**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 1 (Resident #1) of 4 residents whose records were reviewed for accuracy and completeness. -The facility failed to document Resident #1's fall incident per policy in an incident report. This deficient practice could place residents at risk for improper care due to incomplete or inaccurate records. Findings included: Record review of Resident #1's admission Record dated 03/25/2025, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included lack of coordination, weakness, and falls. Record review of Resident #1's MDS assessment dated [DATE], revealed a BIMS score of 11 indicating moderate cognitive impairment. Record review of Resident #1's Progress Notes dated 02/27/2025 at 3:28 p.m., reads in part notify MD and NP, patient found sitting on the floor by the toilet. Patient assessed and no injuries noted. Patient stated he really needed to go to the restroom. Nurse notified MD and NP, and called FM. Review of facility incident/accident log from January 2025 to 03/25/2025, revealed no information related to Resident #1 having a fall. During an interview on 03/26/2025 at 9:53 a.m., LVN E said on 02/27/2025 during her shift, Resident #1 had a fall. LVN E said she had been out to lunch and when she came back the other nurse LVN F said they found Resident #1 down in the restroom. LVN E said she assessed Resident #1, and he told her that he needed to go to the restroom and did so independently without calling or waiting for assistance. LVN E said Resident #1 did not have any injuries or complaint of pain or discomfort. LVN E said she documented the fall in the progress notes but was not sure if an incident report had been completed. During an interview on 03/26/2025 at 10:08 a.m., LVN F said on 02/27/2025 he covered LVN E's hall while she went for lunch. LVN F said CNA H called him and said Resident #1 fell. LVN F said Resident #1 got up and went to bed. LVN F said Resident #1 denied hitting his head or any pain. LVN F said he told LVN E when she got back about the fall. LVN F said he did not complete any documentation regarding the fall as LVN E returned and took over. During an interview on 03/26/2025 at 10:34 a.m., CNA H said on 2/27/2025, Resident #1 went to the restroom by himself. CNA H said Resident #1 pulled the call button cord in the restroom which she responded to and found Resident #1 on the restroom floor in a seated position. CNA H said Resident #1 did not complain of any pain and said he was fine. CNA H said Resident #1 got up and sat on the wheelchair and went back to bed while LVN F was notified of the fall. CNA H said she was not aware of any incident report that needed to be completed about the fall and said that nurses are the ones who document. During an interview on 03/26/2025 at 10:50 a.m., the DON said an incident report should be generated for all falls. The DON said an incident report was not done for Resident #1's fall on 02/27/2025. The DON said generating an incident report would help to track incidents involving residents. The DON said the risk of failing to complete an incident report was resident record would not be accurate which may affect care provided to the resident especially regarding injuries and notifications. The DON said for this incident Resident #1 was assessed and found to be without injury. The DON said the person responsible to ensure completion of an incident report would be the nurses, nurse management including the DON. Review of facility provided Incidents - Accidents policy dated 11/2018, reads in part the facility shall maintain a file of all written reports of each incident and accident affecting a resident that is not an expected outcome of a resident's condition or disease process.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. -Access to trash can next to handwashing sink was not hands free as the lid of the trash can was damaged. -The facility failed to ensure food items in the facility's only walk-in refrigerator were sealed and labeled appropriately. -The facility failed to ensure food items in the facility's only walk-in freezer were dated and stored appropriately. -The dishwashing and sanitization machine was dirty with dried caked on substance on top of the machine and streaking down the front of the machine. -The kitchen ice machine was dirty with dried caked on substance around the ice dispenser door. -Multiple vents observed with dust and debris over cooking prep areas. -Wall and ceiling observed with dried yellow splatter in a kitchen prep area. These failures could place residents at risk for food-borne illness, and food contamination. Findings include: Observation on 03/26/2025 at 11:03 a.m., observed next to handwashing sink a small (13 gallon) trashcan with a damaged metal lid. Observed that the foot pedal to access the hands-free lid was not working and the lid was not fully set on top of the trash can. Observation and interview on 03/26/2025 at 11:04 a.m., of the walk-in refrigerator revealed on a storage rack brownish/yellow shredded lettuce wrapped loosely in a cellophane with ends opened (not fully sealed). The lettuce wrapped item was not labeled. Dietary Staff I said that all food items should be labeled with the date that the item was opened. The Dietary Staff I said the food item was not properly sealed and the contents were not fresh or appropriate for use. Dietary Staff I said all staff in the kitchen were responsible to ensure that food was not stored in this manner. Dietary Staff I removed the item to throw away. Observation and interview on 03/26/2025 at 11:06 a.m., of the walk-in freezer revealed a sealed storage bag of unknown food item on a storage rack. The Dietary Staff I said the food item in the storage bag was some type of beef that was removed from the original package. The storage bag was not labeled. The Dietary Staff I said that the bag should have been labeled and was not properly stored in the freezer as it was out of the original package. Observation and interview on 03/26/2025 at 11:08 a.m., observed a food service staff member at a prep station with an open bag of shredded lettuce. The lettuce observed with brownish and yellowish lettuce. The food service staff member said he was going to use the lettuce to make a Caesar salad for a resident. The Dietary Staff I told the food service staff member not to use the lettuce as it appeared brownish. The Dietary Staff I took the bag of lettuce and threw out the lettuce. Observation on 03/26/2025 at 11:10 a.m., revealed the dishwashing and sanitization machine was dirty with dried caked on white substance on top of the machine and streaking down the front of the machine. Observation and interview on 03/26/2025 at 11:10 a.m., revealed in the kitchen prep area, dried yellowish splatter against the wall and ceiling. The Dietary Staff I said that the splatter occurred during the evening shift on 03/24/2025 when another kitchen staff member used the blender, and something went wrong and caused the splatter all over the area. The Dietary Staff I said that the kitchen prep table was cleaned but the wall and ceiling was not cleaned resulting in the pureed food drying up. Observation on 03/26/2025 at 11:15 a.m., revealed ceiling vents over food prep areas were dirty with dark dust on and surrounding the vent. Observation on 03/26/2025 at 11:17 a.m., revealed dried caked on white substance around the ice machine dispenser door in the kitchen. The ice machine was the only one in the kitchen and actively being used. During an interview on 03/27/2025 at 10:45 a.m., the Dietary Manager (DM) said he had been the DM at the facility for a year. The DM said that the splatter on the wall and ceiling in the kitchen prep area occurred on 03/24/2025 when a dietary staff member opened the blender while making pudding and it splashed on the walls. The DM said the prep table was immediately cleaned but the walls and ceiling were not cleaned immediately. The DM said that was not acceptable and the area should have been cleaned. The DM said the vents found dirty over the prep area had been dirty for a few weeks and he had not had an opportunity to clean them. The DM said that dirty vents could affect food prep if dust or debris falls in the prep area causing possible contamination of food. The DM said he had been aware for weeks that the trash bin next to the handwashing station was not in good condition and that he needed to buy a new trash can. The DM said the risk of trash can not being hands free was contamination of hands from touching the lid. The DM said all food items in the refrigerator and freezer should be labeled. The DM said there was no label on the freezer bag for the shredded beef that had been removed out of the original package. The DM said it was all dietary staff members responsibility to check labels and correct if items are not labeled. The DM said the ice machine and dishwashing machine should be wiped down daily to prevent the dried caked on substance. The DM said there was risk that some of the caked-on substance could end up getting mixed in the ice when using the ice machine. The DM said there was a risk that the caked-on substance could get on clean and sanitized dishes that come out of the machine. During an interview on 03/27/2025 at 2:40 p.m., the Administrator said the purpose of a clean kitchen was to ensure everything is sanitary for all residents and prevent food contamination. The Administrator said the risk of not having a clean kitchen was contaminated food. The Administrator said the person responsible to ensure that the kitchen was in good working order was the Dietary Manager (DM). During an interview on 03/27/2025 at 2:45 p.m., the DON said the purpose of a clean kitchen and good dietary services was to prevent food borne illness. The DON said the risk of not have a sanitary kitchen was contaminated food and possible gastro issues. The DON said that there had been no gastro issues at the facility at the time. Review of facility provided Dietary Food Storage policy dated 12/2020, reads in part Food and non-food supplies will be purchased, received and stored under sanitary safe and secure conditions as required to meet, federal, state and local laws. Procedure process included: The Dining Services Manager is responsible for receiving and storing all food and supplies in a proper area. All products will be labeled with the date received in the facility. Review of facility provided Dietary Cleaning Policy dated 12/2020, reads in part This facility will store, prepare, distribute, and serve food under sanitary conditions to ensure that proper sanitation and food handling practices to prevent the outbreak of food borne illnesses is attained continuously. Staff will use a clean as you go technique to keep the facility and neighborhood kitchen areas clean, functional, and attractive. The following areas and equipment will be cleaned daily (included): dishwasher, and kitchen walls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 5 (Resident #3) r esidents reviewed for infection control in that: The facility failed to dispose of Resident #3's dirty brief and wipes smeared with feces that were left on the room floor wrapped in a linen. This failure could place residents at risk for cross contamination resulting in acquired infection. Findings included: Record review of Resident #3 's face sheet dated 07/19/24 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of dementia. Record review of Resident #3's annual MDS assessment dated [DATE] reflected her cognitive was severely impaired. During an interview on 07/12/24 at 4:09 pm, Resident #3's family member was at bedside and denied any concerns with care provided. Resident #3's family member stated the facility kept her room clean and was provided with good care. During an observation on 07/19/24 at 10:59 am revealed Resident #3 was asleep in her bed. 1 brief and 3 wipes were noted at Resident #3's bedside on the floor. The brief and 3 wipes had feces and were wrapped in a linen. During an interview on 07/19/24 at 11:01 am, CNA A stated she was the CNA responsible for Resident #3 and had recently changed her brief. CNA A stated she forgot she left the dirty brief and wipes on the floor, wrapped in a dirty linen. CNA A stated she had intended to pick up but got busy with getting Resident #3 a fresh pitcher of water. CNA A stated she received training upon hire regarding infection prevention during perineal care and included disposing of dirty briefs in a trash bag and keeping dirty linen in a plastic bag to be sent to laundry. CNA A stated she received infection prevention training upon hire and quarterly. CNA A stated risk for leaving dirty brief on the floor was cross contamination. CNA A stated CNAs were responsible for ensuring dirty brief were properly disposed after completing perineal care. During an interview on 07/19/24 at 1:19 pm, the DON stated CNAs and charge nurses were responsible for ensuring no dirty briefs and/or wipes were properly disposed of in a trash bag after perineal care was provided and dirty linens to not be kept in the resident's room. The DON stated it was expected for CNAs have trash can at bedside before starting perineal care to ensure it was readily accessible to dispose pf dirty briefs and/or wipes to avoid leaving them on the floor. The DON stated CNAs had received training on infection prevention with perineal care upon hire and annually. The DON stated failure to dispose of dirty briefs and wipes when left on the floor could place residents at risk for cross contamination. Record review of Infection Control: Handling soiled linen policy dated 09/01/18 read in part It is the policy of [this facility] that linens are handled, stored, processed, and transported so as to prevent the spread of infection . used or soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. Record review of Nursing: Perineal Care policy dated 08/16/17 read in part It is [this facility] practice to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. All staff members involved in performing perineal care to residents will promote cleanliness, prevent infections to the extent possible, prevent and assess for skin breakdown and promote comfort. Procedure: gather supplies needed, always rinse after washing, unless using non-rinse cleanser, maintain clean technique and observe isolation precautions when applicable, knock and gain permission to enter resident's room, provide privacy, inform resident on procedure performed, set up supplies . the policy did not specify disposing of dirty brief and wipes in trash bag/can.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 2 residents (Resident #237) reviewed for peripheral intravenous care. The facility failed to ensure Resident #237's midline dressing was changed after becoming soiled on 6/2/24. This failure could place residents at risk of developing an infection. The findings included: Review of Resident #237's admission Record, dated 6/5/24, revealed he was a [AGE] year old male admitted to the facility on [DATE]. Review of Resident #237's admission MDS Assessment, dated 5/23/24, revealed a BIMS score of 15 (indicating he was cognitively intact) with no signs or symptoms of delirium. He had diagnoses of multi drug resistant organism and septicemia. He received insulin, antibiotic, diuretic, and opioid medications. He received IV medications and had IV access. Review of Resident #237's Progress Notes revealed the following: Nurse's Note dated 6/2/24 at 10:03 AM Resident completed vancomycin IV therapy in AM, noted dressing wet. Upon administration of flushing with 0.9% NS, noted leaking in dressing. MD and NP notified, received new order for new midline to be placed by 'outside company'. Call placed at this time, as per representative, RN will be in facility today to have it placed. Review of Resident #237's care plan, most recent revision date of 6/5/24, revealed: Focus: I am on IV Vancomycin via midline for pneumonia and prone to complications. Goal: Midline will show no signs/symptoms of infection and other complications through the next review date. Interventions: Administer IV fluids/antibiotic as ordered. Change dressing every 7 days and PRN per facility policy. Flush midline as ordered. Monitor every shift for signs/symptoms of infection. Notify MD of any changes. Review of Resident #237's Order Summary Report, dated 6/5/24, revealed the following orders: IV Site Change dressing once weekly and PRN. Measure extending line and check for displacement. If more than 1 cm, notify physician for further orders (day shift every 7 days AND as needed). During an observation and interview on 6/4/24 at 09:32 AM, Resident #237 was observed sitting in a chair in his room. Resident #237 had a single lumen midline noted to his left upper arm. The dressing, dated 5/28/24, was brown tinged and peeling away from the resident's skin. Resident #237 stated that the dressing got wet a few days ago when a student nurse was flushing the line and the syringe wasn't connected all the way. He stated that the staff nurse checked it and had someone from the hospital come to check it because they thought the line itself was leaking, but everyone said it (the midline) was fine and to leave the dressing in place. Resident #237 was unable to remember the date of the occurrence. In an interview on 6/6/24 at 10:20 AM with ADON A and ADON B, ADON A stated the facility worked with a company that placed midlines and came to the facility to check placement/replaced them when they were not working. ADON A stated that the company did send a nurse to assess Resident #237's midline on 6/3/24 but the line itself was functioning and the placement was good, so they did nothing to it. ADON B stated that facility nurses were responsible for midline dressing changes per MD orders, which were typically to change the dressing every 7 days and PRN. ADON A and ADON B both stated that the dressing should have been changed but ADON A stated it wasn't that bad and she had seen worse . In an interview on 6/6/24 at 4:17 PM with the DON, she stated that when they completed their midline site assessments, nurses should ensure midline dressings were clean, dry, and intact, with no debris getting into the midline. She stated that all facility nurses could do midline dressing changes as long as they had been trained. She stated all staff nurses were offered the training. She stated it was not a required training, but nursing management strongly encouraged that all nurses received the training. She stated that nurses were to assess midline sites at least once a shift, so the sites were looked at no less than every 12 hours. She stated that Resident #237's midline dressing should have been changed per facility policy because it was soiled and was peeling away from his skin. She stated that the most critical possible negative outcome of a soiled dressing remaining on the resident was an increased risk of infection. Review of facility policy titled Midline Dressing Changes, effective date 4/1/11, revealed, in part: Policy: Midline catheter dressing will be changed at specified intervals, or when needed, to prevent catheter related infections associated with contaminated, loosened or soiled catheter site dressings. General Guidelines: Change midline catheter dressing every 7 days, or if it is wet, dirty, not intact, or compromised in any way.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide laboratory services to meet the needs of its residents, for 1 of 3 (Resident # 136) residents reviewed for laboratory orders. The facility failed to follow physician orders on 05/29/24 that required obtaining a lab and provide needed treatment for Resident #136. This failure could place residents at risk for untreated medical issues and diminished quality of care. Findings included: Record review of Resident # 136's face sheet dated 06/06/2024 reflected a [AGE] year old female admitted on [DATE] with a diagnoses of acute embolism (blocked artery), thrombosis (blood clot), difficulty in walking, and weakness. Record review of Resident #136's admission MDS assessment dated [DATE] reflected Resident #136 had a BIMS score of 15, which indicated intact cognition. Resident #137 did not have any behavioral or mood issues. She was continent of bowel and bladder. Resident #137 ambulated by self and required limited assistance with most ADLs . Record review of Resident #136's Physician Orders dated 05/29/24 reflected the following laboratory to be performed by the facility: 1) ESR Erythrocyte Sedimentation rate 2) CBC with differential (Complete blood count) 3) C Reactive protein test to check for inflammation, infection, and heart disease risk. During an interview with Resident #136 on 06/04/24 at 8:36a.m, she said she has been in the facility for a few weeks. She explained she was doing well except that the facility has not been able to provide a laboratory test ordered by her doctor after an appointment visit. She stated she had talked to the nurses, and none seemed to know what happened to her physician orders. Resident #134 explained her RP took her to the doctor's appointment and gave the order to one of the nurses. In an interview with her RP on 06/04/24 at 12:43p.m, he said he was the responsible party for Resident #136. He explained he took the resident to her orthopedic doctor's appointment and received orders from the physician for some needed lab work to be done. He gave the order to the charge nurse, LVN B, so the test could be done. The RP said he has been calling and no one seems to know where the physician orders were kept. He stated it was important that the test was done so Resident #136 can receive timely and needed treatment. During an interview with the DON on 06/05/24 at 3:40p.m, she stated she was aware Resident #136 had an appointment with her doctor but did not bring back a physician order. She stated she informed her that Resident #136's RP confirmed he gave the physician orders to the charge nurse on duty . During an interview with LVN B on 06/06/24 at 11:42a.m, she was the charge nurse on duty when the RP came to the facility. She explained she remembered talking to the RP about Resident #136's Laboratory test. She did not remember receiving the physician orders. LVN B explained it was a crazy day having to complete 2 new admissions that day. She said she cannot say with certainty she received physician orders from the RP. She stated she cannot say if she did or didn't receive the physician orders . Record review of the policy on physician orders undated reflected the following: Policy: The attending physician shall authenticate orders for the care and treatment of assigned residents. Policy Explanation and Compliance Guidelines: 1. Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician. A consulting physician/practitioner may include, but is not limited to, a resident's: a. Surgeon b. Dialysis physician/nephrologist c. Wound clinic physician. d. Specialist such as urologist, cardiologist, gastroenterologist, dentist, ophthalmologist, OB/GYN e. Nurse practitioner, clinical nurse specialist, or physician assistant to any of the above physicians.