottom. The Wound Care Nurse and CNA C had proceeded to provide incontinent care to the resident because her brief was wet. Interview on 08/27/23 at 10:13 AM with LVN B revealed she must clean Resident #4 very often because of how Resident #4 would slide down in her chair and incontinent care causes dressings to become dislodged. LVN B stated the last time she had provided wound care was 08/26/23 after it had gotten dislodge, but she did not have documentation of the time. The nurse stated she did not chart the prn wound changes because she just does not. However, she said the last charted wound change was for 08/26/23 at 9:42 AM. She stated Resident #4's wound was located on her coccyx area in between the glutes at the top with redness around the open with jagged edges. She stated the resident had voiced and exhibited pain regarding her wound. She stated when she gets the wound cleaned, she voices that she is in pain and will say ouch. She stated she was not aware of the resident wound being uncovered. LVN B stated the wound was not supposed to be uncovered, it was to always remain covered. She stated the resident was to receive daily and prn when dressing dislodge. The cna will let the nurse know when the dressing dislodges. She stated if Resident #4 wound was not covered, the risk had posed infection and delay of wound healing. She stated the last skin assessment on the resident was yesterday 08/26/23 and she does not recall the last time the resident was seen by a physician. She stated the wound looks the same as it did when wound care first had begun. She stated whenever staff would inform her of an uncovered wound she would immediately to clean and cover the area. She stated the resident had not voiced that she was not receiving wound care or that her wound was not covered. She stated she had received in services on wound care in the last month. Interview on 08/27/23 at approximately 10:30 AM with CNA C revealed she was caring for Resident #4. She stated Resident #4 had wounds on the right side below the coccyx area. She stated Wound Care Nurse or LVN B provide wound care. She stated the wound was supposed to be always covered. She stated she had noticed this morning around 8 am the dressing was missing, and it was not inside the resident brief at that time. CNA C stated she did not know how long Resident #4's dressing had been uncovered. She stated she did not inform LVN B immediately about the wound being uncovered because breakfast trays were already being passed. CNA C stated she was rushing to get Resident #4 up and dressed and to the dining area. She stated she would inform LVN B once she had brought the resident to her room. She stated when Resident #4's wound was uncovered or soiled, she was supposed to notify LVN B immediately after. CNA C stated she had completed in services on wound as it related to providing incontinent care. She stated the risks for leaving a wound uncovered could cause an infection. Interview on 08/27/23 at 10:55 AM with the Wound Care Nurse revealed the wound care physician would come on Tuesday and she rounds with her. She stated Resident #4 was seen by the wound care physician. She stated Resident #4 had moisture associated skin damage. She stated it was typically diagnosed for residents with incontinent or residents with yeast folds. She stated the wound was located on the upper buttocks but was not a pressure wound because it was moisture associated. She stated the wound was located on the right upper buttocks. She stated the wound was painful for the resident during the time of wound care that was performed. She stated the resident had not experienced pain from her wound prior to today. She stated the resident received wound care daily. She stated the resident can verbalize needs but has moments of confusion. She stated she completes wound care during the week for Resident #4 and the floor nurses would complete wound care on the weekends. She stated the resident's wound was not covered when she went to perform wound care. She stated the resident's wound was to be covered due to daily wound care and she was supposed to have a dressing on her wound. She stated if the dressing had become dislodged a new dressing was supposed to be applied. She stated she did not know the approximate dimensions but said her wound was better. She stated if the CNA saw the residents dressing was off Resident #4 right upper buttocks, the nurse should have been notified to place a dressing on the wound. She stated there was a risk of infection because the wound was open and could deteriorate. She stated the wound had minimal redness. She stated the minimal redness could also be from her having an open wound. Interview on 08/27/23 at approximately 3:57 PM with the Wound Care Physician revealed Resident #4 was seen on 8/15/23. She stated Resident #4 wound was not a pressure ulcer because the wound was not on a bony prominence. She stated Resident #4 had an upper right buttock wound due to moisture skin damage. Right buttocks orders were daily and as needed. She stated when the dressing had dislodged the dressing needed to get replaced. Wound Care Physician stated the risk of leaving open wounds uncovered would delay wound healing. Interview