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to conduct assessments that accurately reflected the resident's status for 4 of 12 residents (Residents #10, #15, #28, and #237) reviewed for resident assessments. The facility failed to ensure Resident #10's admission MDS Assessment accurately reflected her diagnosis of anxiety. The facility failed to ensure that Resident #15's admission MDS Assessment accurately reflected his skin status or diagnosis of anxiety/use of anti anxiety medication. The facility failed to ensure Resident #28's Medicare 5 Day MDS Assessment accurately reflected his diagnosis of Diabetes Mellitus. The facility failed to ensure Resident #237's admission MDS Assessment accurately reflected his diagnosis of chronic pain. These failures could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well being. The findings included: Resident #10 Review of Resident #10's admission Record, dated 6/6/24, revealed she was an [AGE] year old female admitted to the facility on [DATE]. Review of Resident #10's admission MDS Assessment, dated 4/18/24, revealed a BIMS score of 13 (indicating she was cognitively intact) with no signs or symptoms of delirium. She had no reported behaviors. Anxiety was not identified on her active diagnosis list. She received antipsychotic, antianxiety, antidepressant, anticoagulant, and hypoglycemic (including insulin) medications. Review of Resident #10's care plan, most recent revision date 4/30/24 revealed: Focus: I am currently on antianxiety medication related to anxiety and prone to side effects. Goal: The resident will be free from discomfort or adverse reactions related to antianxiety therapy through the review date. Interventions: Administer antianxiety medications as ordered by physician. Monitor/document side effects and effectiveness every shift. Monitor/document/report as needed adverse reactions to antianxiety therapy, change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/vertigo; fatigue, insomnia, appetite loss, weight loss, nausea, vomiting, dry mouth, and dry eyes. Review of Resident #10's Order Summary Report, dated 6/6/24, revealed the following orders: Buspirone Hcl oral tablet 10mg give 1 tablet by mouth every 8 hours for anxiety Seroquel Oral Tablet 50mg give 1 tablet by mouth one time a day for dementia/anxiety Resident #15 Review of Resident #15's admission Record, dated 6/5/24, revealed he was a [AGE] year old male admitted to the facility on [DATE] with a diagnosis including difficulty walking. Review of Resident #15's May 2024 Medication Administration Record revealed he was prescribed Hydroxyzine 25mg for anxiety beginning 5/15/25 (admission). Review of Resident #15's initial MDS assessment, dated 5/22/24, revealed: He scored a 15 out of 15 on his mental status exam (indicating he was cognitively intact). Anxiety was not identified on the active diagnosis list. No wounds were identified on the initial assessment. Review of Resident #15's care plan, initiated 5/30/24, revealed: Focus Resident was on an antibiotic for Right lower extremity cellulitis. Goal: Resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions included administer antibiotic medications as ordered by the physician, monitor/document side effects, and effectiveness every shift. Review of Resident #15's Skilled nursing Flow Sheet for 5/15/25 (admission nursing note) revealed that his right and left leg had an unidentified concern, and the right foot had an unspecified issue. (No further information available in the notes, but he had some sort of wound on his right foot.) Observation and interview on 6/4/24 at 09:15 AM revealed Resident #15 sitting up in his wheelchair. Resident #15 pulled up the right pants leg and said he had a sore on the bottom of his foot. Resident #15's ankle was observed to be red and pitted. Resident #15's feet were so swollen the socks on his feet were cut at the ankle to accommodate the swelling. There was no sign or PPE to indicate Resident #15 should be on enhanced barrier precautions. Resident #28 Review of Resident #28's admission Record, dated 6/5/24, revealed he was a [AGE] year old male originally admitted to the facility on [DATE], with a most recent admission date of 5/18/24. Review of Resident #28's Medicare 5 Day MDS Assessment, dated 5/25/24, revealed a BIMS score of 15 (indicating he was cognitively intact) with no signs or symptoms of delirium. He had no reported behaviors. Diabetes was not identified on his active diagnosis list. He received insulin, an antidepressant, and an antibiotic. Review of Resident #28's care plan revealed no care plan in place regarding his diagnosis of diabetes. Review of Resident #28's Order Summary Report, dated 6/5/24, revealed the following order: Insulin Lispro Injection Solution 100 UNIT/ML: Inject as per sliding scale: if 70 139 = 0 units; 140 180 = 3 units; 181 240 = 4 units; 241 300 = 6 units; 301 350 = 8 units; 351 400 = 10 units; 401+ = 12 units call MD, subcutaneously before meals and at bedtime for diabetes mellitus. Resident #237 Review of Resident #237's admission Record, dated 6/5/24, revealed he was a [AGE] year old male admitted to the facility on [DATE]. Review of Resident #237's admission MDS Assessment, dated 5/23/24, revealed a BIMS score of 15 (indicating he was cognitively intact) with no signs or symptoms of delirium. He had no reported behaviors. Chronic pain was not identified on his active diagnosis list. He received scheduled pain medication and as needed pain medication. He received insulin, antibiotic, diuretic, and opioid medications (medications used to use acute and/or chronic pain) . Review of Resident #237's care plan, most recent revision date of 6/5/24, revealed: Focus: I am prone to acute and chronic pain related to chronic debility decline. Goal: The resident will not have an interruption in normal activities due to pain through the review date. Interventions: Administer analgesia as per MD orders. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. In an interview on 6/6/24 at 10:57 AM the MDS Coordinator stated she was responsible for completing all comprehensive assessments for residents in the facility. She stated that long term residents had a quarterly assessment completed every three months and an annual comprehensive assessment after three quarterly assessments were completed. She stated that when she did her comprehensive assessments, she definitely went to look at, and speak to the resident. She stated that when a resident had been at the facility for an extended period, diagnoses like diabetes or psychiatric illness should have been carried over from one MDS assessment to the next (annual to quarterly). She stated that she gathered information for the assessments from admission forms and from the facility's electronic health records for each resident, in addition to interviews with the resident and their family or representatives. The MDS Coordinator did not realize Resident #14's Hydroxyzine counted as an antianxiety medication since its drug classification was antihistamine. In a follow up interview on 6/6/24 at 3:29 PM, the MDS Coordinator stated that she got the diagnoses for the MDS assessments from the physician's orders or hospital history and physical documents (if the resident was admitted directly from the hospital, which was most often the case). She stated that she was the only person in the facility that completed the MDS assessments. She stated that if a resident was admitted to the facility with an order for insulin, she would make sure that there was a diagnosis on the MDS assessment for diabetes or if there were multiple orders with a diagnosis of chronic pain, that there was a corresponding diagnosis on the MDS assessment. She stated that, in the case of Residents #28 and #237, she did not know why their diagnoses of diabetes and chronic pain were missed, especially since the medications themselves were addressed in both resident's assessments. She stated she believed that Resident #10's diagnosis of anxiety was added after her assessment had been completed and that was the reason it was not included on the MDS assessment. In an interview on 6/6/24 at 4:17 PM with the DON, she stated that the facility referred to the MDS 3.0 RAI Manual provided by CMS for facility procedure regarding resident assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #10 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 06/06/24 02:39 PM Resident is receiving Seroquel for dx of dementia and anxiety. The anxiety diagnosis is not identified on the MDS. The MDS states that the resident is taking an antipsychotic medication without an indication. There is no care plan in place for the use of an antipsychotic medication. Resident #28 FTag Initiation 06/05/24 10:00 AM MDS did no reflect resident's diagnosis of diabetes mellitus. Care plan did not address resident's diagnosis of diabetes or use of insulin. Based on interviews and record review the facility failed to develop and implement a comprehensive, person centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well being for 3 of 6 residents (Residents #10, #15, and #28) reviewed for care plans. Resident #10 did not have a care plan to address her antipsychotic use. Resident #15 did not have a care plan to address CAA areas of vision, psychosocial status, urinary status, skin status, active diagnosis, or anti anxiety use. Resident #28 did not have a care plan to address his diabetic status or insulin use. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Resident #10 Review of Resident #10's admission Record, dated 6/6/24, revealed she was an [AGE] year old female admitted to the facility on [DATE]. Review of Resident #10's admission MDS Assessment, dated 4/18/24, revealed a BIMS score of 13 (indicating she was cognitively intact) with no signs or symptoms of delirium. She had no reported behaviors. She had diagnoses of non Alzheimer's dementia, cognitive communication deficit, and Type 2 Diabetes Mellitus. She received antipsychotic, antianxiety, antidepressant, anticoagulant, and hypoglycemic (including insulin) medications. Review of Resident #10's care plan, most recent revision date 4/30/24 revealed no care plan in place regarding her use of an antipsychotic medication. Review of Resident #10's Order Summary Report, dated 6/6/24, revealed the following order dated 05/17/24: Seroquel Oral Tablet 50mg give 1 tablet by mouth one time a day for dementia/anxiety Resident #15 Review of Resident #15's admission Record, dated 6/5/24, revealed he was a [AGE] year old male admitted to the facility on [DATE] with a diagnosis including difficulty walking. Review of Resident #15's initial MDS assessment, dated 5/22/24, revealed: He had impaired vision and wore corrective lenses. He scored a 15 out of 15 on his mental status exam (indicating he was cognitively intact). He was occasionally incontinent of bladder. Active diagnoses included anemia and hypertension. (Anxiety was not identified.) He was at risk for developing pressure ulcers but no wounds, including foot problems, were identified on the initial assessment. His antianxiety use was not identified. Review of Resident #15's May 2024 Medication Administration Record revealed he was prescribed medications: Hydroxyzine 25mg for anxiety beginning 5/15/24. Lisinopril 2.5mg for hypertension beginning 5/16/24. Metoprolol Tartrate 25mg for hypertension beginning 5/16/24. Review of Resident #15's Skilled nursing Flow Sheet for 5/15/25 (admission nursing note) revealed that his right and left leg had an unidentified concern, and the right foot had an unspecified issue. (The note indicated there was some form of wound on the right foot but no further information was found.) Review of Resident #15's care plan, initiated 5/30/24, revealed: Focus Resident was on an antibiotic for right lower extremity cellulitis. Goal: Resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions included administer antibiotic medications as ordered by physician, monitor/ document side effects, and effectiveness every shift. (There was no care plan to address the type or frequency of the wound care, there was no care plan to address any enhanced barrier precautions.) There was no care plan to address Resident #15's vision status, communication, urinary status, psychosocial function, or skin status triggered in the CAA section of the MDS. Observation and interview on 6/4/24 at 09:15 AM revealed Resident #15 sitting up in his wheelchair. Resident #15 pulled up the right pants leg and said he had a sore on the bottom of his foot. Resident #15's ankle was observed to be red and pitted. Resident #15's feet were so swollen the socks on his feet were cut at the ankle to accommodate the swelling. There was no sign or PPE to indicate Resident #15 should be on enhanced barrier precautions. Resident #28 Review of Resident #28's admission Record, dated 6/5/24, revealed he was a [AGE] year old male originally admitted to the facility on [DATE], with a most recent admission date of 5/18/24. Review of Resident #28's Medicare 5 Day MDS Assessment, dated 5/25/24, revealed a BIMS score of 15 (indicating he was cognitively intact) with no signs or symptoms of delirium. He had no reported behaviors. He had diagnoses of obstructive uropathy, septicemia, hyperlipidemia, paraplegia, seizure disorder, depression, osteomyelitis, insomnia, history of stroke, and cognitive communication deficit. He received insulin, an antidepressant, and an antibiotic. Review of Resident #28's care plan revealed no care plan in place regarding his diagnosis of diabetes. Review of Resident #28's Order Summary Report, dated 6/5/24, revealed the following order dated 05/18/2024: Insulin Lispro Injection Solution 100 UNIT/ML: Inject as per sliding scale: if 70 139 = 0 units; 140 180 = 3 units; 181 240 = 4 units; 241 300 = 6 units; 301 350 = 8 units; 351 400 = 10 units; 401+ = 12 units call MD, subcutaneously before meals and at bedtime for diabetes mellitus . Interview on 06/06/24 at 10:57 AM the MDS Coordinator stated she was responsible for the comprehensive care plan. She stated she care planned medications, risk for falls, pain, pressure ulcers, anticoagulant use, antidepressant use, all of that . She stated she did the care plan if the resident was at the facility for more than 21 days. She said after 21 days, the comprehensive care plan replaced the baseline care plan completed by the nurses on admission. The MDS Coordinator stated, everyone uses the care plan. The MDS Coordinator said she did not know why there would be sections where there were no interventions that came through on the care plan. The MDS Coordinator stated she did not think there was a care plan for Resident #15's vision, communication, urinary, psychosocial function, or skin status. She was informed those were all CAA areas. The MDS Coordinator stated she would expect to see a care plan for an anti anxiety medication. The MDS Coordinator said that Hydroxyzine was an antihistamine. She was informed it was prescribed for the use as an anti anxiety and replied, yes she would expect to see a care plan for anxiety. The MDS Coordinator agreed the care plans were not accurate at all because the nurse's base line care plans needed to be more accurate. The MDS Coordinator stated if an LVN did an admission they could not do the staging of a wound so all they could do was document that a wound did exist. That resulted in an inaccurate MDS and an inaccurate comprehensive care plan because the staging did not get communicated. The MDS Coordinator said she monitored care plans by attending clinical meetings. The MDS Coordinator said if she became aware something was needed, she went into the care plan, and entered it. The MDS Coordinator stated the potential risk to the resident for the care plan not being done was the care not getting done. During a follow up interview on 06/06/24 at 11:47 AM the MDS Coordinator stated she had training on how to do care plans, but it had not been recent. In an interview on 6/6/24 at 3:29 PM, the MDS Coordinator stated she started the comprehensive care plan based on the MDS assessment. She said that when she started the comprehensive care plan for a resident, she included the care areas she saw in the assessment she had completed. She stated that Resident #28's care plan was missing diabetes and insulin because he was a resident prior to his current admission and his old care plan was not reactivated. She stated that any nurse was able to do this when a resident was readmitted to the facility during the admission process, but the floor nurses that completed the admissions did not do it often. She stated that Resident #10's care plan for antipsychotic medication use should have been completed by the nurse who did her admission to the facility. She stated that all facility nurses were able to add to or create new items in each resident's care plan. She stated that she did not routinely go back and look at the care plans once she had done her part on them unless she was personally made aware of a change that was needed . Review of the facility's policy and procedure on Comprehensive Care Plans, dated 8/18/17 revealed, Policy: It is the policy of [Corporation] to develop and implement a comprehensive person center care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that are identified in the resident's compressive assessment. Policy Explanation and Compliance Guidelines: Person centered means to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. The comprehensive care plan will describe, at a minimum, the following: a. the services that are to be furnished to attain or maintain the resident's highest practicable mental and psychosocial well being. b. any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. d. the resident's goal for admission, desired outcomes, and preferences for future discharge, e. discharge plans as appropriate. Resident #15 Care Planning Copied from another care area: [NAME], [NAME] (26221) 06/04/24 02:23 PM No communicateion w VA as res believes documented

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure that residents who have not used psychotropic drugs [NAME] not given these drugs unless the medication [NAME] necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Residents #10, #21, and #137) of 5 residents reviewed for unnecessary medications., The facility failed to ensure Resident #10 had an appropriate diagnosis for the use of Seroquel (an antipsychotic used to treat schizophrenia and bipolar disorder). The facility failed to ensure Resident #21 was not given risperidone (an antipsychotic) without a diagnosis. The facility failed to ensure that Resident #137 did not receive an antipsychotic (Seroquel/Quetiapine Fumarate) that was not necessary to treat Dementia. These failures put residents at increased risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status from receiving unnecessary antipsychotic medications. Findings included: Resident #10 Review of Resident #10's admission Record, dated 6/6/24, revealed she was an [AGE] year old female admitted to the facility on [DATE]. Review of Resident #10's admission MDS Assessment, dated 4/18/24, revealed a BIMS score of 13 (indicating she was cognitively intact) with no signs or symptoms of delirium. She had no reported behaviors. She had diagnoses of non Alzheimer's dementia, cognitive communication deficit, and Type 2 Diabetes Mellitus. She received antipsychotic, antianxiety, antidepressant, anticoagulant, and hypoglycemic (including insulin) medications. Review of Resident #10's care plan, most recent revision date 4/30/24 revealed no care plan in place regarding her use of an antipsychotic medication. Review of Resident #10's Order Summary Report, dated 6/6/24, revealed the following order: Seroquel Oral Tablet 50mg give 1 tablet by mouth one time a day for dementia/anxiety Resident #21 Record review of Resident #21's face sheet dated 6/5/2024 revealed she was [AGE] years old, initially admitted on [DATE], and readmitted [DATE]. Record review of Resident #21's Assisted Living Facility admission documents dated (04/08/2022) indicated a history of delusions and was taking risperidone (anti psychotic) 0.5 MG twice a day. Record review of Resident #21's Geriatric Behavioral Care Unit history and physical dated 11/25/2023 revealed she had visual and tactile hallucinations. She was taking risperidone 0.25 mg tablets (antipsychotic) at bedtime. Record review of Resident #21's annual MDS assessment dated [DATE] revealed she had a BMS score of 5 (severe cognitive impairment). She had diagnoses including dementia and depression. Record review of Resident #21's electronic diagnosis listing dated 06/05/2024 revealed she had a diagnosis of major depressive disorder, recurrent, severe with psychotic symptoms. Record review of Resident # 21's Care plan dated 12/07/2023 revealed she took risperidone for major depression with psychosis. Record review of Resident #21's physician's order dated 06/03/2024 for Risperdal (brand name risperidone) 0.5 MG to be given at bedtime revealed the order did not indicate what the medication was to treat. Record review of Resident #21's June 2024 MAR revealed she received 0.5 MG of Risperdal on June 3, 4, and 5 without an indication of what the medication was intended to treat. In an interview on 06/06/24 at 10:27 AM the DON revealed when a medication [NAME] prescribed the prescription needed to indicate what the medication was intended to treat. This ensured that the resident received the correct medication for the correct diagnosis. She stated the nurse should clarify with doctor that the appropriate medication was being given for the resident's diagnosis, and this should have been done for Resident #21. She stated that Risperdal could put residents at risk for adverse side effects, somnolence (sleepiness), disorientation, and falls. Resident #137 The findings included: Record review of Resident #137's face sheet indicated he was an [AGE] year old male admitted to the facility on [DATE] and re admitted on [DATE] with the diagnoses of unspecified dementia (brain impairment), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and lack of coordination. Record review of Resident #137's admission MDS assessment dated [DATE] indicated he had a BIMS score of 11 which indicated she had moderate cognitive impairment. The MDS also did not indicate the resident had a diagnosis to support the use of anti psychotic medication Seroquel/Quetiapine, but Resident #137 received the medication on a routine basis. Record review of Resident #137's care plan for May 2024 indicated no specific plan for Seroquel use as psychotropic medications. Record review of Resident #137's order summary report dated 04/13/24 indicated he had an order for Quetiapine Fumarate Tablet 25mg (an antipsychotic medication used to treat schizophrenia and bipolar disorder). Give 1 tablet via G tube at bedtime for sundown syndrome/agitation. During an interview on 06/05/24 at 3:51 p.m., the DON said she was not aware Resident #137 was receiving antipsychotic medication, of Seroquel. She explained she was made aware by a staff member during the resident's discharge. She stated there was no documentation by the physician regarding the reason the resident was receiving this medication without the right diagnosis. The DON explained she has been in the facility since last month and trying to review the medications to ensure the residents were getting meds according to their diagnosis . Record review of the facility's policy for use of antipsychotic drugs undated reflected: Policy: It is the facility's policy that each resident's drug regimen is free from unnecessary drugs, including unnecessary antipsychotic drugs. Policy Explanation and Compliance Guidelines: Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drugs therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. Generally, these conditions include: a. Schizophrenia, schizo affective disorder, schizophreniform disorder b. Delusional disorder c. Mood disorders (e.g., bipolar disorder, severe depression refractory to other therapies and/or with psychotic features) d. Psychosis in the absence of dementia e. medical illnesses with psychotic symptoms (e.g., neoplastic disease or delirium) and/or treatment related to psychosis or mania (e.g., high dose steroids) f. Tourette's Disorder g. Huntington disease h. Hiccups (not induced by other medications) i. Nausea and vomiting associated with cancer or chemotherapy.

Based on observations, interviews, and record review the facility failed to store all drugs and biologicals in locked compartments for 3 of 4 medication carts reviewed for medication storage and security. Medication Carts 100, 200, and 300 were left in the hallway unlocked and unattended. These failures could place clients at risk for drug diversion or accidental ingestion. Findings included: Observation on 06/04/24 at 08:57 AM revealed the hall 100 medication cart was unlocked and unattended in front of a resident's room. Staff moved it to in front of the nurse's station facing outward still unlocked and unattended, facing outward (anyone passing by have access to the drawers), and walked away from it. At 9:02 a.m. staff returned to the cart, set up medication and then left, again leaving the cart unlocked and unattended. The staff continued to leave the cart unlocked and unattended until surveyor left at 9:11 a.m. Observation on 06/04/24 at 08:38 AM LVN C walked away from the 300 Hall Medication Cart leaving it unlocked, unattended, and facing outward. At 8:42 AM the Medication Cart was observed to be still unlocked and unattended with staff walking right by it. Observation on 06/04/24 at 11:48 PM revealed the 200 Hall medication cart was unlocked, unattended, and facing out at the nurse's station. Observation on 06/04/24 at 12:37 PM revealed the 200 Hall and 300 Hall medication carts were unlocked, unattended, and facing outward at the nurse's station. Observation on 06/04/24 at 02:29 PM revealed the 200 Hall medication cart was unlocked, unattended, and facing outward at the nurse's station. Interview on 06/05/24 at 01:52 PM with both ADONs and the DON revealed the expectation for the medication carts were that they were locked when the nurse stepped away from it. The ADONs said they monitored that medication carts were locked by doing frequent rounding and they checked that keys were not left on top of the cart and that the lock was pushed in. The DON said the potential to the residents for unlocked unattended medication carts were the potential for drug diversions or residents getting into the medication cart. Interview on 06/06/24 at 11:49 AM the Administrator stated the DON informed her of the medication carts being left unlocked and unattended. The Administrator said, that was nursing 101 but it happened because of changes in staff and was super fixable . Review of the facility's policy and procedure on Storage and Expiration of Medications, Biologicals, Syringes and Needles, effective 12/1/07 revealed: Facility should ensure that only authorized Facility staff, as defined by Facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medication in compliance with Applicable Law. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on observations and interviews and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored foods were properly stored, labeled, and dated. This failure could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: Observation on 6/4/24 at 8:45 AM of the walk-in refrigerator revealed a large plastic tub on the bottom rack of shelving that contained a large, torn open, plastic bag of raw, pre-cut white meat. The bag containing the meat had no label or date. The plastic tub had approximately 0.5 inch of bloody liquid collected in the bottom where it had leaked out of the open bag of meat (no spillage was noted outside of the tub). Observation on 6/4/24 at 8:50 AM of the walk-in freezer revealed one 5-pound bag of frozen, sliced, yellow-colored vegetables with no label and no date. In an interview on 6/5/24 at 12:20 PM, the Food Service Director stated that the meat in the plastic tub had been placed there to thaw but he was not certain of the date it was removed from the freezer. He stated that he was not aware that the bag the meat was in was open. He stated the bag should have been sealed and labeled with what the meat was and a use by date or the date it was placed in the refrigerator to thaw. The FSD stated that the bag of vegetables in the freezer should have been labeled with what the contents were when the bag was removed from the original box it came in even though it was obvious that it was a bag of French fries . In an interview on 6/5/24 at 12:20 PM, the Registered Dietician stated that all food, when removed from the original packaging, should be labeled, and dated with a use by date or a received on. He stated that the meat in the plastic tub should have been placed in smaller, resealable bags to thaw in the refrigerator to prevent leaking. The RD stated that the bag of vegetables in the freezer should have been labeled with what the bag contained and a received-on date when they were removed from their original packaging . Review of undated facility policy titled Food Receiving and Storage revealed, in part: All foods stored in the refrigerator or freezer will be covered, labeled, and dated ('use by' date).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 4 (Resident #137, #8, #15, #87 ) of 6 reviewed for incontinent care and 3 of 4 residents reviewed for infection control practices. The facility failed to ensure that CNA D performed proper hand hygiene and glove changes while providing incontinence care to Resident #137. The facility failed to ensure residents were identified for enhanced barrier control for Residents #8, #15, #87. This failure could place residents at risk for the spread of infection. Findings included: Incontinent Care Review of Resident #137's face sheet dated 06/06/24, revealed a 69- year- old male admitted to the facility on [DATE] with diagnoses including Pulmonary embolism and diabetes mellitus. Review of Resident #137's admission MDS assessment dated [DATE] revealed Resident #137 required set up with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #137 was occasionally incontinent of bowel and bladder. Review of Resident #137's Care Plan dated 06/03/24 revealed no plan for bowel or bladder incontinence. Observation of incontinence care for Resident #137 on 06/06/24 at 10:10 a.m. revealed CNA D washed her hands before start of care. She removed the resident ' s soiled brief. Resident #137 ' s brief was soiled with urine and fecal matter. CNA D wiped the resident from front to back. CNA D's gloves were visibly soiled with fecal matter. She did not wash her hands, change gloves, or perform hand hygiene before putting on Resident #137's clean brief and placing it underneath him. She fastened the clean brief with the same soiled gloves. CNA D retrieved the trash and walked out of Resident #137 ' s room without washing her hands. In an interview on 06/06/24 at 10:18 a.m. with CNA D, she revealed she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #137. CNA D stated she has been in the facility 1 month and had infection control training during orientation. She said the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. During an interview with the DON on 06/06/24 at 1:40 p.m., she revealed she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility protocols during care, one of which was to ensure hand washing and change of gloves as needed while providing care. Review of the facility's perineal care policy dated 08/16/17 reflected the following: PURPOSE: It is (this company ' s policy) practice to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown. POLICY: All staff members involved in performing perineal care to residents will promote cleanliness, prevent infections to the extent possible, prevent and assess for skin breakdown and promote comfort. 1. Practice Guideline observations and/or verifications are conducted by the Director of Nursing Services (DNS), or designee, to ensure compliance with this policy annually and as needed. PROCEDURE 2. Gather supplies needed . a. Basin Method: i. Basin ii. Towels iii. Perineal Cleanser iv. Drape (If applicable) b. Disposable Wipe Method i. Wipes ii. Towels iii. Drape (If applicable) 3. Always rinse after washing, unless using a non-rinse cleanser. 4. Maintain clean technique and observe isolation precautions when applicable. 5. Knock and gain permission to enter resident ' s room. 6. Provide privacy. 7. Inform resident on procedure to be performed. 8. Set up supplies. Enhanced Barrier Protection Review of Resident #8 ' s admission Record, dated 6/5/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including osteomyelitis (bone infection). Review of Resident #8 ' s admission MDS Assessment, dated 5/3/24, revealed: His mental status score was 13 of 15 (indicating he was cognitively intact). He received IV medications while in the facility and was admitted with a midline (IV placed in a deep vein in the upper arm). Review of Resident #8 ' s Care Plan revealed: Care plan initiated 5/29/24 for Resident #8, he has a foley catheter for urinary retention. The identified goal was that the resident will remain free from catheter-related trauma through review date. Identified interventions included Monitor/report to doctor for signs or symptoms of urinary tract infection. Observation on 06/04/24 at 08:25 AM revealed Resident #8 in bed. Resident #8 had a catheter. Resident #8 had nothing outside his room notifying staff about enhanced barrier precautions posted or additional PPE available. Review of Resident #15 ' s admission Record, dated 6/5/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including difficulty walking. Review of Resident #15 ' s initial MDS assessment, dated 5/22/24, revealed: He scored a 15 of 15 on his mental status exam (indicating he was cognitively intact) No wounds were identified on the initial assessment. Review of Resident #15 ' s care plan, initiated 5/30/24, revealed: Focus Resident was on an antibiotic for right lower extremity cellulitis. Goal: Resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions included administer antibiotic medications as ordered by physician, monitor/ document side effects, and effectiveness every shift. Observation and interview on 6/4/24 at 09:15 AM revealed Resident #15 sitting up in his wheelchair. Resident #15 pulled up the right pants leg and said he had a sore on the bottom of his foot. Resident #15 ' s ankle was observed to be red and pitted. Resident #15 ' s feet were so swollen the socks on his feet were cut at the ankle to accommodate the swelling. There was no sign or PPE to indicate Resident #15 should be on enhanced barrier precautions. Review of Resident #87 ' s admission Record, dated 6/5/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease. Review of Resident #87 ' s Order Summary, dated 6/5/24 revealed she received dialysis services three times a week. Observation and interview on 06/04/24 at 09:02 AM revealed Resident #87 ' s room had an oxygen sign posted, but nothing about enhanced barrier precautions. Resident #87 was not in the room and LVN C stated Resident #87 was at dialysis. Observation on 06/05/24 at 08:17 AM showed Residents #8, #15, and #87 ' s room did not have anything posted about enhanced barrier protection or any PPE outside of the resident ' s rooms. Interview on 06/05/24 at 02:09 PM with the DON, and both ADONs, the DON stated Enhanced Barrier precautions was a CDC recommendation started on 4/1/24 for anyone with an indwelling device: a g-tube (feeding tube), a catheter, or open wounds. The DON stated anything that went internally into a resident. The DON said enhanced barrier protection required a gown and gloves if the staff provided direct patient care. The DON stated the facility had seven (7) residents with open wounds, two (2) with g-tubes, three (3) with catheters, six (6) with dialysis shunts, and two (2) with intravenous medications. The DON said at the time of the survey the staff were just wearing gloves to meet the enhanced barrier protection needs of those residents. The DON stated the facility was waiting on direction from the corporation on ordering bins to have outside of the doors. The DON said the facility had some PPE holders that went over the door but they (the DON and ADONs) did not know what the corporation wanted to do. The DON said there were still PPE containers left from the covid isolation epidemic. The DON and ADONs said they had been at the facility for three weeks. The ADONs said the outcome to the residents included transferring bacteria and infection to residents due to open areas if PPE was not worn. The DON said Resident #87 was on dialysis and needed enhanced barrier protection. The DON said the facility did not implement enhanced barrier protection because not every staff member was in-serviced on PPE use yet. The DON said no resident had a facility-acquired infection because of the staff not following enhanced barrier precautions. Interview on 06/06/24 at 11:49 AM the Administrator stated the DON did let her know about the enhanced barrier precautions. The Administrator was informed that the CMS expectation had been in place since April. The Administrator said it was not implemented at this facility because the facility had just changed DONS and the facility did not see the CDC guideline. The Administrator said she was not aware she could take the infection control preventionist course as a non-clinical staff as a way to understand the regulation better. Review of the In-service dated 6/5/24 revealed: Enhanced Barrier Precautions to be implemented for all patients with indwelling devices that may cause them to be at greater risk for infection transmission. You will soon see an increase in the circumstances with we are asking you to wear a gown and gloves while caring for residents. This is based on new recommendations from the Centers for Disease Control and Prevention to prevent our residents and staff from multidrug-resistant organisms (MDRO), which can cause serious infections and are hard to treat. These new recommendations are called Enhanced Barrier Precautions. Enhanced Barrier Precautions require staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading an MRDO. These include the following residents: Residents known to be infected or colonized with an MRDO. Residents with an indwelling medical device including central venous catheter, urinary catheter, feeding tube (PEG Tube, G-tube), tracheostomy/ventilator regardless of their MDRO status, and Residents with a wound, regardless of their MDRO status. We will be posting signs on the doors of residents for whom EBP are recommended. The signs will also include reminders of the activities during which a gown and gloves should be worn. No policy regarding Enhanced Barrier Precautions was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan for 1 (Resident #3) of 6 residents reviewed for repositioning. The facility failed to ensure Resident #3 was repositioned every 2 hours. This failure could affect others by placing them at risk of potential medical complications related to changes in condition. Findings included: Record review of Resident #3's face sheet dated 09/13/2023 revealed an [AGE] year-old female who was re-admitted on [DATE] with diagnosis of failure to thrive (general state of decline in elderly patient) and muscle weakness. Record review of Resident #3's MDS quarterly assessment dated [DATE] revealed she could not complete BIMS interview, she was severely cognitive impaired. Required extensive assistance with 2-person physical assistance for bed mobility and was at risk for pressure ulcer/injury risk with no pressure ulcer noted. Record review of Resident #3's care plan dated 02/25/2022 and last reviewed revealed a focus area for pressure ulcer development related to immobility with interventions that included follow facility policies/protocols for the prevention/treatment of skin breakdown and needs moisturizer applied to my skin. Do not massage over bony prominences and use mild cleansers for peri-care/washing. Record review of Resident #3's skin assessment dated [DATE] revealed no redness and/or pressure ulcer to sacrum (the large wedge-shaped bone, consisting of five fused vertebrae, in the lower part of the back). During observation on 09/13/2023 at 9:23 am, Resident #3 was not verbal, did not answer any questions. Resident #3 was in bed, lying on her back and head of bed was elevated 30 degrees. Three pillows noted at bedside on chair. During observation on 09/13/2023 at 11:32 am, Resident #3 was not verbal, did not answer any questions. Resident #3 was in bed, lying on her back and head of bed was elevated 30 degrees. Three pillows noted at bedside on chair. During observation on 09/13/2023 at 1:52 pm, Resident #3 was not verbal, did not answer any questions. Resident #3 was in bed, lying on her back and head of bed was elevated 30 degrees. Three pillows noted at bedside on chair. During interview on 09/13/2023 at 1:52 pm, CNA A stated he was the CNA responsible for Resident #3. CNA A stated he had last repositioned Resident #3 to her side around 10:30 am and could not tell what side and where he placed the pillows. CNA A then stated he had not repositioned Resident #3 at all in the morning. CNA A stated he received training upon hire regarding repositioning at least every 2 hours. CNA A stated risks include possible pressure ulcer. CNA A did not answer reason for Resident #3 not being repositioned throughout the morning. During interview on 09/13/2023 at 1:59 pm, RN B stated she was not the charge nurse for Resident #3 but could answer questions due to Resident #3 charge nurse being busy with another resident. RN B stated CNAs were responsible for repositioning residents at least every 2 hours. RN B stated risks included skin breakdown . During observation and interview on 09/13/2023 at 2:02 pm, RN B and the DON assisted with repositioning Resident #3 to her right side. The DON was behind Resident #3 to assess her back and stated Resident #3 had redness to her sacrum. The DON stated the redness and Resident #3 sacrum was blanchable (this indicates normal blood flow). During interview on 09/13/2023 at 2:07 pm, the DON stated CNAs were responsible of repositioning residents at least every 2 hours to prevent skin breakdown. The DON stated charge nurses should be checking for repositioning during their rounds. The DON stated risks included redness to skin that could result in skin breakdown. The DON stated she conducted daily checks to ensure the residents were repositioned. During interview on 09/13/202 at 2:31 pm, the Administrator stated CNAs were responsible of repositioning residents at least every 2 hours to prevent skin breakdown. The Administrator stated the DON and charge nurses should be checking for repositioning during their daily rounds. Administrator stated risks included redness to skin that could result in skin breakdown. Record review of Pressure Injury Prevention and Management policy dated 08/16/17 revealed in part the facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. 3.B: Licensed nurses will conduct a full body skin assessment on all residents upon admission and readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. E: Interventions will be documented in the care plan and communicated to all relevant staff. F: Compliance with interventions will be documented in the weekly summary charting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive for one (Resident #23) of six residents reviewed for advance directives. The facility failed to ensure that Resident #23 ' s code status was correctly indicated in his physical chart. This failure could result in residents receiving unwanted treatment or not receiving desired treatment. Findings include: Record review of Resident #23 ' s face sheet dated [DATE] documented in part that he was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #23 ' s History and Physical dated [DATE] documented in part that he had a history of end stage renal disease, CVA (stroke), and a left below-the-knee amputation. Record review of Resident #23 ' s physician ' s advance directive order dated [DATE] documented that he was a DNR. Record review of Resident #23 ' s physical medical chart on [DATE] at 2:45 PM revealed a sticker on the first page of the chart stating, Full Code. Review of all contents of the physical medical chart revealed no TX OOH DNR. Record review of Resident #23 ' s admission Check List dated [DATE] (hard copy in resident ' s physical chart) documented that the resident ' s code status had been entered into the computer. The admission Check List stated If DNR, signed and completed DNR must be in chart. Record review of Resident #23 ' s electronic Care Plan dated [DATE] documented that he was a DNR. In an interview and observation on [DATE] at 03:03 PM, RN F stated Resident #23 ' s code status was DNR. She then reviewed Resident #23 ' s physical chart and commented that it had a sticker that said full code. She was then observed to review Resident #23 ' s physical chart in full and stated she was not able to find a copy of the TX OOH DNR. She reviewed the Resident's IDT admission Evaluation with Baseline Care plan which was in the chart (date not provided) and stated it indicated the resident had no Advance Directives. She said that the conflicting information on the resident's code status put him at risk of delayed response to emergency situations. In an interview on [DATE] at 09:47 AM, the Social Worker said she had spoken to Resident #23 on [DATE] and he had stated that he was a DNR. She said she documented this on his Psychosocial Profile dated [DATE] but she did not do anything to the physical chart. She said she, the Admissions Coordinator and the Transitional Care Nurse were all involved in assessing and documenting a new resident ' s code status. When asked who was responsible for putting the TXOOH DNR in the electronic record she said the nurses were. She did not know who was responsible for putting together the physical chart. In an interview on [DATE] at 10:08 AM, the admission Coordinator said she interviewed Resident #23 on 03/27/or [DATE] and he said he did not have a DNR. She said she did not document this conversation because the computer defaults to full code. She said that if a resident or resident ' s family had DNR at the time of the admission interview, she (the admission Coordinator) would give a copy to the Social Worker, DON or ADON. She did not know what was done with the completed DNR once given to the Social Worker, DON or ADON. In an interview on [DATE] at 10:19 AM with the DON and Administrator, the DON said Resident #23 ' s TX OOH DNR document was in the Miscellaneous documents in his electronic file, and that his electronic file was uploaded on [DATE], prior to his admission on [DATE]. She did not know why his physical medical record had a Full Code sticker on it. She said that staff may have been waiting for the DNR document to be uploaded in the electronic record and put the Full Code sticker on the chart in the meantime. When asked where the TX OOH DNR was, she said it was in his electronic Miscellaneous file on page six of a document from the resident ' s PACE program (a Managed Care Provider). The DON said that nurses would know to look in the Miscellaneous file to find the DNR. The DON said she did not know if staff had received training regarding Advance Directives but would check her files. Documentation of staff training regarding Advance Directives was not received prior to exit. The DON said that the inconsistency in documenting Resident #27 ' s code status could put him at risk of the facility having to call his next of kin to find out if he had DNR or not. She did not say it put the resident at risk of receiving unwanted treatment or not receiving desired treatment. The facility policy Cardiopulmonary Resuscitation dated [DATE] stated the facility would adhere to resident ' s rights to formulate advance directives. Basic life support including CPR would be provided in the absence of advance directives or DNR orders. The policy did not say where DNR orders would be placed in residents ' electronic record or physical chart. In an interview on [DATE] at 10:19 AM with the DON and Administrator, additional policies related to DNRs or other Advance Directives were requested. The DON stated that the policy Cardiopulmonary Resuscitation dated [DATE] was the only policy the facility had related to DNRs or other Advance Directives. The policy provided, Cardiopulmonary Resuscitation dated [DATE] did not say where DNR orders would be placed in residents ' electronic record or physical chart. Resident #23 Advance Directives [DATE] 10:44 AM [DATE] 02:37 PM on [DATE] - DNR order on Facility Record - No document in Documents file. Review of hard chart reveals no DNR document and front page states Full Code. [DATE] 03:03 PM interview and record review with RN Licely [NAME] - reviews [NAME] electronic chart for code status and states he is a DNR. Reviews hard chart and states that there is a sticker that says full code. Reviews resident chart and states she is unable to find a copy of the TX OOH DNR. Reviews residetn IDt admission Evaluataion with Baseline Care plan and states that it indicates no Advance Directives - . Says that this puts residetn at risk of delayed response to emergency sitatuaion. States she is not able to find the completed DNR form in the residetn's chrat. [DATE] 09:47 AM [NAME], LBSW - Resident - admissions asks if ADs are in place - Family will provide information regarding status all ADs including DNR. Full code is default - and some ay not have documents in place. DNR if wanted - SW will do visit with resident and visit option based on resident's Cog status and input from family. Will initiate process of enacting DNR. [NAME] Transition nurse - will upload copy of DNR and update resident code status, also Patty admission in admission will to that. Uploaded DNR will go into Miscellaneous. DNR sitcker and copy of DNR are put in physical chart by [NAME] or SW. Admissions must have reviewed thconfirmed - he is frm Bienvivir. [DATE] - SW talked with resident and he confirmed DNR status and this was input in psychosocial assessment. She did not do anthhing with phycical chart. should be a copy 3/24 Packet frm Bienvir page 6 of 12. Nurse would not know what to do and might intiate complressions. [DATE] 10:08 AM - Patty [NAME] - Regarding Advance Directives - will ask if they have it - it appears on check list, also sign something that they do or don't. For tesident with a DNR - if they have a copy will get it and give to nnursieng oro SW. If they dont' [NAME] copy hadn ask wif they want to sign a new one. Will let nursing and SW know - would deliver document to DON, ADON, SW. Did interveiw with Mr. [NAME] but he did not want to sign anything. He said he did not have a DNR. Did not documetn conversation this anywhere because defaults to full code. Saw him about two days after admission (Monday or Tuesday). Resident was somehat resistanet to a conversation. Did ask about DNR - I don't have one. Risk to him s that he would not know what to do if he coded. Did not talk with [NAME] about Mr. [NAME] at all. [DATE] 10:19 AM ADMIN and DON - DON - get code stats report nurse to nurse from hsotpial to who ever is [NAME] admission - - will consider them full code until paper is in hand. His file was upladed 3/24. 3/25 admit was DNR. Since -nurse would go to miscellaneout and find the DNR. electronic nurses know to know to lokok in packe for DNR. Has not seen chart - may have waited to see document snd put Full code sitcke pending receipt of document. does not know why the full code is on chart if docuent is in Bienviir packet. the risk of the inconsistency would have to call next of kin to find out if he had DNR or not. Doe not have another Ad policy or one specific to DNR. Try to review code status on admissions. Would hae to look at who admitted him. Training for staff regarding Advance Directiee will have to check.