on 08/27/23 at approximately 6:38 PM with the DON (Director of Nursing) revealed Resident #4 had a wound on the upper right buttocks. He stated the wound was to be covered with dry dressing. The DON stated the orders stated the resident wound was to remain covered with dry dressing daily prn or if it gets dislodged. He stated Resident #4 was at risk for delayed wound healing if the wound was not covered. He stated Wound Care Nurse was responsible for Resident #4 wound care during the week and the floor nurse was responsible for wound care on the weekend. He stated the expectation of staff was to notify the nurse immediately when they see a wound was not covered or dressed. The DON stated the staff had received an Inservice on wound care in the last month. Review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol policy dated April 2018 reflected, The physical will help staff characterize the likelihood of wound healing based on review of pertinent factors' for example: Healing or Prevention Likely: The resident's underlying physical condition, prognosis, personal goals, and wishes, care instructions, and ability to cooperate with the treatment plan make wound healing and subsequent wound prevention realistic .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for one (Vista 8 Nurse Medication Cart) of eight medication carts observed for Pharmaceutical Services, in that: LVN A did not continue to count, maintain, or periodically reconcile three medication blister packs of a controlled drug (Oxycodone - a schedule II narcotic pain reliever) that remained on the Vista 8 medication cart after Resident #1's discharge from the facility on [DATE]. This failure risks possible drug diversion due to controlled medications accessible to staff after a resident's discharge from the facility. The findings were: Resident #1's closed clinical records indicated the resident was a [AGE] year-old admitted to the facility on [DATE] to Vista 8 - room [ROOM NUMBER]. Resident #1 had medically complex conditions and diagnoses, including Muscle Weakness (Generalized); Unsteadiness on Feet; Difficulty in Walking, Not Elsewhere Class; Need for Assistance with Personal Care; And Dysphagia, Oral Phase. An MDS assessment dated [DATE] indicated the resident had a BIMS score of 09, which indicate a moderately impaired cognition per staff assessment. The MDS pain assessment indicated Resident #1 received a scheduled and PRN pain medication regimen for occasional pain intensity rated 5/10 using a numerical rating scale. Resident #1's baseline care plan showed a Left AKA (Above the Knee Amputation) and diabetic foot ulcer/gangrene (dead tissue caused by an infection or lack of blood flow). The baseline care plan interventions included: Physical and Occupational Therapy to strengthen the right lower extremity and body for safe transferring; the bed in a low position; frequent rounding; and call light within reach as fall prevention interventions. High-risk medications identified included psychotropic, anticoagulant, and pain medication - Oxycodone. Record review of Resident#1's Physician's orders dated [DATE] revealed the admitting nurse, RN C, transcribed an order for Oxycodone 5 mg tablet [generic] - 0.5 tablet by mouth every 4 hours as needed for Pain. The pharmacy delivered Rx# 13823099, 84 halved tabs, on [DATE]. Record review of Resident#1's Controlled Drug Receipt/Record/Disposition Form dated [DATE] indicated Oxycodone 5 mg 1 tablet was last administered on [DATE] @ 2350 (11:50 PM). The facility failed to provide a copy of Resident #1's PRN (as needed) Medication Administration Record (MAR) for [DATE] upon request by the surveyor. The [DATE] MAR received by the facility only listed scheduled medications and did not show Oxycodone 5mg tablets prescribed on a PRN basis, which is requested by the resident as needed for Pain. During an observation on [DATE] at 9:53 AM with LVN A of the Vista 8 nurse medication cart, three medication blister packs wrapped with the matching Controlled Drug Receipt/Record/Disposition Form were discovered in the bottom of the narcotic drawer, separate from other controlled medications. The medication label on the medication blister packs displayed Resident #1's name and reflected Rx# 13823099 - #1 of 3 (8 half tablets), #2 of 3 (30 half tablets), and #3 of 3 (24 half tablets) with #16 punched out - there were a total of 62 halved tablets. During an interview on [DATE] at 9:53 AM, LVN A said that she wrapped the matching Controlled Drug Receipt/Record/Disposition Form around the three medication blister packs and placed them in the bottom of the drawer about a week ago after learning that Resident #1 had discharged . LVN A could not recall how she learned of the discharge; she thought maybe on the electronic health record (EHR) dashboard. LVN A did not know how long the resident was gone from the facility. LVN A stated the compliance nurse would come through and collect any controlled medications remaining after a resident discharge. LVN A said she had not counted the pills since she placed them at the bottom of the drawer. LVN A stated the risk of not removing the controlled drugs from the medication cart per policy; could forget about the medications, or