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care of the resident for one (Resident #96) of six residents reviewed for baseline care plans. The facility failed to include a care plan for anticoagulants on Resident #96 ' s baseline care plan. This failure could put residents at risk of undetected medication side effects. Findings include: Record review of Resident #96 ' s face sheet documented that she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #96 ' s History and Physical dated 03/27/2023 documented in part that she had diagnoses of intra-articular tibial plateau fracture (Broken bone at the knee joint) and she was to have DVT prophylaxis (something to prevent blood clots). Record review of Resident #96 ' s physician ' s order dated 03/31/2023 documented that she was to receive 30 MG/0.3 ML of Enoxaparin Sodium (an anticoagulant to prevent blood clots) by subcutaneous injection (a shot) each morning as a preventive. Record review of Resident #96 ' s MAR for April 2023 documented in part that she received 30 MG/0.3 ML of Enoxaparin Sodium through subcutaneous injection daily from 04/01/2023 through 04/13/2023 when the MAR was reviewed. Record review of Resident #96 ' s IDT admission Evaluation with Baseline Care Plan dated 03/31/2023 documented no care plans related to anticoagulants. In an interview on 04/14/23 at 11:17 AM, the DON said that the admitting nurse was responsible for completing the baseline care plan. She said it did not matter whether anticoagulants were on Resident #96 ' s care plan or not because the nurses monitor residents and notify the doctor if changes are identified. She said that residents should have anticoagulants on their care plan since anticoagulants thin the blood and residents may have an increased tendency to bleed. She said nurses should monitor residents who take anticoagulants for bruising, bleeding, or changes in stool color. Record review of the facility policy Baseline Care Plan dated 08/16/2017 documented in part that the facility would develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care. The baseline care plan would include the minimum healthcare information necessary to properly care for a resident. The policy did not specify who in the facility would complete the baseline care plan. Resident #96 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 04/12/23 11:16 AM Resident is in the Initial Pool. According to RR the resident takes an Antianxiety. Buspiron 10 mg TID According to RR the resident takes an Anticoagulant. - Lovenoz 30 MG Q AM According to RR the resident takes an Insulin. - she is not taking insulin - Actos 15 MG - for blood sugar but not insulin. According to RR the resident takes an Opioid. - Tramaol 50 MG Q 6 hrs PRN - Has not requested this According to RR the resident takes an Antidepressant. - Lexapro 20 MG Q day. Anticoagulant is on the MDS but not on either care plan baseline or comprehensive care plan. 04/14/23 11:17 AM DON - anticoagulans shouldb on base [NAME] care plan - If resident is h ere long enough woul be o n comprehansive. Staff standrd woul dlook for brusiing bleeding stool collor, Wouild be lok infor this because thins the bllo - increased tenedency to bleeding. Nursing practice is to monitor - it does not matter if it is ion the care plan or not. risk to patient is for bleeding but any change of contidion i sreported to doctor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to change midline dressing in accordance with physician orders and the comprehensive care plan for 1 (Resident #39) of 16 residents reviewed for quality of care The facility failed to change Resident #39 Midline dressing according to physician ' s orders. These deficient practices could have placed residents at risk for cross-contamination resulting in acquiring infections. Findings included: Record Review of Resident #39 ' s face sheet dated 04/14/23 revealed an [AGE] year-old male with an admission date of 03/24/23. Record Review of Resident #39 ' s History and Physical dated 03/14/23 revealed a diagnosis of Periprosthetic Joint infection, left shoulder and MRSA (Methicillin-Resistant Staphylococcus Aureus). Record Review of MDS assessment dated [DATE] revealed Resident #39 had a BIMS score of 15 indicating he was cognitively intact. In section I of the MDS assessment Resident #39 revealed active diagnosis of infection due to unspecified internal joint prosthesis, and infection due to other internal joint prosthesis. Record Review of the comprehensive care plan dated 03/25/2023 revealed Resident #39 has a Midline and interventions included change dressing every 7 days and as needed per facility protocol. Record Review of physician orders dated 03/30/23 instructed to change dressing once weekly and PRN (every dayshift every Sun IV therapy). Resident physician orders dated 03/ 24/23 instructed to administer ceftriaxone 2gm (IV antibiotics) for joint infection via midline once a day. Observation at 03:00 PM on 04/11/23 revealed Resident #39 was in his room during the interview and noted dressing on Midline dated 4/3/23. Interview and record review with the DON on 04/13/2023 at 11:30 AM confirmed the physician order for Resident #39 was to change the Midline dressing every 7 days and was scheduled to be changed on Sundays. DON verified the treatment record and documented the Midline dressing was changed on 04/03/2023. DON stated failure to change Midline dressing according to the physician ' s orders can place the resident at risk for infection. Record Review of Policy titled Wound Treatment Guidelines dated 08/17/2017 in part stated wound care treatments will be provided in accordance with physician orders, including the frequency of dressing change. Record Review of Policy titled Catheter Insertion and Care dated 4/1/2011 in part documented change transparent semi-permeable membrane dressing at least every 7 days and as needed when wet, soiled, or not intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 3 (Resident #8, Resident #5, and Resident #96) of 5 residents observed for oxygen management. 1. The Facility failed to change oxygen tubing for Resident # 8 according to physician's orders. 2. The facility failed to ensure Resident # 5's oxygen sign was posted on entrance door to resident's room. 3. The facility failed to store Resident #96 ' s respiratory treatment mask with a protective cover. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support, decline in health, and expose them to oxygen hazards. Findings included: Resident #8 Record review of the facility's Hospital Transfer/Discharge Report Sheet for Resident #8 revealed admission to nursing facility on 01/04/2023. Record review of History and Physical dated 01/06/2023 for Resident #8 revealed a [AGE] year-old female with a diagnosis of influenza A virus- and age-related physical debility (general weakness or feebleness that may be a result or an outcome of one or more medical conditions that produce symptoms such as pain, fatigue, cachexia and physical disability, or deficits in attention, concentration, memory, development and/or learning). Record review of Resident #8 MDS Significant change assessment dated [DATE], was diagnosed dementia and occlusion and stenosis of right middle cerebral artery (Atherosclerotic plaques accumulate in the walls of the arteries and cause them to narrow (stenosis) or become so thick they completely block the flow of blood (occlude), no shortness of breath was marked or oxygen therapy. Record review of hospice comprehensive assessment and plan of care update report dated 03/31/2023, of Resident #8 revealed a diagnosis of dependence on supplemental oxygen and occlusion and stenosis (Atherosclerotic plaques accumulate in the walls of the arteries and cause them to narrow (stenosis) or become so thick they completely block the flow of blood (occlude) of right middle cerebral artery. On 01/04/2023 Resident #8 was on oxygen 2.5 liters per minute as needed for shortness of breath. Record review of facility's order recap for Resident #8 ordered on 04/12/2023 revealed an order for oxygen at 3 liters per minute via nasal cannula as needed for hypoxia and shortness of breath. Change oxygen tubing/equipment weekly on Sunday every night shift. Observation on 04/11/2023 at 9:57 AM in Resident #8's room revealed resident was on a concentrator with nasal cannula dated 01/29/2023. Observation on 04/12/2023 at 10:15 AM with LVN A revealed Resident #8 was getting oxygen by concentrator, and oxygen nasal cannula was dated 01/29/2023. Interview on 04/12/2023 at 10:28 AM with the risk of not having a sign posted outside of a resident's room when using oxygen could be flammability. DON stated Resident #8s nasal cannula needed to be changed. DON stated the nurses are responsible for changing the cannula. Resident #5 Record review of facility Transfer/Discharge Report Sheet Resident #5 revealed admission to facility on 03/29/2023. Record review of History and Physical dated 03/29/2023 for Resident #5 revealed an [AGE] year-old female with a diagnosis of asthmatic bronchitis and unspecified asthma. Record review of admission MDS dated [DATE] for Resident #5 revealed resident was on oxygen therapy for respiratory treatment for shortness of breath or trouble breathing when lying flat. Record review of Resident #5 order summary report dated 03/30/2023 revealed Resident #5 was on oxygen at 2 liters per minute as needed and every shift for shortness of breath and hypoxia. Change oxygen tubing/equipment on Sundays. Record review of Resident #5 care plan dated 03/31/2023 revealed resident had constriction of the airways and difficulty or discomfort in breathing and will be getting oxygen via nasal cannula at 2 liter per minute 04/11/2023 that Resident #5 had oxygen therapy for ineffective gas exchange and will be continuous oxygen via nasal cannula at 2 liter per minute. Observation on 04/11/2023 at 9:05 AM revealed no oxygen sign posted outside of Resident #5's entrance door while resident was using oxygen. Interview on 04/12/2023 at 10:06 AM with LVN A revealed anytime there was a concentrator in the room, there must be an oxygen sign posted outside of the room. LVN A stated the risk of not having an oxygen sign posted outside of the resident's room was a fire hazard. LVN A stated the nasal cannula must be changed out every Sunday, once a week, if not the risk could be respiratory infection. Observation and interview on 04/12/2023 at 10:30 AM with DON inside Resident #5's room revealed she had her nasal cannula on with the concentrator on and in use. DON stated the nasal cannula dated 01/29/2023 was outdated and needs to be changed. DON stated nasal cannulas are changed out every Sunday once a week. DON stated the night shift nurses are responsible for changing out the nasal cannulas on Sunday. DON started Resident #5 needed to have an oxygen sign posted outside of her room since she was using oxygen. Interview on 04/13/2023 at 2:44 PM with LVN B who was the charge nurse both Resident #5 and Resident #8 stated if a concentrator was in use in the resident's room, then the resident needed to have an oxygen sign. LVN B stated the risk to not having an oxygen sign posted could be flammability. LVN B stated the oxygen tubes are changed out once a week or as needed by the night shift nurse. LVN B stated she would not know the risk of not changing out the oxygen tubes weekly. Record review of facility policy Oxygen concentrator dated 06/05/2023 indicated to place an oxygen warning sign on the resident's door. Cannulas and masks should be changed weekly or as necessary. Resident #96 Record review of Resident #96 ' s face sheet documented that she was [AGE] years old and was admitted to the facility on [DATE]. Record review of Resident #96 ' s History and Physical dated 03/27/2023 documented in part that she had diagnoses including chronic obstructive pulmonary disease (lung disease where the small airways in the lungs are damaged making it harder for air to get in and out.) Record review of Resident #96 ' s physician ' s order dated 04/05/2023 documented an inhaled breathing treatment (Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 IUD) every 8 hours to treat wheezing. Record review of Resident #96 ' s April 2023 MAR documented that she was administered Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML by inhalation three times a day (6:00 AM, 2:00 PM and 10:00 PM) daily from 04/05/2023 to 04/14/2023. An observation on 04/11/23 at 09:04 AM revealed a nebulizer machine with attached tubing and a nebulizer mask on top of Resident #96's bedside dresser. In an interview on 04/11/23 09:10 AM, RN H stated that Resident #96 ' s nebulizer mask should be stored in a plastic bag when not in use because of infection control concerns. RN H said if the mask was not covered, dust and germs might get in the mask and the resident might breathe those in during treatment and cause her to get an infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and expiration date when applicable for 1 (Resident #247) of 2 residents reviewed for labeling in that: 1. The facility failed to ensure Resident # 247's Glucerna feeding bag was labeled with the date or the time the bag was hung. 2. The facility failed to ensure the flush bag was not labeled at all. These deficient practices could cause a decline in health in residents. Findings included: Record review of facility Transfer/Discharge Report Sheet for Resident #247 revealed admission to facility on [DATE]. Record review of Resident # 247's History and Physical dated [DATE] revealed a [AGE] year-old female with a diagnoses of stroke, Alzheimer disease, diabetes mellitus (A disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine). Record review of admissions MDS assessment dated [DATE] revealed Resident #247 was diagnosed with dysphagia (difficulty swallowing) and feeding tube. Record review of Resident # 247's care plan dated [DATE] revealed gastrostomy tube in place due to dysphagia (difficulty swallowing), aspiration, will maintain adequate nutrition and hydration. Record review of order recap dated [DATE] for Resident #247 revealed enteral feedings and feeding pump 6 cans per day of Glucerna continuous at 60 milliliters per hour. Observation on [DATE] at 9:32 AM revealed the feeding bag label did not have date the feeding bag was hung. The water flush bag did not have a label. Interview on [DATE] at 10:28 AM DON stated tube feedings needed to be labeled correctly as it was missing the date and time it was hung. DON stated the risk of the feeding bags not being labeled correctly, the staff would not know if the feeding bags had been changed or if the resident would have an expired bag. Interview on [DATE] at 2:44 PM with LVN B stated the requirement for labels on feeding bags are the name of resident, room, formula, rate, time, and date. LVN B stated water flush bags also needed to be labeled. LVN B stated the feeding bag/flush from Resident #247 was labeled incorrectly because it was missing the physician's name and date it was hung. LVN B stated the risk to the residents for not labeling correctly could be loose stoles and the nursing staff would not knowing if the formula given to the resident was being tolerated. Interview on [DATE] at 3:00 PM with DON stated they did not have a feeding tube policy regarding labeling. Record review of facility Appropriate use of feeding tubes dated [DATE] revealed feeding tubes (nasogastric, gastrostomy, jejunostomy) will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. FACILITY Infection Control [DATE] 11:35 AM resident done with quarantine on [DATE] wound care cart observation red bag not being utilized and nurse observed caring around the facility - [NAME] Resident #39 FTag Initiation [DATE] 01:43 PM wound care - order indicated for change every Sunday Resident #199 FTag Initiation [DATE] 01:44 PM - wound dressing was not dated FACILITY Infection Control [DATE] 04:08 PM Resident [NAME] - 310 - [NAME] - worked for the state 1991 - worked as a case worker eligibility - Has been does not know. - Fell and has been here because of fractured tibia - Feels very lucid today - usually feels confused and asks that I call husband - they treat her very good. Bath room looks fine. Infection control concern the treatment mask is not bagged. [DATE] 09:04 AM Licely [NAME], RN - states that treatment mask should be in bag because of infection control concerns. Resident might breath in things that get in mask like germs. on her hospital paper work said Buspirone 2 5 MG pills - TID for anxiety. Mitirats a pin 7.5 MG at HS depression. escitaopran - 20 MG q day - Depression. admit date [DATE] [DATE] 11:15 AM DON - between treatments masks whold be stored in bags - for infecgtion prevention - risk to resident of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet the individual needs for 1 (Resident # 246) of 2 residents reviewed for dietary services. The facility failed to ensure Resident #246's lunch meal was a thin liquid consistency diet as ordered by the physician. This failure could place residents at risk of choking and aspiration by not serving the prescribed liquid consistency. Findings included: Record review of facility Transfer/Discharge Report Sheet for Resident #246 revealed admission to facility on 09/27/22 and readmitted on [DATE]. Record review of Resident #246 History and Physical dated 03/31/2023 revealed an [AGE] year-old male with a diagnosis of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Record review of the baseline care plan dated 04/06/2023 for Resident #246 revealed dietary/nutritional status as fluid consistency of regular. Record review of comprehensive care plan dated 04/06/2023 for Resident #246 revealed potential nutritional problem with diet restriction, swallowing problem, puree, and thin liquids. Observe and report any of the following to the nurse: choking, coughing, drooling, holding food inside of mouth and not swallowing, making repeated unsuccessful attempts to swallow food, refusing to eat, or appearing concerned during meals. Refer resident to speech therapist for swallowing evaluation as ordered by MD. Record review of order recap of physician's orders dated 04/06/2023 for Resident #246 revealed a renal diet of puree texture and thin consistency. Record review of Resident #246 Nutrition assessment from the Dietitian dated 04/11/2023 revealed no indication of liquid consistency for Resident #246. Record review of ST Daily Treatment Note dated 04/07/2023 indicated Resident #246 was evaluated and was determined safe swallow and kept at pureed foods and thin liquids. Record review of ST Daily Treatment Noted dated 04/11/23 indicated Resident #246 was reevaluated for coughing when lying flat on his bed and exhibited safe swallowing and remained pureed foods with thin liquids with no signs of aspiration. Observation on 04/11/2023 at 12:50 PM revealed Resident #246 had received a meal ticket that indicated puree texture with thin liquids but was being given nectar liquid consistency during the lunch meal. Meal ticket revealed diet: renal, diet texture: pureed and no indication of liquid consistency. Interview on 04/11/2023 at 12:53 PM, CNA C stated the ticket shows thin liquids but was told by LVN D that Resident #246 was on nectar consistency. CNA C stated if she did not know Resident #246 was not nectar consistency, she would not have given it to him and gone back to ask for the correct liquid consistency. CNA C stated the risk to the resident would be aspiration if it was a different liquid consistency. Interview on 04/11/2023 at 12:58 PM with LVN D stated she had received in a report that Resident #246 was changed to nectar liquids by the night shift nurse. LVN D stated the Speech Therapist would also inform them if Resident #246 was nectar liquids. LVN D stated the risk to Resident #246 could have been aspiration if they would have given him the wrong liquid consistency. Record review on 04/11/2023 1:04 PM with LVN D revealed a communication slip dated 04/07/23 for Resident #246 indicating the speech therapist recommended puree texture with thin liquids and signed by the physician. Interview on 04/13/2023 at 2:14 PM DON stated if residents are coughing or showing signs of difficulty swallowing, depending on the resident's texture and liquid consistency, nursing staff may downgrade but not upgrade. DON stated if the resident shows these signs throughout the day, then the nursing staff would make recommendations to the doctor and let the speech therapist know so he may conduct his evaluation assessment. DON stated the kitchen was notified of changes in diet orders through a communication order that is given to them by the nursing staff. DON stated that nursing staff ensure that diet textures during meals are correct. Interview on 04/14/2023 at 8:51 AM with the Dietitian revealed there had to be a telephone order for changes of dietary orders. The Dietitian stated she can only downgrade and not upgrade diet orders. The dietitian stated diet orders and fluid consistency should be served according to physician's orders. Interview on 04/14/2023 at 9:31 AM with Speech Therapist revealed he does assessment for dysphagia (difficulty swallowing) and then writes his recommendation orders on a communication slip. Speech Therapist stated the physician signs off on his recommendations. The Speech Therapist stated he was informed by LVN D on 04/11/2023 that Resident #246 was having difficulty swallowing but did not tell the nurses to change his liquids consistency from thin to nectar. Speech Therapist stated he was not informed of Resident #246 having any issues with swallowing on the 04/08/23, 04/09/23, & 04/10/23 until 04/11/23. Speech Therapist stated he evaluated Resident #246 on 04/11 and concluded that Resident #246 was to remain thin liquid consistency as the coughing was not coming from difficulty swallowing but from another issues. The Speech Therapist stated that the cough from Resident #246 was coming from the resident being laid down flat causing his diaphragm to cause him problems and when elevated back up the issues would go away not having to do with his swallowing. Speech Therapist stated downgrading his liquid consistency to nectar did not pose a safety risk. Interview on 04/14/23 at 10:57 AM with LVN E stated if a resident was having issues with coughing or swallowing it would be documented on the progress notes, 24-hour report, and other areas. LVN E stated the speech therapist would have to be notified if the resident was coughing or choking if downgraded from liquid consistency from regular thin liquids to nectar thick liquids. LVN E stated she reviewed the progress notes for Resident #246 (for 04/08/23, 04/09/23, 04/10/23) and did not see any reports on Resident #246 coughing or choking when eating or drinking fluids and did not see a notification to the speech therapist or doctor. LVN E stated there was a risk for not documenting but did not know how to appropriately answer the risk. Interview on 04/14/2023 at 1:31 PM with the Administrator and the DON. The Administrator and DON confirmed the facility's policy and procedure on Serving a Meal dated 08/16/17 revealed diets should be served in accordance with the physician's orders. The DON stated that the communication slip that was sent to the dietary department was not a doctor's order. DON reported that when a diet or fluid was downgraded or upgraded, they would need to send an electronic telephone order for the physician to sign. DON stated the speech therapist reevaluated Resident #246 on 04/11/23 but did not approve for the resident to get nectar thick liquids and was kept at thin liquids after his reassessment. DON stated if the resident was served the wrong consistency the risk would be aspiration and choking. DON stated there was no documentation for Resident #246 for physician orders, to upgrade liquid consistency to nectar. Record review of facility policy Serving a meal dated 08/16/17 revealed diets should be served in accordance with the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 resident (Residents #247) of 3 reviewed for medication administration. The facility failed to ensure LVN D administered Resident # 247 medications according to the physician ' s order. This deficient practice could place residents with g-tubes at risk of not receiving their medication in accordance with the physician ' s order. Findings included: Record Review of Resident #247 face sheet dated 4/14/2023 Resident #247 was a 70 yr. old female admitted on [DATE]. Record Review of Resident #247 ' s History and Physical dated 03/16/23 revealed a diagnosis of Alzheimer ' s dementia, cva (stroke), and dysphagia (difficulty swallowing). Record Review of MDS assessment dated [DATE] revealed Resident #247 had a diagnosis of dysphagia (difficulty swallowing). Section K, in the MDS documented Resident #247 has a feeding tube (a medical device used to provide nutrition). Record Review of the comprehensive care plan dated 03/30/2023 revealed Resident #247 has a g-tube related to dysphagia. Record Review of physician orders dated 03/30/23 revealed an order for every shift to ensure routine care check of enteral tube placement via aspiration & auscultation before medication administration, before performing the gastric residual check, flush with 10 ml of water between each individual medication, and with 30 ml of water before and after medication administration. Include the orders for the Carvedilol, Memantine, Januvia, and Metformin. Record Review of Resident #247 medication administration record for Resident #247 revealed she was scheduled to receive Carvedilol 25mg 1 tablet every 12 hrs., Memantine 10mg 1 tablet daily, Januvia 100mg 1tab daily, metformin HCI 500mg 1 tablet twice a day. All medications were scheduled for medication administration at 09:00 AM crush via g-tube. Observation on 4/11/23 at 09:26 AM LVN D revealed LVN D crushed Carvedilol, Memantine, Januvia, and Metformin each medication individually and mix the medication in a 9 oz cup with approximately 8 oz of water mix until mostly dissolved. LVN D checked for g-tube placement and residual obtain 5ml of residual. LVN D administered the medication mixture after g-tube was flushed with 6 oz of water. Resident #247 tolerated well; left at a 35-degree angle. Interview with LVN D on 4/11/23 at 9:40 AM revealed she was trying to save time and was unaware she was not able to mix medication and did not realize the order specified the amount of fluid needed between medications. She stated that since a bolus was given didn ' t think it would harm the patient, but too much fluid can put the resident at risk for abdominal distention. Interview with the DON and the Administrator on 4/14/23 at 11:30 revealed when administering medications via g-tube, they should not be mixed together, and the order did specify a specific amount and LVN D should have followed the order. Stated nurses are trained in medication administration yearly and upon hire, confirmed orders for the fluid amount used during medication administration. DON stated too much fluid administration in the g-tube can place a resident at risk for fluid overload. Record Review of Policy titled Preparation and General Guidelines dated 2006 in part stated medication is administered in accordance with written orders of the attending physician. Confirmed with DON no other available policy for G-tube medication administration. FACILITY Medication Administration 04/11/23 04:28 PM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure three hotdog buns were labeled or sealed. An open container of chocolate syrup was not labeled per facility protocol, had a use by date in 2022, and had dried drips of chocolate syrup on the sides of the bottle. Cook G did not change gloves or wash her hands as she moved from washing a dish to preparing food, and dripped dish-washing water from the used gloves onto a blender she was using to prepare food. These failures could put residents at increased risk for food borne illnesses. Findings include: An observation on 04/11/2023 at 8:02 AM in the walk-in refrigerator revealed three hotdog buns in an unsealed clear plastic bag with no label on the bag. In an interview on 04/11/2023 at 8:02 AM, the Culinary Director stated that all food was to be labeled with the name of the food item, the date the food item was opened, and the expiration date when the food was to be thrown away. He said that the problem with the unlabeled hot dog buns was that the kitchen workers would not know when they were opened or when they would expire and would need to be discarded. He said that not having this information could put the facility residents at risk of eating spoiled food and it could make them sick. He handed the hot dog buns to an employee and told her to throw them out. Observation on 04/11/2023 at 8:15 AM in the food preparation area of the kitchen, an open bottle of chocolate syrup was observed sitting next to bottles of spices. When picked up it felt light for its size and had visible drips of chocolate syrup down the sides of the bottle. Observation of the bottle revealed that it had no label indicating the name of the item, date it was opened or date to be discarded. Inspection of the product label revealed a Best By date of 11/04/2022. In an interview on 04/11/2023 at 8:15 AM, the Culinary Director said that he did not know why the bottle of chocolate syrup was placed next to the spices. He said that there was no way to know when it was opened or when it might expire, and that as a result they could not know if it was safe for the residents to consume. He said that it could cause resident ' s stomach upset and diarrhea. In observation on 04/11/2023 at 11:05 AM, [NAME] G was observed pureeing chicken using a blender. She washed her hands, donned clean gloves then took the blender jar to the three-compartment sink and washed the blender jar first in soapy water, then dipped it in the sanitization rinse sink. Without changing gloves or washing her hands, she took the blender jar and lid back to the blender and proceeded to blend vegetables. As she was blending the vegetables, water was observed dripping out of the gloves onto the blender. In an interview on 04/11/2023 at 11:10 AM with the Culinary Director and [NAME] G, [NAME] G said that she made a mistake when she did not remove the dirty gloves after washing the blender jar, wash her hands and put on clean gloves before pureeing the vegetables. She said she knew she was supposed to wash hands and change gloves after washing the blender jar because of infection control issues. The Culinary Director said [NAME] G was nervous because she was being observed and had been trained to wash hands and change gloves as part of the food preparation process. The Culinary Director instructed [NAME] G to throw out the pureed vegetables and prepare more. In an interview and record review on 04/13/2023 at 8:28 AM the Culinary Director said that he and kitchen workers were responsible for labeling and checking food items for expiration dates. He stated that he had his own check list he used on occasion to track his duties which included checking labeling and expiration dates. He stated he did not use the list consistently and was not able to provide any recently completed check lists. He also said that employees were given the duty of checking labels and expiration dates on a cleaning detail check list, and one of the duties included checking expiration dates. He provided a list (untitled, undated) but in review of the document was not able to show where it directed staff to check labeling or food expiration dates. He said that the last time kitchen employees had been trained about labeling, expiration dates, gloving and hand washing was about three weeks before the interview (exact date not known). Record review of the policy Date Marking for Food Safety dated 2018 documented in part that the facility adhered to a date marking system to ensure the safety of food. Food shall be clearly marked to indicate the date of day by which the food should be consumed or discarded. The individual opening or preparing a food shall be responsible for date-marking the food at the time the food is opened or prepared. The discard date may not exceed the manufacturer's use-by date or 4 days whichever is the earliest. The head cook or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. The Dietary manager shall check refrigerators weekly for compliance. Record review of the policy Handwashing Guidelines – Dietary Employees dated 08/16/2017 documented in part that hands should be washed after touching anything unsanitary such as dirty dishes, when changing food preparation procedures, and before donning gloves for working with food. FACILITY Kitchen 04/11/23 08:02 AM Culinary Director [NAME] - in refrigerator open bag with three hotdog buns with no label. unlabeled open container of chocolate syrup with Exp date of 11/04/2022. Risk - don't know when opened so don't know how long it will be good. Possible a threat to the safety of the product for residents to consume. Residents could have stomach issues, diaharrea. 04/11/23 11:10 AM CD [NAME] and cook [NAME] - issues with gloving in process of doing Puree - Puree OK but issues with infection control - uses same gloves to wash blender parts and then in preparation of pureed vegetables without glove change or hand washing. Wash water seen dripping from inside right hand glove onto surface of blender while in the process of blending the vegetables. When asked about gloving she states without prompt that she should have changed gloves and washed hands , re-gloved after washing the blender parts. That there is a risk of contamination of the food due to the failure, that resident could get sick. - 04/13/23 8:28 AM - CD - Just inserviced staff about labeling and gloving. Last time was about three weeks ago. He checks daily using a daily sanitization check list. Also assigned to staff based on detail cleaning check list (list provided) but he is not able to identify this task on the cleaning list. Policy Date Marking for Food safety - dated 2018 (picture in camera).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that assessments accurately reflected the resident's status for one (Resident #34) of 12 residents reviewed for accuracy of assessments. Resident #34's MDS did not reflect the condition of his teeth. This failure put residents at increased risk of not having their care needs identified and addressed. Finding Include: Record review of Resident #34's admission Record dated 02/16/2022 documented that he was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #34's History and Physical dated 2/4/2022 documented that he had diagnoses including history of hypertension, renal failure and congestive heart failure. He had a colostomy, was receiving dialysis and had a catheter. He was alert and oriented. He had poor dentition (teeth). Record review of Resident #34's admission MDS dated [DATE] documented that his BIMS was 6 (Severe Cognitive Impairment). He had no behaviors that interfered with his care. He required extensive assistance from one person to maintain personal hygiene including brushing his teeth. The MDS indicated that he had no problems with his teeth. Record review of Resident #34's IDT admission Evaluation with Baseline Care Plan for admission on [DATE] with most recent admission of 12/23/2021 documented that he required a mechanically altered diet, had broken or loose-fitting dentures and was at risk for weight loss due to chewing problems. Record review of Resident #34's Comprehensive Care Plan dated 01/31/2022 documented that he had nutrition problems due to renal diet restrictions but did not mention his oral health. There was no care plan in place to address his dental care needs or issues related to his oral health. In observation and interview on 02/14/22 at 09:56 AM Resident #34 stated that he was not given a toothbrush or toothpaste. Observation of the chest of drawers in his room revealed an unopened tube of toothpaste and a toothbrush that was still in a wrapper. He expressed concern about the condition of his teeth. Observation of his teeth revealed that his teeth were yellow with receded gums. His gums looked red and puffy. He stated he got no help to clean his teeth. In an interview on 02/15/22 at 03:34 PM CNA F stated that the resident had complained to her about his teeth hurting him. As a result, he did not want to eat even though the texture of his food had been changed to try to get him to eat. She stated that even with puree he did not eat and that even with the puree he had said he had pain in his teeth. She stated that he did not allow staff to help with brushing his teeth because they hurt him. She stated that she had mentioned to nurse that he was not eating, that he had refused help brushing his teeth and that he said he was in pain. In an interview on 02/15/22 at 03:54 PM LVN C stated that she did not recall if the CNAs had reported that Resident #34 had tooth pain. She stated that the resident did have a poor appetite and that the physician was aware of it. She stated that the CNAs were good about reporting resident concerns, and that tooth pain is something that should be reported to her. Record review of the undated facility policy Minimum Data Set - Resident Assessment stated in part that it was the policy of the facility to use the resident assessment instrument [MDS] to initiate a comprehensive assessment of each resident's needs, including dental and nutritional status. The assessment would be used to develop, review and revise the resident's comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #6 Nutrition 02/14/22 11:36 AM Admit 1/20/22 - only one weight recorded. - 02/15/22 04:13 PM [NAME], LVN since bV don 't have orders to [NAME] weights. Since she is dialysis patient shold be be weightd - No weekly orders - 02/13/22 12:47 PM Daughter is in room and states that food served does not match menu. plate card states green beans but plate contains pinto beans. Tray card states ground ham but plate contains cubed ham. 02/16/22 09:28 AM Per dietitian should receive ground meat and ground carrots. Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 1 meal (lunch) reviewed for residents with a diet order for pureed texture and for one resident (Resident #6) of 158 residents reviewed for provision of food in in a form designed to meet individual needs. Cook Q failed to prepare enough food by not did not following established facility recipes when preparing pureed food to feed 18 residents that had orders for Pureed Diets. Resident #6 did not receive finely chopped foods as per prescriber's orders. This placed residents who received pureed diets at-risk of inadequate nutrition and weight loss and put residents with orders to receive finely chopped foods at increased risk of choking, aspiration and infection. The findings include: Puree Diet Preparation: Observation &and iInterview on 002/0013/2200 at 11:52 AM, with [NAME] Q reported that she had already Pureed the Beans using the recipe for 10 Servings, and was going to Puree the Ham, and Carrots for the lunch meal using the recipe for 10 Servings. The Pureed the Beans was a Honey-thick consistency. Carrots:Cook Q Poured eight 4 oz. Portion Control Serving Spoons of Carrots and ten 4 oz. soup ladles of broth into food processor; Carrots were pureed and poured into a metal container. [NAME] stated, Now I am going to mix in Thick-It Thickener Powder until I get the right consistency. The Carrot should not drip from the spoon. The cook demonstrated the to surveyor Ppureed cCarrots slowly dripped from spoon. It was observed that cook added 4 scoops of Thick-It Thickener Powder to the Puree Carrots. The texture was a Honey-thick Consistency. Ham: [NAME] Q Poured eight 4 oz. Portion Control Serving Spoons of diced Ham and eight 4 oz. soup ladles of beef broth into food processor; poured pureed Ham in a metal container. The texture was a Honey-thick Consistency. The [NAME] stated, This is how I prepare the Pure food every day. Record Review Pureed Carrots Recipe Number: 28820 New Menu Spring/Summer 2021- Day 15 - Lunch documented in part: Portion Size After Pureed: #12 Dip Ingredients (10 Servings): Buttered Carrots 1 qt. 1 cup, Margarine, Solids 1/4 cup Place carrots and margarine in a washed and sanitized food processor; blend until smooth. Portion with a #12 scoop. *Note: Any liquid specified in the recipe is a suggested amount of liquid (if needed). Some recipes items will require no liquid added to achieve the desired consistency. 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. 2. If the product needs thickening, gradually add a commercial or natural food thickener (ex, potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. 3. Follow any facility policies/procedures, such as the puree volume method procedure, to ensure a correct portion is served. Top pureed foods with appropriate sauces or gravies, as needed, to ensure adequate moisture for safe consumption and enhanced flavor. Record Review Pureed Ham Recipe Number: 34558 New Menu Spring/Summer 2021- Day 15 - Lunch documented in part: Portion Size After Pureed: #8 Dip Ingredients (10 Servings): Country Ham 1 lb. 14 oz., Water 1 cup, Base, Ham, may use pork or chicken base in place of ham base Dissolve base in water to make broth. Place prepared Ham slices in a clean and sanitized food processor. Add prepared broth gradually as needed and blend until smooth. Portion with a #8 dip. *Note: Any liquid specified in the recipe is a suggested amount of liquid (if needed). Some recipes items will require no liquid added to achieve the desired consistency. 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. 2. If the product needs thickening, gradually add a commercial or natural food thickener (ex, potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. 3. Follow any facility policies/procedures, such as the puree volume method procedure, to ensure a correct portion is served. Top pureed foods with appropriate sauces or gravies, as needed, to ensure adequate moisture for safe consumption and enhanced flavor. Record Review Pureed Pinto Beans Recipe Number: 3188 New Menu Spring/Summer 2021- Day 15 - Lunch documented in part: Portion Size After Pureed: #8 Dip Ingredients (10 Servings): 2 cups Water, 2 tsp. Base, Beef, Pinto Beans 1 qt. 1 cup Dissolve beef base and hot water to make a broth. Remove portions needed from the regular prepared recipe,; place in a washed and sanitized food processor. Gradually add broth; blend until smooth consistency has been achieved. Portion with a #8 scoop. *Note: Any liquid specified in the recipe is a suggested amount of liquid (if needed). Some recipes items will require no liquid added to achieve the desired consistency. 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. 2. If the product needs thickening, gradually add a commercial or natural food thickener (ex, potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. 3. Follow any facility policies/procedures, such as the puree volume method procedure, to ensure a correct portion is served. Top pureed foods with appropriate sauces or gravies, as needed, to ensure adequate moisture for safe consumption and enhanced flavor. Interview and Record Review on 2/13/22 at 1:02 PM, with Food Director of Pureed Pinto Beans Recipe Number: 3188, Pureed Ham Recipe Number: 34558, and Pureed Carrots Recipe Number: 28820 confirmed that the [NAME] had prepared a recipe for only (10 Servings) of the Pinto Beans, Ham, and Carrots. The Food Director stated, We prepare and serve food to the residents in the Nursing Facility and Assisted Living Unit. We served a total of 18 Pureed Diets today at Lunch, and 10 of those Pureed diets were served to residents at the Nursing Facility with a recipe that was prepared for 10 Servings. So, the residents did not get the correct Portion Size according to each recipe that was prepared for Beans, Carrots, and Ham because the cook used the recipe for 10 Servings. Food Service Director provided surveyor a list of 18 residents that had Physician's Orders for Pureed Diets. Observation and Interview 2/13/22 at 12:16 PM, with Food Director revealed that Pureed food was serve in a dinner plate, and the Pureed food was running together. Food Director stated, That is how we have been preparing and serving the Pureed Food for the two years that I have been working here. It was observed that cook did not have ground Ham in the serving line. Telephone Interview on 02/16/22 at 5:14 PM, with the Dietitian Consultant and Food Director, Dietary Consultant reported that her main responsibility was to provide dietary consultation to the residents. Dietitian Consultant stated, Food Director reported to me that [NAME] had not properly followed the recipes to obtain the right consistency of Pureed foods on Sunday 02/13/22, resulting in residents not receiving the correct serving portion of Ham, Carrots, and Pinto Beans. The Pureed Food consistency should be like mashed potatoes. The residents were not getting the correct servings of meat, vegetables, and bread because the food was being diluted too much with broth. The serving of meat should be 4 oz., failure to serve the correct portion of protein over prolonged time could result in Protein Malnutrition. Dietitian stated the cook should prepare enough food based on the resident census to prevent running out of food in the tray line. Dietitian reported that she conducted on site sanitization inspections of the kitchen once a month and had not identified any problems. Dietitian stated, The Grill should be cleaned after each use using a wire brush, cleaned with soapy water and dry well. Surveyor asked Dietitian for copies of monthly visits for the past 6 months. Dietitian stated, I will be at the facility tomorrow. Resident #6 Record review of Resident #6's admission Record dated 02/16/2022 documented that she was [AGE] years old, was initially admitted to the facility on [DATE] and her most recent admission was on 08/04/2021. Record review of Resident #6's History and Physical dated 06/03/2021 documented that she had diagnoses including Alzheimer's Dementia, end-stage renal disease with dialysis, chronic respiratory failure with hypoxia (below-normal level of oxygen in the blood), and dysphagia (difficulty in swallowing food or liquid) . Review of Resident #6's admission MDS dated [DATE] documented that she had clear speech but was rarely understood and rarely understood others. Her BIMS was 6 (severe cognitive impairment). She was able to eat independently after staff had set up her tray. She had trouble breathing in any position. She weighed 117 pounds and was receiving a mechanically altered diet. Record review of Resident #6's Clinical Physician Orders accessed on 02/16/2022 documented a physician's order dated 11/08/2021 that she was to receive a finely chopped diet with thin liquids. Review of Resident #6's Quarterly MDS dated [DATE] documented that she had clear speech. She sometimes understood others and was sometimes understood. Her BIMS was 7 (severe cognitive impairment). She required limited physical assistance from one person to eat. She weighed 117 pounds and was receiving a mechanically altered diet. Record review of Resident #6's Care Plan dated 08/06/2021 documented that she was to receive food in a mechanical soft form. The interventions included to provide and serve diet as ordered. In observation, record review and interview on 02/13/22 at 12:47 PM Resident #6's family member was in the room and was observed to be helping the resident eat. Observation of Resident #6's meal revealed that she had been served cubed ham (about 1 CM X 1 CM), beans (pinto or other dried bean ) and sliced carrots. No food on the plate was ground . Record review of the dietary slip on the tray (titled Lunch-Day 15 - 2/11/2022) documented the resident's name and that she was to have a diet texture of Dental Soft (Mech Soft). Items listed on the dietary slip included Ground Country Ham slice with gravy, LS (Low Salt) green beans and Soft Buttered Carrots. Resident #6's family member stated that it was common that the food served did not match the menu. She also stated that the food was seldom ground. In an interview on 02/16/22 at 09:28 AM the Dietitian Consultant stated that the form in which Resident #6 received her mid-day meal on 02/13/2022 was incorrect. She stated that the resident should receive ground meat and ground carrots. She stated that this put the resident at risk of choking and aspiration. Policy & Procedures: Record Review on 02/16/22 at 5:19 PM, with Food Director of facility's Dietary Policy & Procedures revealed: 1. Puree Food Preparation Policy & Procedure dated 08/16/17 documented in part: Policy: To provide puree food that has been prepared in a manner to conserve nutritive value, flavor, and appearance. Policy Explanation and Compliance Guidelines: Each resident must receive, and the facility must provide food that is prepared by methods that conserve nutritive value, flavor, and appearance. General Information: Puree foods should contain no lumps or chunks. The goal is a smooth, soft, homogenous (alike) consistency similar, to soft mashed potatoes. 