someone could steal them. During an interview on [DATE] at 10:24 AM, ADON B indicated she generally made daily rounds to ensure expired or unused (after a resident discharge) controlled medications were counted, removed from the medication carts, and delivered to the DON for drug destruction. ADON B said the process of removing drugs was no later than three days after a resident was transferred to the hospital (in case of the resident returns). When asked about Resident #1, ADON B was unsure of the discharge date , then later said it was [DATE]. ADON B denied knowledge of unused narcotics still on the cart. She stated she had not conducted rounds recently to remove controlled medications. She noted the compliance officer had collected controlled medications in the past; however, have informed nurses scheduled on the Vista 8 Unit to notify her to remove drugs from the medication cart. ADON B said the nurses had received training to count pills and do reconciliation. ADON B said the count was supposed to be done for each controlled medication on each shift, including discontinued and unused drugs for discharged residents until removed. On [DATE] at 10:47 AM, ADON B accompanied the surveyor to the Vista 8 Nurse Medication Cart, where the discovered medications remained. ADON B told LVN A that she is to give all unused medications after a resident discharge, including controlled drugs, to ADON B as soon as possible. ADON B and LVN A verified the count of the three medication blister packs of Oxycodone. ADON B made a new entry on the Controlled Drug Receipt/Record/Disposition Form with the date, circled the total number of pills, and both nurses signed alongside the count. ADON B stated that she would generally lock controlled drugs in a desk drawer in her office or take them to the DON if not busy but would take them to DON now. The DON met ADON B and the surveyor at her office on the 5th floor. The DON unlocked the door to gain entrance into her office. ADON B and DON confirmed the count of the three medication blister packs of Oxycodone, and the DON unlocked a cabinet to store the medications. During an interview on [DATE] at 10:56 AM, the DON stated there was no risk for not logging receipt of the medications right away, why would I need to log the medications in right away when we both signed, and we know I received them? When asked what the system was to account for the receipt of all controlled drugs and to prevent drug diversion, it was at that time that the DON logged in the medications brought by the ADON B onto a Drug Destruction Inventory List. The DON stated she is responsible for the control of medication for disposal and must schedule an hour or two on Fridays just to log in medications because she does not always have time. The DON said if she didn't log in the medications upon receipt, liquid medications could spill on them, or a pill could pop out of the blister pack. The DON stated the purpose of the Drug Destruction Inventory List is to account for all controlled medication for destruction. The DON said if a prescription were not on the Drug Destruction Inventory List, the pharmacist, nor anyone else, would know of the medicine, and if it were not on the log, it could go unnoticed or stolen. In an interview on [DATE] at 5:26 PM, the Administrator said the nurses should know to remove discharged residents and discontinued medications from their medication carts. The Administrator said nurses were in-serviced by the DON and ADONs (ADON B - Vista 8 and ADON D - Vista 5, Vista 7) on drug diversion and proper protocols for counting narcotics, destroying narcotics, and managing medication carts on [DATE] to prevent drug diversion or accidental exposure. Controlled medications are given to the DON to log and secure for destruction. Review of the facility's Discontinued Medications, Med Pass policy revised [DATE] stated, in part, the following: Discontinued medication must be destroyed or returned . following established procedures. Review of the facility's Drug Diversion policy dated [DATE] stated, in part, the following: Controlled substances in Schedules II, III, and IV are subject to special handling, storage, disposal, and record-keeping requirements. The Director of Nursing is responsible for the control of such drugs. A physical inventory of these medications will be made at the change of each nursing shift. A review of the facility's Discarding and Destroying Medications, Med Pass policy revised in [DATE] stated, in part, the following: Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's primary kitchen where all facility food is prepared. 1. The facility failed to ensure food items were covered, labelled, and dated. 2. The facility failed to ensure food items were kept away from airborne contaminants. 