2. Food Preparation Guidelines dated 08/16/17 documented in part: Policy: To assure that the nutritive value of food is not compromised because of prolonged food storage, light, and air exposure, prolonged cooking of foods in a large volume of water, and prolonged holding on steam table, or the addition of baking soda. Food should be palatable, attractive, and at the proper temperatures, as determined by the type of food, to ensure resident's satisfaction and meet individual needs. Policy Explanation and Compliance Guidelines: -The cook, or designee, should prepare menu items following the written menus and standardized recipes. -Food should be cut, chopped, pureed or ground to meet the individual needs of the residents . -Each meal should be presented in an attractive and appetizing manner: Servings should be placed on plates to prevent running together with other food items -Food should be protected from contamination, while being stored, prepared, and transported. -Food is prepared by methods that conserve nutritive value, flavor, and appearance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #23,Resident #189, and Resident #34) of 12 residents reviewed. A. Resident #23 and Resident #189 oxygen therapy did not reflect on their care plans. B. Resident #34's teeth condition was not addressed on his care plan This failure put residents at increased risk of not having their care needs identified and addressed. Findings include: Record review of Resident #23 face sheet (not dated) revealed Resident #23 was a [AGE] year-old female admitted on [DATE]. Record review of Resident #23 History and Physical dated 9/21/21 revealed a diagnosis of acute and respiratory failure with hypoxia, acute respiratory disease due to Covid 19 virus, Covid 19 virus infection, depression, chronic kidney disease, diabetes type II, diabetes with chronic arthropathy. Record review of Resident #23 electronic order dated 1/28/22 revealed an order for oxygen at 2 liters per minute vis nasal cannula as needed. Record review of Resident #23 care plan dated 01/14/2022 had no mention of Resident #23 receiving oxygen therapy. Record review of Resident #189 face sheet (not dated) revealed Resident #189 was a [AGE] year-old female admitted on [DATE]. Record review of Resident #189 History and Physical dated 02/08/2022 revealed a diagnosis of hypertension, Covid 19, anemia, hypothyroidism, gout and diabetes. Record review of resident #189 electronic order dated 02/02/2022 revealed an order for oxygen at 2 liter per minute via nasal cannula continuous. Record review of Resident #189 care plan dated 02/07/2022 revealed no mention of oxygen therapy. During interview and record review on 02/15/22 at 10:26 AM DON stated there is no current person in charge of care plans at the moment. DON stated care plans are being created by DON and ADON. DON referred to her computer and reviewed Resident #23 and Resident #189 electronic records and stated oxygen therapy is not mentioned on either resident's care plans. DON stated any treatment a resident is receiving should be documented on the care plan for proper monitoring. DON stated by not having the oxygen therapy on residents individualized care plan could result in not having proper monitoring. DON did not have an answer for oxygen therapy not being included on Resident #23 and Resident #189 care plan. Record review of Resident #34's admission Record dated 02/16/2022 documented that he was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #34's History and Physical dated 2/4/2022 documented that he had diagnoses including history of hypertension, renal failure and congestive heart failure. He had a colostomy, was receiving dialysis and had a catheter. He was alert and oriented. He had poor dentition (teeth). Record review of Resident #34's admission MDS dated [DATE] documented that his BIMS was 6 (Severe Cognitive Impairment). He had no behaviors that interfered with his care. He required extensive assistance from one person to maintain personal hygiene including brushing his teeth. The MDS indicated that he had no problems with his teeth. Record review of Resident #34's IDT admission Evaluation with Baseline Care Plan for admission on [DATE] with most recent admission of 12/23/2021 documented that he required a mechanically altered diet, had broken or loose-fitting dentures and was at risk for weight loss due to chewing problems. Record review of Resident #34's Comprehensive Care Plan dated 01/31/2022 documented that he had nutrition problems due to renal diet restrictions but did not mention his oral health. There was no care plan in place to address his dental care needs or issues related to his oral health. In observation and interview on 02/14/22 at 09:56 AM Resident #34 stated that he was not given a toothbrush or toothpaste. Observation of the chest of drawers in his room revealed an unopened tube of toothpaste and a toothbrush that was still in a wrapper. He expressed concern about the condition of his teeth. Observation of his teeth revealed that his teeth were yellow with receded gums. His gums looked red and puffy. He stated he got no help to clean his teeth. In an interview on 02/15/22 at 03:34 PM CNA F stated that the resident had complained to her about his teeth hurting him. As a result, he did not want to eat even though the texture of his food had been changed to try to get him to eat. She stated that even with puree he did not eat and that even with the puree he had said he had pain in his teeth. She stated that he did not allow staff to help with brushing his teeth because they hurt him. She stated that she had mentioned to nurse that he was not eating, that he had refused help brushing his teeth and that he said he was in pain. In an interview on 02/15/22 at 03:54 PM LVN C stated that she did not recall if the CNAs had reported that Resident #34 had tooth pain. She stated that the resident did have a poor appetite and that the physician was aware of it. She stated that the CNAs were good about reporting resident concerns, and that tooth pain is something that should be reported to her. During interview on 02/15/22 at 01:15 PM ADON stated there was no person assigned to care plans at the moment. ADON stated care plans are being created and updated by DON and ADON at the moment. ADON stated care plans are created using hospital history and physical and physicians' orders. ADON stated a resident receiving oxygen therapy should be included on their care plan to properly monitor progress and if any concerns arise. During interview on 02/16/22 at 09:45 AM Administrator stated DON and ADON are in charge of creating and updating care plans at the moment, Administrator stated all treatments, medications, and anything medical that requires constant monitoring should be included in care plans for staff to have something to refer to when monitoring progress. Administrator stated by not having care plans accurately updated with care each resident receives could affect the monitoring received by staff and will not be able to determine progress or decline a resident may show. Record review of Comprehensive Care Plan policy dated 8/16/17 revealed 4. The comprehensive care plan will describe, at a minimum, the following: a. the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial wellbeing; 7. The comprehensive care plan will include measurable objectives and timeframes to meet the residents needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents progress. Resident #34 Dental 02/15/22 03:34 PM [NAME], CNA - works 2-10 - week days - worked with him three times - colostomy, foley - depressed, very particular - does not like lights, sounds; -teeth are painful. offered different textures, even with puree he does not eat. has said has pain in teeth - his baths are in AM on MWF - He has not asked for evening baths - just wants to sleep and to not be bothered. Baths for A beds are in AM and B bed is PM - MWF - even numbers; T/Th/Sat are odd numbered rooms. He does not allow them to help with the teeth says because they hurt him - it may be an excuse -not eating well - Has mentioned to nurse that he is not eating. Has told nurse that he refused dental hygiene and that he says he is in pain. [NAME], LVN - 02/15/22 03:54 PM - has PRN Tylenol but is not asking for it - Does not remember if CNAs have said he has pain although they are good at reporting everything. Does have a poor appetite and MD is aware. He has refused medications and CNAs have reported he refuses help. Has never reported that his teeth hurt to her or CNAs. Does think that tooth pain would be reported by CNAs. Does not remember if reported that he refuses baths. T/TH/S are his dialysis days at 5:00 AM - confirmed by order dated 02/01/2022. - Resident is currently Medicare. MDS shows requires extensive assistance by one for Personal Hygiene - does not show dental issues although these are on care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide each resident with necessary respiratory care consistent with professional standards of practice, for 3 of 12 residents (Resident #190, Resident #23 and Resident #189) reviewed for oxygen therapy. A. Oxygen tubing for Resident #'s 23, 189 and 190 were not dated. These failures could have placed residents receiving oxygen therapy at risk for respiratory illness. Findings include: During observation on 02/13/22 at 09:20 AM Resident #190 nasal cannula was not dated. Record review of Resident #190 face sheet (not dated) revealed Resident #190 was [AGE] year-old male admitted on [DATE]. Record review of Resident #190 History and Physical dated 02/08/2022 revealed aa diagnosis of coronary artery disease with coronary artery bypass grafting, cerebrovascular accident with aphagia, hyperlipidemia, and dementia. Record review of Resident #190 During observation on 02/13/22 at 09:37 AM Resident #23 nasal cannula was not dated. Record review of Resident #23 face sheet (not dated) revealed Resident #23 was a [AGE] year-old female admitted on [DATE]. Record review of Resident #23 History and Physical dated 9/21/21 revealed a diagnosis of acute and respiratory failure with hypoxia, acute respiratory disease due to Covid 19 virus, Covid 19 virus infection, depression, chronic kidney disease, diabetes type II, diabetes with chronic arthropathy. Record review of Resident #23 electronic order dated 1/28/22 revealed an order for change oxygen tubing/ equipment weekly on Sundays. During observation on 02/13/22 at 09:38 AM Resident #189 nasal cannula was not dated, and a new nasal cannula sealed in bag was on bedside nightstand. Record review of Resident #189 face sheet (not dated) revealed Resident #189 was a [AGE] year-old female admitted on [DATE]. Record review of Resident #189 History and Physical dated 02/08/2022 revealed a diagnosis of hypertension, Covid 19, anemia, hypothyroidism, gout and diabetes. Record review of resident #189 electronic order dated 02/06/2022 revealed an order of change oxygen tubing/ equipment weekly on Sunday. Record review of Sunday night shift nurses schedule for Sunday 02/06/2022 revealed LVN M, LVN N, and ADON had worked. During interview on 02/13/2022 at 10:00 AM LVN M stated she was placing new sealed nasal cannulas at bedside for night shift nurses to change overnight. LVN M stated nasal cannulas were not currently dated. LVN M stated nasal cannulas should have a date reflecting they were last changed with a date of 02/06/2022. LVN M stated Sunday night shift nurses are in charge of changing and dating nasal cannulas. LVN M stated nasal cannulas need to be dated to verify that they had been changed when needed. LVN M stated by not dating nasal cannulas could result in nurses assuming the nasal cannulas and prolonging the time nasal cannulas got replaced; this would lead to bacteria growth potentially putting receiving oxygen therapy at risk for respiratory illness. During interview on 02/14/22 at 10:31 AM LVN O stated nasal cannulas are to be dated when changed to verify that it has been completed and to know when to change it again. LVN O stated by not having nasal cannulas dated nurses can assume that nasal cannulas had been changed and probably go weeks with same nasal cannula causing bacteria growth that could lead to respiratory illness. LVN O stated nasal cannulas are to be changed and dated on Sunday night by night shift nurses. LVN O stated she received training upon hire regarding oxygen equipment care upon hire and as needed. During interview on 02/15/22 at 10:26 AM DON stated Sunday night shift nurses are in charge of changing and dating nasal cannulas. DON stated nasal cannulas are required to be dated to keep track pf when it was last changed. DON stated nurses are trained regarding oxygen care upon hire. DON stated ADON and DON are in charge of conducting random rounds to verify that nasal cannulas are changed and dated within the 7-day time frame. DON stated by not dating nasal cannulas could lead nurses to believe that nasal cannulas were changed and could go days longer with the same nasal cannula; bacteria growth can occur leading to potential respiratory illness to those residents receiving oxygen therapy. During interview on 02/16/22 at 09:45 AM Administrator stated nasal cannulas are to be dated when changed every Sunday by night shift nurses. Administrator stated nasal cannulas are required to be dated to confirm that the task was completed. Administrator stated by not dating nasal cannulas a resident could go longer periods of time with same nasal cannula if overlooked causing bacteria growth that could lead to potential respiratory illness. Administrator stated nurses are trained regarding oxygen care upon hire. Record review of Oxygen Concentrator policy dated 2017 revealed no mentioning of nasal cannula needing to be dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering medications for 4 (residentResidents #194, #196, #37 and #15) of 12 residents reviewed for pharmaceutical services; failed to have an established system in place for accurate reconciliation for 3 (Hall 100, 200 and 300) of 3 halls that had residents with orders for controlled substances. A. LVN C failed to administer insulin to residentResident #194 according to Manufacturer's Specifications. B. LVN C failed to administer Multivitamin to residentResident #194 according to physician's orders. C. LVN B failed to administer Calcium Acetate to residentResident #196 according to physician's orders. D. LVN B failed to administer Sucralfate residentResident #37 according to physician's orders. E. ResidentResident #194 insulin dependent diabetic did not have orders to check blood glucose levels. F. Resident #197 insulin dependent diabetic did not have orders to check blood glucose levels G. LVN C administered Novolog Insulin to residentResident #15 without priming (removing air bubbles from the needle) the insulin pen. H. Licensed Staff were not signing Controlled Drugs Count Record when Controlled Drugs were reconciled at change of shift according to facility policy. I. Licensed Staff were not labeling medication containers upon receiving change in physician's orders according to facility policy. J. Licensed Staff were not preforming Glucose Quality Assurance (QA) checks on Glucometers in 3 of 3 Medication Carts according to Manufacturer's Specifications. K. 3 of 3 Medication Carts were not kept clean, nutritional supplement bottles were not dated after opening according to Manufacturer's Specifications, medication bottles with dried drippings This deficient practice could affect residents by placing the residents at risk of not being administered medications according to physician's orders and risk of drug diversion. The findings include: Resident #194: Record Review of admission Record for residentResident #194 dated [DATE] documented in part: admission Date: [DATE] Record Review of History & Physical dated [DATE] for residentResident #194 documented in part: [AGE] year-old male status post inflammation of the bile duct with stone removal, inflammation of the pancreas, infection with life threating low blood pressure, pneumonia, and pulmonary nodule. Past Medical History: Diabetes Mellitus Type 2, hypothyroidism, hypertension, age related physical debility, heart failure, pressure ulcer of sacral region, stage 1, chronic kidney disease stage 3. Record Review of admission Minimum Data Set (MDS) dated [DATE] for residentResident #194 documented in part: admitted from acute hospital; Hearing-adequate; clear speech; makes self-understood; understands others; vision-adequate; BIMS score 11 (moderately impaired) ; ADLs-requires extensive assistance of one person with bed mobility, transfers, locomotion on & off unit; dressing, toilet use, and personal hygiene; supervision of one person with eating; total assistance of one person with bathing; wheelchair; occasionally incontinent of urine; incontinent of bowel; pain; two stage 2 pressure ulcers; insulin injections; antibiotic; oxygen therapy; Occupational/Physical Therapy. Review of Care Plan dated [DATE] for residentResident #194 documented in part: Resident has Congestive Heart Failure, Pacemaker, Antibiotic Therapy for Lung Infection, Oxygen Therapy. Record Review of Physician's Order dated [DATE] for residentResident #194 documented in part: Insulin Lispro Solution inject as per sliding scale: 200-249=3 units subcutaneously before meals for DM. Multi-Vitamin give 1 tablet by mouth one time a day for supplement. Review of Medication Administration Record dated [DATE] for residentResident #194 documented in part: Insulin Lispro Solution inject as per sliding scale: 200-249=3 units subcutaneously before meals for DM. Blood Sugar at 7:30 AM, 11:00 AM, and 5:00 PM . Multi-Vitamin give one tablet by mouth one time a day for supplement. Observation on [DATE] at 11:44 AM LVN C said she was going to check residentResident #194's blood sugar, blood sugar was at 229. LVN C said, she has an order for sliding scale coverage with Humalog and I am going to give him 3 units of the Humalog (Lispro Solution) as ordered according to sliding scale. Observation on [DATE] at 12:34 PM, LVN C administered to residentResident #194, 3 units of Humalog subcutaneous to right upper at 12:34 PM. Observation [DATE] at 1:06 PM, revealed residentResident #194 was asleep in bed, untouched meal tray by side of bed. Interview [DATE] at 1:06 PM, LVN reported that she had not checked if residentResident #194 had lunch. LVN C stated, I needed to go check if CNA assisted residentResident #194 with his meal, because he needs to eat or have a snack 15 minutes after Humalog (Lispro) has been administered. Observation on [DATE] at 1:07 PM, Surveyor accompanied LVN C to residentResident 194's room and confirmed that resident was asleep in bed and had not had lunch. Meal Tray was on top of bedside table by the side of the bed and was untouched. LVN C stated, He has not eaten yet. But you know what, his doctor just called and gave me an order to give him a Boost Glucose Control supplement. Let me go and get him one. Observation on [DATE] at 1:07 PM, LVN C, awoke residentResident #194 and offered to give him the Boost Glucose Control Supplement. Resident drank 227 ml of Boost Glucose Control Supplement. Nurse confirmed it was more than 22 minutes that insulin had been administered. Interview on [DATE] at 12:53 PM, DON reported Humalog is rapid acting insulin, and resident should eat a snack or a meal within 15 minutes after insulin has been administered to prevent hypoglycemia. According to Manufacturer's specifications obtained on [DATE] at https://www.humalog.com/index.aspx documented to administer Humalog within fifteen minutes before a meal or immediately after a meal. Observation on [DATE] at 8:22 AM, LVN C crushed one tablet of Multivitamin with Minerals, mixed with Yogurt, and administered to residentResident #194. Interview and record review on [DATE] at 10:58 AM, with RN ADON of Discontinued Order printed on [DATE], documented had been discontinued on [DATE]. RN ADON stated, The resident never got the Multiple Vitamins-Minerals because it was ordered and discontinued on the same day on [DATE]. Surveyor confirmed with ADON that nurse [NAME] LVN had administered Multiple Vitamins-Minerals during the medication pass observation that was done on [DATE]. Resident #196: Record Review of admission Record for residentResident #196 dated [DATE] documented in part: admission Date: [DATE] Record Review of History & Physical dated [DATE] for residentResident #196 documented in part: [AGE] year-old female with past Medical History of Alzheimer's Dementia, Congestive Heart Failure, Severe Pulmonary Hypertension, Type 2 Diabetes Mellitus, Hypertensive Disease, Chronic Kidney Disease Stage 3. History of Present Illness: Age related physical debility, Anemia, Pain, Depressive Episodes, Acute Respiratory Failure with Hypoxia (don't have enough oxygen in your blood), Pressure Ulcer of sacral region, stage 2, Deep Tissue Damage (is an injury to the soft tissue under the skin due to pressure and is usually over boney prominence) of left heel, Muscle Wasting & Atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass). Record Review of admission Minimum Data Set (MDS) dated [DATE] for residentResident #196 documented in part: admitted from Acute hospital; Hearing-adequate; Clear Speech; Usually makes self-understood; Usually understands others; Vision-Adequate; BIMS Score 8 (Moderately Impaired); ADLs-requires limited assistance of one person with bed mobility, dressing, eating, and personal hygiene; extensive assistance of one person with transfer; total assistance of one person with toileting and bathing; wheelchair; incontinent of bowel & bladder; Pain; Resident has a pressure ulcer/injury over bony prominence; One stage 2 pressure ulcer; One Deep Tissue Injury; Speech/Occupational/Physical Therapy. Review of Care Plan dated [DATE] for residentResident #196 documented in part: Resident has CHF, HTN, Diuretic Therapy. Review of Physician Order Summary dated [DATE] for residentResident #196 documented in part: Calcium Acetate Tablet 667 (Calcium Acetate Phosphorus Binder) give 2 tablets by mouth with meals. ( Calcium acetate is used to control high blood levels of phosphorus in people with kidney disease who are on dialysis (medical treatment to clean the blood when the kidneys are not working properly)). Administer medications in applesauce or other suitable vehicle. Review of Medication Administration Record dated February 2022 for residentResident #196 documented in part: Calcium Acetate 667 mg two tablets by mouth for phosphorus binder at 8:00 AM, 12:00 Noon, and 6:00 PM. Observation & Interview [DATE] 11:31 AM, LVN B crushed one tablet of Calcium Acetate 667 mixed with pudding and administered to residentResident #196. Observation, Interview and Record Review on [DATE] at 3:31 PM, LVN B confirmed that the Physician Order Summary Report dated [DATE] and Medication Administration Record dated February 2022 for residentResident #196 documented Calcium Acetate 667 mg give two tablets by mouth with meals for phosphorus binder at 8:00 AM, 12 Noon, and 6:00 PM. LVN B stated, A change of direction label was not placed, on the Medication Blister Packet, to alert the Nurses resident's order had been changed and now is getting two tablets of the Calcium Acetate 677 mg by mouth with meals. LVN B stated, I was trained at the facility, that I could give medications an hour before or one hours after the prescribed time, even though the orders documents to be given with meals. LVN B reported that lunch was served in the 200 Hall at 12:30 PM through 12:45 PM. Interview and Record Review [DATE] at 12:30 PM with RN DON, reported that they have specific times to administer medications with meals for each hall. DON stated, LVN B should have administered the Calcium Acetate 667 mg two tablets by mouth no earlier than 12:30 PM, because that is when meal trays are sent to the 200 Hall. LVN B and should waited until the resident started to eat her meal. DON confirmed that Physician Order Summary and Medication Administration Record dated February 14, 2022 for residentResident #196 documented Calcium Acetate 667 mg give two tablets by mouth with meals for phosphorus binder. The DON reported that Nurses had been trained to place a change of direction label on the medication containers when orders are changed to prevent medication errors. Resident #37: Record Review of admission Record for residentResident #37 dated [DATE] documented in part: Initial admission Date: [DATE]; re-admission Date: [DATE]. Record Review of History & Physical dated [DATE] for residentResident #37 documented in part: [AGE] year-old female with End Stage Renal Disease-dependence on renal dialysis, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Cognitive Communication Deficit, Gastro-Esophageal Reflux. Continue Sucralfate Tablet 1 GM, 1 tablet on an empty stomach, orally, four times a day. Record Review of admission Minimum Data Set (MDS) dated [DATE] for residentResident #37 documented in part: Hearing-adequate; Clear Speech; usually makes self-understood; usually understands others; Vision-adequate; BIMS Score 10 (Moderately Impaired); ADLS: requires limited assistance of one person with bed mobility, dressing, and personal hygiene; extensive assistance of one person with transfer and toilet use; supervision of one person with eating; total assistance of one person with bathing; wheelchair; frequently incontinent of urine; continent of bowel; therapeutic diet; insulin injections; diuretic; dialysis; Speech/Occupational/Physical therapy; Review of Care Plan dated [DATE] for residentResident #37 documented in part: Resident has chronic renal failure; Requires oxygen therapy for shortness of breath Review of Physician Order Recap Report dated [DATE] for residentResident #37 documented in part: Order Date: [DATE]; Start Date: [DATE]; Sucralfate Tablet 1 GM give 1 tablet by mouth two times a day. Review of the Medication Administration Record dated February 2022 for residentResident #37, documented Sucralfate 1 GM give 1 tablet by mouth two times a day at for GI at 7:30 AM and 4:00 PM. Observation on [DATE] at 3:43 PM, with LVN B said she was going to administer residentResident #37 Sucralfate 1 GM give one tablet by mouth. Interview & record review [DATE] at 3:44 PM, with LVN B, confirmed that the Medication Blister Packet dated [DATE] for residentResident #37 documented Sucralfate 1 GM give 1 tablet by mouth four times a day. LVN B stated, We have been trained to put a Change of Direction Label to alert the Nurses of a change in Physician's Order. LVN B confirmed that the Pharmacy Label on the blister packet documented, Take on an Empty Stomach 1 hour before or 2-3 hours after a meal. Take at least 1 hr. before or 1 hr. after antacids, iron or vitamins/minerals. LVN [NAME] reported that Dinner was served in the 300/200 Halls at 5:40 PM. Observation [DATE] at 5:06 PM, Resident asleep in bed. LVN B stated, Resident #37 went to dialysis and reported that she was very tired and wanted to sleep for a while. Observation [DATE] at 5:08 PM, CNA entered room with dinner meal tray. CNA left the meal tray at bedside for residentResident #37. Observation and Interview at 5:30 PM, with CNA P, reported that residentResident #37 arrived from dialysis at 3:30 PM. CNA stated We had saved her lunch tray for her to eat when she returned from dialysis. I heated her lunch tray when she came from dialysis and she ate some of her meal at approximately 3:30 PM. Resident was very tired and wanted to sleep. I went in a couple of minutes ago to offer her dinner, but the resident said that she was not hungry. I will leave the dinner tray at the bedside for the on-coming shift that starts at 6:00 PM, so they can heat the tray later during their for the resident. Observation on [DATE] at 6:00 PM, revealed that resident was asleep in bed and dinner tray was untouched at the bedside. Interview [DATE] at 6:00 PM, LVN [NAME] reported that CNA P had reported to her that residentResident #37 ate her lunch meal at 3:30 PM upon return from dialysis. Interview and Record Review [DATE] at 12:30 PM, with DON of mealtimes Skilled Nursing stated, We have scheduled the mealtimes like this to ensure that medications are administered timely when ordered to be give before/after meals and insulin administration. Breakfast: 100/200 halls 7:30 AM; 300/200 halls 7:40 AM; Lunch: 100/200 halls: 12:30 PM; 300/200 halls 12:40 PM; Dinner: 100/200 halls: 5:30 PM; 300/200 halls 5:40 PM. Resident #15: Review admission Record dated [DATE] for resident Hardy documented in part: Date of admission: [DATE] Review of History & Physical dated [DATE] for resident Hardy from Managed Care Center documented in part: [AGE] year-old female with Diabetes Mellitus Type 2 with current use of insulin, hypothyroidism, anemia, chronic kidney disease due to diabetes mellitus, degenerative arthritis of spine Review of Quarterly MDS assessment dated [DATE] for resident Hardy documented in part: Hearing-adequate; clear speech; makes self-understood; understands others; vision-adequate; BIMS score 13 (Cognitively Intact), ADLs-requires supervision of one person with bed mobility, transfer, waking in room & corridor, eating, toilet use, and personal hygiene; limited assistance of one person with dressing; Diabetes Mellitus; insulin injections Review of Care Plan dated [DATE] for resident Hardy documented in part: Resident has Diabetes Mellitus. Administer Diabetic medications as ordered by physician. Review of Physician Order Summary dated [DATE] for resident Hardy documented in part: Novolog FlexPen Solution Pen-injector 110 Unit/ML (Insulin Aspart) inject as per sliding scale: blood glucose 301-350 inject 8 units subcutaneously before meals and at bedtime for Diabetes Mellitus Observation at 5:35 PM, LVN D said she was going to check residentResident #25's blood glucose. Blood Glucose was 327. LVN D reported that she would be administering 8 units of Aspart insulin using a FlexPen. LVN D did not prime the FlexPen prior to administering 8 units of Aspart insulin to the left upper arm. LVN D reported that she had been trained in Nursing school how to use a FlexPen. LVN D stated, I was trained to only prime FlexPen when the FlexPen is brand new. I have not received any training here at the Nursing home on how to administer insulin using a FlexPen. Interview and rRecord rReview on [DATE] at 4:25 PM, LVN D stated, I did some reading last night at home on the use of Insulin FlexPen, and I realized that I should have primed the FlexPen prior to administering the insulin to residentResident #15, yesterday when you were doing the medication pass observation with me. Centralized Medication Room: Observation , interview, and record review on [DATE] 09:56 AM, with RN ADON of the locked Controlled Medication metal box attached to the bottom shelf of the refrigerator revealed that there was a box that contained a bottle of Lorazepam Oral Concentrate 2 mg/ml that had an actual Count of 30 ML; Morphine Sulfate Solution 100/5ml there were 23 syringes that contained 2.5 ml and there was not a Control Drug - Count Record in the binder of Controlled Medications that required refrigeration. ADON reported that residentResident #198 on [DATE]. ADON stated, I need to look for the Control Drug - Count Record for the Lorazepam Oral Concentrate and Morphine Sulfate Solution and then take the medication to the DON, to store in the locked cabinet in her office for drug destruction with the consultant pharmacist. Controlled Drugs - Count Records: Record review [DATE] of Controlled Drugs - Count Record for 3 of 3 Medication Carts revealed the following: Hall 100: February 2022 Time: 6:00 PM - 6:00 AM Nurse OFF Signature: Controlled Drugs - Count Record for February 2022 at 6:00 PM - 6:00 AM did not have Nurse Off Signature on [DATE], [DATE], [DATE], [DATE], and [DATE] February 2022 Time: 6:00 AM - 6:00 PM Nurse OFF Signature: Controlled Drugs - Count Record for February 2022 at 6:00 AM - 6:00 PM did not have Nurse Off Signature on [DATE]. February 2022 Time: 6:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for February 2022 at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE], [DATE], [DATE], and [DATE] Hall 100: [DATE] Time: 6:00 PM - 6:00 AM Nurse Off Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse Off Signature on [DATE], [DATE], [DATE], [DATE], and [DATE] [DATE] Time: 6:00 AM - 6:00 PM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 AM - 6:00 PM did not have Nurse On Signature on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE];[DATE]. [DATE] Time: 6:00 AM - 6:00 PM Nurse Off Signature: Controlled Drugs - Count Record for [DATE] at 6:00 AM - 6:00 PM did not have Nurse Off Signature on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] [DATE] Time: 6:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE], [DATE], [DATE], and [DATE] Hall 100: [DATE] Time: 6:00 PM - 6:00 AM Nurse Off Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse Off Signature on [DATE], [DATE], [DATE], [DATE], and [DATE] [DATE]:00 AM - 6:00 PM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 AM - 6:00 PM did not have Nurse ON Signature on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] [DATE]:00 AM - 6:00 PM Nurse Off Signature: Controlled Drugs - Count Record for [DATE] at 6:00 AM - 6:00 PM did not have Nurse Off Signature on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] [DATE]:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] Hall 200: February 2022 Time: 6:00 PM - 6:00 AM Nurse OFF Signature: Controlled Drugs - Count Record for February 2022 at 6:00 PM - 6:00 AM did not have Nurse Off Signature on [DATE], [DATE], and [DATE] February 2022 Time: 6:00 AM - 6:00 PM Nurse ON Signature: Controlled Drugs - Count Record for February 2022 at 6:00 AM - 6:00 PM did not have Nurse ON Signature on [DATE] February 2022 Time: 6:00 AM - 6:00 PM Nurse OFF Signature: Controlled Drugs - Count Record for February 2022 at 6:00 AM - 6:00 PM Nurse OFF Signature on [DATE], and [DATE] February 2022 Time: 6:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for February 2022 at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE] Hall 200: [DATE] Time: 6:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse On Signature on [DATE], and [DATE] Hall 300: February 2022 Time: 6:00 PM - 6:00 AM Nurse On Signature: Controlled Drugs - Count Record for February 2022 at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE], [DATE], and [DATE] [DATE] Time 6:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE] [DATE]Time: 6:00 PM - 6:00 AM Nurse Off Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM Off Signature on [DATE] Interview and Record Review on [DATE] at 4:22 PM, [NAME] LVN reported that nurses had been trained to count Controlled Drugs at the change of shift with the on-coming and off-going Nurse, then sign the Controlled Drugs - Count Record. Nurse [NAME] confirmed that were 5 blanks on the Control Drugs - Count Records for the months of [DATE], January - February 2022. Nurse [NAME] reported that they had been trained to put a change of direction label on the medication containers when there was a change in direction for medication administration. Nurse [NAME] reported that they had also been trained to administer medications according to physician orders, such as administering medication with meals. Interview and Record Review on [DATE] at 4:25 PM, [NAME] LVN reported that nurses had been trained to count Controlled Drugs at the change of shift with the on-coming and off-going Nurse, then sign the Controlled Drugs - Count Record. Nurse [NAME] confirmed that there were many blanks on the Controlled Drugs - Count Records. Interview and Record Review on [DATE] at 4:47 PM, LVN C reported that nurses had been trained to count Controlled Drugs at the change of shift with the on-coming and off-going Nurse, then sign the Controlled Drugs - Count Record. LVN C confirmed that there were many blanks on the Controlled Drugs - Count Records. LVN C reported that she had been trained to give a resident a snack or meal 15 minutes after administering Rapid-Acting Insulin to prevent Hypoglycemia. LVN C stated, she did not remember what the facility policy & procedure on insulin administration documents about Rapid-Acting insulins. LVN C reported that they had been trained to put a change of direction label on the medication containers when there was a change in direction for medication administration. Interview and Record Review 0n [DATE] at 3:06 PM, with DON and RN ADON confirmed that there were multiple blanks on the Controlled Drugs - Count Record dated [DATE], [DATE], and February 2022 where Licensed Staff were not consistently signing the form at the change of shift when Controlled Drugs were counted by the on-coming and off-coming Nurse according to facility policy & procedure. Medication Carts: Wing 100 - Observation and interview [DATE] at 4:40 PM with Director of Nursing revealed: Opened 32 oz. bottle of Concentrated Liquid Protein was not dated when opened. DON confirmed that Manufacturer's Specification on supplement bottle documented 3 months shelf life from date opened. The supplement bottle had dried drippings on the sides of the bottle and around the bottle cap. DON was not aware that Licensed Staff were not dating supplement bottles when opened according to Manufacturer's Specifications. Wing 200 -Observation [DATE] at 3:58 PM with DON revealed: -3rd drawer in medication cart had paper particles on the bottom of the drawer. -Opened 30 oz. bottle of Liquid Protein Concentrated Nutrition bottle was not dated when opened. Manufacturer's Specification on supplement bottle documented 3 months shelf life from date opened. -Opened 32 oz. of Concentrated Liquid Protein was not dated when opened. Manufacturer's Specification on supplement bottle documented 3 months shelf life from date opened. -Opened 16 fl. oz. bottle of Lactulose Solution USP medication had dried drippings on the side of bottle. -Plastic grocery bag that contained multiple medication bottles was stored in a drawer in the medication Cart. DON reported that those were medications that were brought from home upon admission and were going to be given to the family to take home. Wing 300-Observation [DATE] at 4:15 PM LVN B and DON revealed: -Opened 32 oz. of Concentrated Liquid Protein was dated as opened [DATE]. Manufacturer's Specification on supplement bottle documented 3 months shelf life from date opened. The bottle had dried drippings on sides of bottles and around the bottle cap. -3rd drawer dusty bottom of drawer with small paper particles, dried medication dripping on drawer -Opened 16 fl. oz bottle Iron supplement Liquid had dried drippings on side of bottle. Glucometer QA Checks: Interview and Record Review on [DATE] at 3:09 PM, DON reported the night nurse complete the Glucometer Check once on the night shift. Review of the QA Glucometer Checks dated February 2022, documented Night Nurses were performing Glucometer Solution Test using Glucose Control Solutions daily on the night shift . Medication Cart #1: Observation and iInterview on [DATE] at 3:10 PM, with DON revealed: DON reported that QA checks are done every night by the night nurses, using the Glucose Control Solutions to confirm the meter and test strips are working properly. DON confirmed that the box and two bottles of control solutions had not been dated when opened. Review with DON of the Manufacture Insert for Glucose Control Solutions documented in part: Newly opened bottles of control solutions must be marked with the date opened on the space provided on the control solution labels. Discard any unused control solutions 90 days after opening or after expiration date, whichever comes first. The DON placed the undated box of Glucose Control Solutions back in the medication cart in the top drawer. Medication Cart #2: Observation and iInterview on [DATE] at 3:13 PM, with DON revealed: Glucose Control Solutions box was dated [DATE]. The control solution bottles were not dated when opened. The DON stated, We need to place a new box of Glucose Control Solutions in the medication cart, since these ones are expired. I need to do some training on this as soon as possible. Medication Cart #3: Observation and Interview on [DATE] at 3:15 PM, with DON revealed: Glucose Control Solutions were dated as opened [DATE]. DON stated, We need to place a new box of Glucose Control Solutions in the medication cart, since these ones are expired. Record Review of the Glucose Control Solutions insert dated 2016 documented in part: Intended Use: The purpose of the control solutions test is to validate the performance of the Glucose Monitoring System using a testing solution with a known range of glucose. A control test that falls within the acceptable range indicates the user's technique is appropriate and the meter and test strips are functioning properly. Conduct test as follows: Newly opened bottles of control solutions must be marked with the date opened on the space provided on the control solution labels. Check the expiration date of the control solutions to make sure they have not expired. Discard any unused control solutions 90 days after opening or after expiration date, whichever comes first. Interview and Record Review [DATE] at 5:02 PM, with DON of facility's policy & procedure on General Dose Preparation and Medication Administration revised [DATE] documented in part: Applicability: This policy sets forth the procedures relating to general dose preparation and medication. Procedure: -Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record. -Facility staff should crush oral medications only in accordance with Pharmacy guidelines. Prior to medication administration: Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct time, for the correct resident, as set forth in facility's medication administration schedule. Confirm that the MAR reflects the most recent medication order. -During medication administration, Facility staff should take all measures required by Facility Policy and Applicable Law, including but not limited to the following: Administer medications within timeframes specified by Facility policy or manufacturer's information. Follow manufacturer medication administration guidelines. Interview and Record Review [DATE] at 5:10 PM, with DON of facility's policy & procedure on LTC Facilities Receiving Pharmacy Products and Services from Pharmacy revised [DATE] documented in part: Change Orders: Any request to change an existing order should treated by Facility as a new order, with a corresponding cancellation of the previous order. Facility may fax change orders to Pharmacy. Changing Electronic Orders: Facility should discontinue the current order in the electronic ordering system and enter a new order per policy. Facility should notify Pharmacy not to send the medication and attach a Change in Directions sticker to the existing quantity of medications. Interview and Record Review [DATE] at 12:53 PM, with DON of facility's policy & procedure on Fingerstick Blood Glucose Review Date: 1/19 documented in part: Policy: Fingerstick Blood Glucose Procedure: A physician's order is required. Guidelines: The meter will be cleaned, maintained and properly calibrated per manufacturer's guidelines. The meter will be checked for proper function before adjusting medication based on meter results. DON stated, Residents need to eat a snack or meal within 15 minutes of receiving Rapid Acting Insulin to prevent hypoglycemia. Interview and Record Review [DATE] at 5:05 PM, with DON of facility's policy & procedure on Inventory Control of Controlled Substances revised on -[DATE] documented in part: Applicability: This po[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Residents #13) of 5 residents reviewed for unnecessary medications. Resident # 13 was administered Olanzapine (an antipsychotic medication) but did not have a diagnosis of psychosis. This failure put residents at risk for receiving unnecessary antipsychotics which could increase their risk for side effects. Findings include: Record review of Resident #13's admission Record dated 02/16/2022 documented that she was [AGE] years old and was admitted to the facility on [DATE]. Record Review of Resident #13's History and Physical dated 05/25/2021 documented diagnoses including dementia, Alzheimer's disease, and high blood pressure. It documented that she was deaf and mute. There were no diagnoses of depression or psychiatric history or issues. Record review of Resident #13's Level 1 PASSR assessment (to assess for mental illness, developmental or intellectual disability) dated 05/22/2021 documented that there was no evidence that she had mental illness, developmental or intellectual disability. Record Review of Resident #13's admission MDS dated [DATE] documented that she had no speech but usually understood others. Her BIMS was 13 (Cognitively intact). She had no symptoms of delirium, depression, or psychosis and no behaviors that interfered with her or others care. No psychiatric or mood disorders were documented. It was documented that she had been administered an antipsychotic medication on six of the past seven days. Record Review of Resident #13's Quarterly MDS dated [DATE] documented that her BIMS was 9 (Moderate Cognitive impairment). She had no symptoms of delirium, depression, or psychosis and no behaviors that interfered with her or others care. No psychiatric or mood disorders were documented. It was documented that she had been administered an antipsychotic medication on seven of the past seven days. No attempt at gradual dose reduction was documented. Record review of Resident #13's Clinical Physician Orders report accessed on 02/16/2022 documented that on 05/23/2021 she was prescribed 2.5 MG of Olanzapine (an Antipsychotic) to be taken at bedtime for Antipsychotic. The order was discontinued on 10/30/2021. On 10/30/2021 she was again prescribed 2.5 MG of Olanzapine (an Antipsychotic) to be taken at bedtime for Antipsychotic. Record review of Resident #13's nurses progress notes from 10/24/2021 - 10/31/2021 - just prior to the reordering of the Olanzapine prescription on 10/30/2021 revealed no behaviors or other signs of distress that may have indicated the need to renew the prescription. Record review of Resident #13's MAR for the month of December 2021 documented that she was administered 2.5 MG of Olanzapine for antipsychotic nightly except tor 12/11/2021. Review of behavior monitoring for antipsychotics documented that no symptomatic behaviors were observed. Record review of Resident #13's MAR for the month of January 2022 documented that she was administered 2.5 MG of Olanzapine nightly for antipsychotic. Review of behavior monitoring for antipsychotics documented that no symptomatic behaviors were observed. Record review of Resident #13's MAR for the month of February 2022 through 02/15/2022 December 2021 documented that she was administered 2.5 MG of Olanzapine nightly for antipsychotic. Review of behavior monitoring for antipsychotics documented that no symptomatic behaviors were observed. Record review of Resident #13's Care Plan last revised 05/29/2021 documented that she was receiving Olanzapine in relation to dementia. In observation/interview on 02/13/2022 at 9:40 AM Resident #13 indicated that she was not able to hear or speak. She was alert and oriented and did not indicate that she was in any distress. She gave OK and Thumbs up hand signals to the attempts to communicate with her. A phone call was attempted to Resident #13's responsible party on 02/14/2022 at 9:06 AM. A message was left requesting a call back, but no call was received prior to exit. In observation/interview on 02/14/2022 at 9:06 AM Resident #13 she indicated with a thumbs-up hand signal that she was not in any distress. In an interview on 02/16/22 03:30 PM the ADON confirmed that Resident #13 was taking olanzapine which was prescribed for anti-psychotic. The ADON would not state if this was an appropriate diagnosis for this medication. She stated that she and the DON were responsible for monitoring for questions about medications and that the physician would be contacted for guidance as needed. She did not know if the physician had been asked for guidance regarding the prescription of Olanzapine for Resident #13. The ADON confirmed that Resident #13 had been receiving Olanzapine since 05/22/2021. She stated that the dosage had not changed since that date. She would not confirm or deny whether gradual dose reduction had been attempted. Record review of the facility policy Psychotropic Medication Use dated 11/28/2016 documented in part that the facility should comply with regulations related to psychotropic medication use. If a prescriber orders a psychotropic medicine in the absence of a diagnosis or specific behavior the facility should ensure that the prescriber reviews the medication plan and considers gradual dose reduction unless it is clinically contraindicated. Review of the website drugs.com on 02/22/2022 documented that Olanzapine is an antipsychotic medication that is used to treat psychotic conditions such as schizophrenia and bipolar disorder (manic depression). Olanzapine is not approved for use in older adults with dementia-related psychosis. Olanzapine may increase the risk of death in older adults with dementia-related psychosis and is not approved for this use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it was free from medication error rate of less than 5%. Two of Four Licensed Vocational Nurses (LVN C, and LVN B) made 4 errors out of 33 opportunities. This resulted in a 12.0 % medication error rate for 3 (#194, #196, and #36) of 12 residents reviewed for medication errors. A. LVN C failed to administer insulin to Rresident #194 according to Manufacturer's Specifications. B. LVN C failed to administer Multivitamin to Rresident #194 according to physician's orders. C. LVN B failed to administer Calcium Acetate to Rresident #196 according to physician's orders. D. LVN B failed to administer Sucralfate Rresident #37 according to physician's orders. This deficient practice placed the residents at risk of harm or of not receiving desired outcomes from medications not being administered medications according to physician's orders and Manufacturer's Specifications . The findings include: Resident #194: (Medication Error #1) Record Review of admission Record for Rresident #194 dated 02/15/22 documented in part: admission Date: 01/31/22 Record Review of History & Physical dated 02/01/22 for Rresident #194 documented in part: [AGE] year-old male status post inflammation of the bile duct with stone removal, inflammation of the pancreas, infection with life threating low blood pressure, pneumonia, and pulmonary nodule. Past Medical History: Diabetes Mellitus Type 2, hypothyroidism, hypertension, age related physical debility, heart failure, pressure ulcer of sacral region, stage 1, chronic kidney disease stage 3. Record Review of admission Minimum Data Set (MDS ) dated 02/07/2022 for residentResident #194 documented in part: Active Diagnoses: admitted from acute hospital; Hearing-adequate; clear speech; makes self-understood; understands others; vision-adequate; BIMS score 11 (moderately impaired cognition); ADLs-requires extensive assistance of one person with bed mobility, transfers, locomotion on & off unit; dressing, toilet use, and personal hygiene; supervision of one person with eating; total assistance of one person with bathing; wheelchair; occasionally incontinent of urine; incontinent of bowel; pain; two stage 2 pressure ulcersDiabetes Mellitus; Orders for insulin injections; antibiotic; oxygen therapy; Occupational/Physical Therapy. Review of Care Plan dated 02/01/22 for residentResident #194 documented in part: Resident has Congestive Heart Failure, Pacemaker, Antibiotic Therapy for Lung Infection, Oxygen Therapy. Record Review of Physician's Order dated 02/14/2022 for residentResident #194 documented in part: Insulin Lispro Solution inject as per sliding scale: 200-249=3 units subcutaneously before meals for DM. Review of Medication Administration Record dated 02/14/2022 for residentResident #194 documented in part: Insulin Lispro Solution inject