3. The facility failed to ensure raw food items were stored on the lowest shelf. These failures could place 84 of 86 residents, who receive food from the kitchen, at risk for food contamination and foodborne illness. Findings included: Observation on 08/01/2022 at 10:19am revealed fuzzy dust clumps on the door frame and automatic door closer on both doors leading into the kitchen. Dust and fuzz clumps were also observed in the kitchen, on the utensil rack hanging over the food preparation area. A dried yellow substance was observed inside the bottom of the double door refrigerator adjacent to the food prep area. The vents on top of the refrigerator were coated with grease and dust. An interview on 08/01/2022 at 10:25am with the Director of Dining Services revealed kitchen staff were responsible for ensuring the kitchen and equipment are clean and free of any dust and grease buildup. When asked about a cleaning schedule, he said he would ask the Soux Chef. He said it is the kitchen staff's responsibility to ensure all equipment is cleaned regularly and free of any type of contaminant that may get into food. He said any buildup of dust and fuzz could become dislodged and end up in food which could place all residents who receive food from the kitchen at risk of foodbourne illness. An observation on 08/01/2022 at 10:55am revealed five trays of raw Tilapia fish on a portable rack in the walk-in cooler. The fish was not covered, labeled, or dated. Another portable rack contained a tray of five plates each containing three scoops of prepared food, none were labeled or dated. A third portable rack contained a tray of raw Bavarian sausages on top of a tray of cooked chicken. A metal insert containing raw breakfast sausages was observed on a stationary rack without a label or date. An interview on 08/01/2022 at 11:05am with the Sous Chef revealed the prepared plates were mechanical soft meals consisting of fish, potatoes, and broccoli. He said he believed the mechanical soft meals were prepared 07/31/2022 for service on 08/01/2022 but could not be sure when they were prepared. He said he was not sure when the Tilapia was placed on the trays in the walk-in cooler. He said the prepared meal plates should be labeled and dated. He stated the Tilapia should be covered, labeled, and dated to ensure it is good and staff know how old the food is. When asked why the raw sausages were above the cooked chicken on the portable rack, he said he was not sure but would ask the cook about it. He said raw meat should always be stored on the lowest shelf to prevent the posisbility of foodbourne illness. He left the walk-in cooler and returned to say the cook told him the sausages were cooked and could be stored above the cooked chicken. When asked what he thought, he said he was going to check the box to see if the sausages were cooked. When asked what he was going to do with the undated / labeled food items, he said he was going to cook them immediately. In an interview on 08/01/2022 at 11:15am the Director of Dining Services stated there was no need to check the box, the sausages stored on the portable rack above the cooked chicken were raw and should be stored on the bottom shelf rather than over the cooked chicken. He said all food should be properly stored to prevent any contamination or foodborne illness. He said this includes covering, dating, and labeling all food. He said the raw tilapia, prepared mechanical soft meals, sausages, and cooked chicken needed to be discarded because it was not stored appropriately and poses a risk of foodborne illness to all residents eating food from the kitchen. He said he would in-service the Sous Chef and staff immediately. An interview on 08/03/2022 at 8:15am with the Administrator revealed her expectation is that all food coming from the kitchen be stored and prepared in a way that prevents any risk of foodborne illness to residents. She said kitchen staff are responsible for ensuring the kitchen and equiptment are kept clean and sanitary. A record review revealed 26 kitchen staff were in-serviced 08/01/2022 on cross contamination and food safety by the Director of Dining Services. The Sous Chef and [NAME] were not listed on the sign in sheet for the in-service. A record review of the facility's Cleaning and Sanitizing policy dated 02/01/2022 revealed the purpose of the policy is to prevent foodborne illness by ensuring that all food and non-food contact surfaces are properly cleaned and sanitized to reduce dangerous pathogens to safe levels.all culinary staff are responsible .Sous Chef will preform random walk throughs and records to ensure proper cleaning and sanitizing is taking place. A record review of the facility's Cross Contamination policy dated 02/01/2022 revealed .all foods shall be stored in clean covered containers in a manner to avoid the contamination of food . raw animal foods shall be stored on the lowest shelves .staff will discard food visually observed as contaminated . A record review of the facility's First In / First Out policy dated 02/01/2022 revealed .a food rotation system is essential for storing food to prevent foodborne illness . follow label by use dates . A record review on 08/4/2022 at 12:00 pm of FDA Food Code dated 2017 section: 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables, (b) Cooked READY-TO-EAT FOOD; 3-305.14 Food Preparation revealed: During preparation, unpackaged FOOD shall be protected from environmental sources of contamination; 4-601.11 Equipment, Food-Contact Surfaces, Nonfood- Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. 4-602.13 Nonfood-Contact Surfaces. Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.