as per sliding scale: 200-249=3 units subcutaneously before meals for DM. Blood Sugar at 7:30 AM, 11:00 AM, and 5:00 PM. Observation on 02/14/22 at 11:44 AM LVN C said she was going to checked residentResident #194's blood sugar , and was blood sugar was at 229 . LVN C said, she hashad an order for sliding scale coverage with Humalog and I am going to give him 3 units of the Humalog (Lispro Solution) as ordered according to sliding scale coverage. Observation on 02/14/22 at 12:34 PM, LVN C administered to residentResident #194, 3 units of Humalog subcutaneous to right upper arm at 12:34 PM and . reported they were pending deliver of lunch meal trays. Resident #194 complained of being nauseated and informed nurse that he was not hungry and wanted to sleep. Observation 02/14/22 at 1:06 PM, revealed residentResident #194 was asleep in bed, there was an untouched meal tray by side of bed. Interview 02/14/2022 at 1:06 PM, Surveyor followed up with LVN C to see if resident had a snack after insulin had been administered at 12:34 PM. LVN C reported that she had not given Resident #194 a snack and had not checked if residentResident #194 had lunch. LVN C stated, I needed to go check if CNA assisted residentResident #194 with his meal, because he needs to eat or have a snack 15 minutes after Humalog (Lispro) has been administered. Observation on 02/14/22 at 1:07 PM, Surveyor accompanied LVN C to residentResident 194's room and confirmed that resident was asleep in bed and had not had lunch . LVN C reported that resident had not been given a snack 15 minutes after insulin was administered to prevent hypoglycemia. LVN C confirmed Meal Tray was on top of bedside table by the side of the bed and was untouched. LVN C stated, He has not eaten yet. But you know what, his doctor just called and gave me an order to give him a Boost Glucose Control supplement. Let me go and get him one. Observation on 02/14/22 at 1:07 PM, LVN C, awoke residentResident #194 and offered to give him the Boost Glucose Control Supplement. Resident drank 227 ml of Boost Glucose Control Supplement. Nurse confirmed it was more than 22 minutes that insulin had been administered. Interview on 2/15/22 at 12:53 PM, DON reported Humalog is rapid acting insulin, and resident should eat a snack or a meal within 15 minutes after insulin has been administered to prevent hypoglycemia. According to Manufacturer's specifications obtained on 2/14/20229 at https://www.humalog.com/index.aspx documented to administer Humalog within fifteen minutes before a meal or immediately after a meal. Resident #194: Medication Error (#2) Review of Physician Order Summary dated 2/15/22 for residentResident #194 documented in part: Multi-Vitamin give 1 tablet by mouth one time a day for supplement. Review of Medication Administration Record dated February 2022 for residentResident #194 documented in part: Multivitamin Men 50 + Tablet (Multiple Vitamins-Minerals) give 1 tablet by mouth one time a day for nutrition support was discontinued on 02/02/22. Observation on 2/15/22 at 8:22 AM, LVN C crushed one tablet of Multivitamin with Minerals, mixed with Yogurt, and administered to residentResident #194. Interview and record review on 2/16/22 at 10:58 AM, with RN ADON of Discontinued Order printed on 2/16/22, documented had been discontinued on 2/02/22. RN ADON stated, The resident never got the Multiple Vitamins-Minerals because it was ordered and discontinued on the same day on 2/02/2022. Surveyor confirmed with ADON that nurse [NAME] LVN C had administered Multiple Vitamins-Minerals during the medication pass observation that was done on 2/15/22. Resident #196: Error (#3) Record Review of admission Record for residentResident #196 dated 01/25/22 documented in part: admission Date: 02/01/22 Record Review of History & Physical dated 02/08/22 for residentResident #196 documented in part: [AGE] year-old female with past Medical History of Alzheimer's Dementia, Congestive Heart Failure, Severe Pulmonary Hypertension, Type 2 Diabetes Mellitus, Hypertensive Disease, and Hypertensive Disease, Chronic Kidney Disease Stage 3. History of Present Illness: Age related physical debility, Anemia, Pain, Depressive Episodes, Acute Respiratory Failure with Hypoxia (don't have enough oxygen in your blood), Pressure Ulcer of sacral region, stage 2, Deep Tissue Damage (is an injury to the soft tissue under the skin due to pressure and is usually over boney prominence) of left heel, Muscle Wasting & Atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass). Record Review of admission Minimum Data Set (MDS) dated [DATE] for residentResident #196 documented in part: admitted from Acute hospital; Hearing-adequate; Clear Speech; Usually makes self-understood; Usually understands others; Vision-Adequate; BIMS Score 8 (Moderately Impaired cognition); ADLs-requires limited assistance of one person with bed mobility, dressing, eating, and personal hygiene; extensive assistance of one person with transfer; total assistance of one person with toileting and bathing; wheelchair; incontinent of bowel & bladder; Pain; Resident has a pressure ulcer/injury over bony prominence; One stage 2 pressure ulcer; One Deep Tissue Injury; Speech/Occupational/Physical Therapy.Active Diagnoses: Hypertension, Renal Insufficiency, Renal Failure, Diabetes Mellitus Review of Care Plan dated 2/08/22 for residentResident #196 documented in part: Resident has Congestive Heart Failure, HypertensionTN, Diuretic Therapy. Review of Physician Order Summary dated 2/15/22 for residentResident #196 documented in part: Calcium Acetate Tablet 667 (Calcium Acetate Phosphorus Binder) give 2 tablets by mouth with meals. (Calcium acetate is used to control high blood levels of phosphorus in people with kidney disease who are on dialysis (medical treatment to clean the blood when the kidneys are not working properly)). Administer medications in applesauce or other suitable vehicle. Review of Medication Administration Record dated February 2022 for residentResident #196 documented in part: Calcium Acetate 667 mg two tablets by mouth for phosphorus binder at 8:00 AM, 12:00 Noon, and 6:00 PM. Observation & Interview 02/14/22 11:31 AM, LVN B crushed one tablet of Calcium Acetate 667 mixed with pudding and administered to residentResident #196. Observation, iInterview and rRecord rReview on 02/14/22 at 3:31 PM, LVN B confirmed that the Physician Order Summary Report dated 02/14/22 and Medication Administration Record dated February 2022 for residentResident #196 documented Calcium Acetate 667 mg give two tablets by mouth with meals for phosphorus binder at 8:00 AM, 12 Noon, and 6:00 PM. LVN B stated, A change of direction label was not placed, on the Medication Blister Packet, to alert the Nurses resident's order had been changed and now is getting two tablets of the Calcium Acetate 677 mg by mouth with meals. LVN B stated, I was trained at the facility, that I could give medications an hour before or one hours after the prescribed time, even though the orders documents to be given with meals. LVN B reported that lunch was served inon the 200 Hall at 12:30 PM through 12:45 PM. Interview and Rrecord rReview 02/15/22 at 12:30 PM, of scheduled Mealtimes for Skilled Nursing Unit with RN DON, reported that they have specific times to administer medications with meals for each hall. DON stated, LVN B should have administered the Calcium Acetate 667 mg two tablets by mouth no earlier than 12:30 PM, because that is when meal trays are sent to the 200 Hall. LVN B and should waited until the resident started to eat her meal. DON confirmed that Physician Order Summary and Medication Administration Record dated February 14, 2022 for residentResident #196 documented Calcium Acetate 667 mg give two tablets by mouth with meals for phosphorus binder. The DON reported that nNurses had been trained to place a change of direction label on the medication containers when orders are changed to prevent medication errors. Resident #37:: Error (#4) Record Review of admission Record for residentResident #37 dated 2/16/22 documented in part: Initial admission Date: 12/28/2021; re-admission Date: 01/28/2022. Record Review of History & Physical dated 01/28/2022 for residentResident #37 documented in part: [AGE] year-old female with End Stage Renal Disease-dependence on renal dialysis, Gastro Esophageal Reflux, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy, Cognitive Communication Deficit, Gastro-Esophageal Reflux. Continue Sucralfate Tablet 1 GM, 1 tablet on an empty stomach, orally, four times a day. Record Review of admission Minimum Data Set (MDS) dated [DATE] for residentResident #37 did not documented in part: Hearing-adequate; Clear Speech; usually makes self-understood; usually understands others; Vision-adequate; BIMS Score 10 (Moderately Impaired); ADLS: requires limited assistance of one person with bed mobility, dressing, and personal hygiene; extensive assistance of one person with transfer and toilet use; supervision of one person with eating; total assistance of one person with bathing; wheelchair; frequently incontinent of urine; continent of bowel; therapeutic diet; insulin injections; diuretic; dialysis; Speech/Occupational/Physical therapy; resident had Gastro Esophageal Reflux Disease. Review of Care Plan dated 01/28/22 for residentResident #37 documented in part: Resident has chronic renal failure; Requires oxygen therapy for shortness of breath, did not document resident had Gastro Esophageal Reflux Disease. Review of Physician Order Recap Report dated 02/16/22 for residentResident #37 documented in part: Order Date: 02/01/22; Start Date: 02/01/22; Sucralfate Tablet 1 GM give 1 tablet by mouth two times a day for Gastrointestinal. Review of the Medication Administration Record dated February 2022 for residentResident #37, documented Sucralfate 1 GM give 1 tablet by mouth two times a day at for GI at 7:30 AM and 4:00 PM. Observation on 02/14/22 at 3:43 PM, with LVN B said she was going to administered to residentResident #37 Sucralfate 1 GM give one tablet by mouth. Interview & record review 2/14/22 at 3:44 PM, with LVN B, confirmed that the Medication Blister Packet dated 1/28/22 for residentResident #37 documented Sucralfate 1 GM give 1 tablet by mouth four times a day. LVN B stated, We have been trained to put a Change of Direction Label to alert the Nurses of a change in Physician's Order. LVN B confirmed that the Pharmacy Label on the blister packet documented, Take on an Empty Stomach 1 hour before or 2-3 hours after a meal. Take at least 1 hr. before or 1 hr. after antacids, iron or vitamins/minerals. LVN [NAME] reported that dDinner was served in the 300/200 Halls at 5:40 PM. Observation 2/14/22 at 5:06 PM, Resident #37 asleep in bed. LVN B stated, Resident #37 went to dialysis and reported that she was very tired and wanted to sleep for a while. Observation 2/14/22 at 5:08 PM, CNA entered room with dinner meal tray. CNA left the meal tray at bedside for residentResident #37. Observation and Interview at 5:30 PM, with CNA P, reported that residentResident #37 arrived from dialysis at 3:30 PM. CNA stated We had saved her lunch tray for her to eat when she returned from dialysis. I heated her lunch tray when she came from dialysis and she ate some of her meal at approximately 3:30 PM. Resident was very tired and wanted to sleep. I went in a couple of minutes ago to offer her dinner, but the resident said that she was not hungry. I will leave the dinner tray at the bedside for the on-coming shift that starts at 6:00 PM, so they can heat the tray later during their for the resident. Observation on 2/14/22 at 6:00 PM, revealed that resident was asleep in bed and dinner tray was untouched at the bedside. Interview 2/14/2021 at 6:00 PM, LVN [NAME] reported that CNA P had reported to her that residentResident #37 ate her lunch meal at 3:30 PM upon return from dialysis. Interview and Record Review 02/15/21 at 12:30 PM, Meal Times for Skilled Nursing withthewith DON of mealtimes Skilled Nursing stated, We have scheduled the mealtimes like this to ensure that medications are administered timely when ordered to be give before/after meals and insulin administration. Breakfast: 100/200 halls 7:30 AM; 300/200 halls 7:40 AM; Lunch: 100/200 halls: 12:30 PM; 300/200 halls 12:40 PM; Dinner: 100/200 halls: 5:30 PM; 300/200 halls 5:40 PM . Interview and Record Review 02/16/22 at 5:02 PM, with the DON of indicated the facility's policy & procedure on General Dose Preparation and Medication Administration revised 01/01/22 documented in part: Applicability: This policy sets forth the procedures relating to general dose preparation and medication. Procedure: -Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record. -Facility staff should crush oral medications only in accordance with Pharmacy guidelines. Prior to medication administration: Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct time, for the correct resident, as set forth in facility's medication administration schedule. Confirm that the MAR reflects the most recent medication order. -During medication administration, Facility staff should take all measures required by Facility Policy and Applicable Law, including but not limited to the following: Administer medications within timeframes specified by Facility policy or manufacturer's information. Follow manufacturer medication administration guidelines. Interview and Record Review 02/16/22 at 5:10 PM, with DON of the facility's policy & procedure on LTC Facilities Receiving Pharmacy Products and Services from Pharmacy revised 10/31/16 documented in part: Change Orders: Any request to change an existing order should be treated by Facility as a new order, with a corresponding cancellation of the previous order. Facility may fax change orders to Pharmacy. Changing Electronic Orders: Facility should discontinue the current order in the electronic ordering system and enter a new order per policy. Facility should notify Pharmacy not to send the medication and attach a Change in Directions sticker to the existing quantity of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to account for Controlled Medications in accordance with State and Federal Laws, by not removing Controlled Medication from medication refrigerator when residents are discharged and failure to sign Control Drug Count Sheets when Controlled Medications are reconciled by Licensed Staff at the change of shift for 1 of 1 centralized medication refrigerator and 3 of 3 Medication Carts in halls (100, 200, and 300). This failure could place controlled medications at risk of drug diversion. Findings included: Centralized Medication Room: Observation, interview, and record review on [DATE] 09:56 AM, with RN ADON of the locked Controlled Medication metal box attached to the bottom shelf of the refrigerator revealed that there was a box that contained a bottle of Lorazepam Oral Concentrate 2 mg/ml that had an actual Count of 30 ml; Morphine Sulfate Solution 100/5ml there were 23 syringes that contained 2.5 ml and there was not a Control Drug - Count Record in the binder of Controlled Medications that required refrigeration. ADON reported that residentResident #198 on [DATE] . ADON stated, I need to look for the Control Drug - Count Record for the Lorazepam Oral Concentrate and Morphine Sulfate Solution and then take the medication to the DON, to store in the locked cabinet in her office for drug destruction with the consultant pharmacist. Medication Carts: Controlled Drugs - Count Records: Record review [DATE] of Controlled Drugs - Count Record for 3 of 3 Medication Carts revealed the following: Hall 100: February 2022 Time: 6:00 PM - 6:00 AM Nurse OFF Signature: Controlled Drugs - Count Record for February 2022 at 6:00 PM - 6:00 AM did not have Nurse Off Signature on [DATE], [DATE], [DATE], [DATE], and [DATE] February 2022 Time: 6:00 AM - 6:00 PM Nurse OFF Signature: Controlled Drugs - Count Record for February 2022 at 6:00 AM - 6:00 PM did not have Nurse Off Signature on [DATE] February 2022 Time: 6:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for February 2022 at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE], [DATE], [DATE], and [DATE] Hall 100: [DATE] Time: 6:00 PM - 6:00 AM Nurse Off Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse Off Signature on [DATE], [DATE], [DATE], [DATE], and [DATE] [DATE] Time: 6:00 AM - 6:00 PM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 AM - 6:00 PM did not have Nurse On Signature on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE];[DATE]. [DATE] Time: 6:00 AM - 6:00 PM Nurse Off Signature: Controlled Drugs - Count Record for [DATE] at 6:00 AM - 6:00 PM did not have Nurse Off Signature on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] [DATE] Time: 6:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE], [DATE], [DATE], and [DATE] Hall 100: [DATE] Time: 6:00 PM - 6:00 AM Nurse Off Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse Off Signature on [DATE], [DATE], [DATE], [DATE], and [DATE] [DATE]:00 AM - 6:00 PM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 AM - 6:00 PM did not have Nurse ON Signature on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] [DATE]:00 AM - 6:00 PM Nurse Off Signature: Controlled Drugs - Count Record for [DATE] at 6:00 AM - 6:00 PM did not have Nurse Off Signature on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] [DATE]:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] Hall 200: February 2022 Time: 6:00 PM - 6:00 AM Nurse OFF Signature: Controlled Drugs - Count Record for February 2022 at 6:00 PM - 6:00 AM did not have Nurse Off Signature on [DATE], [DATE], and [DATE] February 2022 Time: 6:00 AM - 6:00 PM Nurse ON Signature: Controlled Drugs - Count Record for February 2022 at 6:00 AM - 6:00 PM did not have Nurse ON Signature on [DATE] February 2022 Time: 6:00 AM - 6:00 PM Nurse OFF Signature: Controlled Drugs - Count Record for February 2022 at 6:00 AM - 6:00 PM Nurse OFF Signature on [DATE], and [DATE] February 2022 Time: 6:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for February 2022 at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE] Hall 200: [DATE] Time: 6:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse On Signature on [DATE], and [DATE] Hall 300: February 2022 Time: 6:00 PM - 6:00 AM Nurse On Signature: Controlled Drugs - Count Record for February 2022 at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE], [DATE], and [DATE] [DATE] Time 6:00 PM - 6:00 AM Nurse ON Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM did not have Nurse ON Signature on [DATE] [DATE]Time: 6:00 PM - 6:00 AM Nurse Off Signature: Controlled Drugs - Count Record for [DATE] at 6:00 PM - 6:00 AM Off Signature on [DATE] Interview and Record Review on [DATE] at 4:22 PM, [NAME] LVN reported that nurses had been trained to count Controlled Drugs at the change of shift with the on-coming and off-going Nurse, then sign the Controlled Drugs - Count Record. Nurse [NAME] confirmed that were 5 blanks on the Control Drugs - Count Records for the months of [DATE], January - February 2022. Nurse [NAME] reported that they had been trained to put a change of direction label on the medication containers when there was a change in direction for medication administration. Nurse [NAME] reported that they had also been trained to administer medications according to physician orders, such as administering medication with meals. Interview and Record Review on [DATE] at 4:25 PM, [NAME] LVN reported that nurses had been trained to count Controlled Drugs at the change of shift with the on-coming and off-going Nurse, then sign the Controlled Drugs - Count Record. Nurse [NAME] confirmed that there were many blanks on the Controlled Drugs - Count Records. Interview and Record Review on [DATE] at 4:47 PM, LVN C reported that nurses had been trained to count Controlled Drugs at the change of shift with the on-coming and off-going Nurse, then sign the Controlled Drugs - Count Record. LVN C confirmed that there were many blanks on the Controlled Drugs - Count Records. LVN C reported that she had been trained to give a resident a snack or meal 15 minutes after administering Rapid-Acting Insulin to prevent Hypoglycemia. LVN C stated, she did not remember what the facility policy & procedure on insulin administration documents about Rapid-Acting insulins. LVN C reported that they had been trained to put a change of direction label on the medication containers when there was a change in direction for medication administration. Interview and Record Review 0n [DATE] at 3:06 PM, with DON and RN ADON confirmed that there were multiple blanks on the Controlled Drugs - Count Record dated [DATE], [DATE], and February 2022 where Licensed Staff were not consistently signing the form at the change of shift when Controlled Drugs were counted by the on-coming and off-coming Nurse according to facility policy & procedure. Interview and Record Review [DATE] at 5:09 PM, with DON of facility's policy & procedure on Disposal/Destruction of Expired or Discontinued Medications revised on [DATE] documented in part: Applicability: This policy sets forth the procedures relating to medication disposal and destruction. Once an order to discontinue a medication is received, Facility Staff should remove this medication from the resident's medication supply. Facility should transmit or fax a copy of the discontinued order to Pharmacy to remove it from the resident's current medication list and from the Physicians Order sheet and medication administration record. Interview and Record Review [DATE] at 5:05 PM, with DON of facility's policy & procedure on Inventory Control of Controlled Substances revised on -[DATE] documented in part: Applicability: This policy sets forth the procedures for inventory control of controlled substances. Procedure: Facility should ensure that the oncoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk for abuse or diversion at the change of each shift. Reconcile the total of controlled medications on hand and remove medications that are completed or discontinued from the inventory, pursuant to the Controlled Substance Verification/Shift Count Sheet; and Reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification/Shift Count Sheet. Facility should periodically count substances stored in refrigerators or kept in other storage areas. A facility representative should regularly check the inventory records to reconcile inventory. Facility should regularly reconcile. Current and discontinued inventory of controlled substances to the log used in facility's control medication inventory system. Unused controlled substances held in storage awaiting destruction to the declining inventory record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 for 1 of 1 kitchen reviewed for dietary services. A. Foods in Dry Food Storage were opened, undated, and unsealed. B. Food prep areas had items with accumulation of dust, encrusted grease deposits, and other soiled accumulations. C. Food in Freezer opened, undated, and unsealed. D. Walk in Refrigerator Food in Frig #x and #x had opened food, undated and unsealed. D.E. Beverage Station Refrigerator food, undated and unsealed. This failure places residents who eat food prepared by facility at risk of food borne illnesses. The findings include: A. Dry Storage Room Observation and interview on 02/13/22 8:48 AM with Food Director of the Dry Storage area revealed there were six metal racks in the Dry Storage Room.the following: Rack #1 -There were eleven 30 oz. Plastic Spice Bottles that had sticky greasy substance on sides of bottles, and white powder on top of lids and sides of bottles. Food Director stated, It is probably Gravy Mix that is spilling from the opened packets from the top shelf to the were spice bottles are stored. -Opened box of contained 4 Chocolate Tablets was not sealed. Rack #2 -Large plastic Ziploc bag that was halfway filled with a red powder that was opened, not sealed was labeled Chile Powder dated as opened on 09/16/21 -6 Lb. opened carton of Rainbow Sprinkles was not sealed, there were dried light Yellowlight-Yellow drippings on the front side of the container;container. -Large opened, Ziploc bag dated 02/04/22 was not sealed had light brown powder inside the bag, contained three opened 12 oz. Gravy Mix packets that were opened and not sealed. Interview 02/13/22 8:56 AM with [NAME] the Food Director stated, It is Gravy Mix, that is coming out of one of the opened Gray Mix packet. -Unsealed Ziploc bag that contained an opened bag of Spaghetti dated as opened on 01/21/22 was not sealed. -Unsealed Ziploc bag that contained an opened 3.5 Lb. bag of Classic Cornbread Stuffing Mix was not sealed or dated when opened. -Large opened, box of Cheesecake Filling Mix dated as opened on 4/16/21 was not sealed, opened package inside the box was opened and not sealed. -6 Lb. opened carton of Rainbow Sprinkles that was opened and not sealed, had dried dark brown stains on the side of the box. -5 Lb. can of Leafy Spinach had a dent on the top and there were coconut flakes on top of lid stored was stored in metal rack. - Dusty opened 25 Lb. box Chocolate Chips was not sealed, contained a large, unsealed plastic bag with Chocolate Chips. There was an unsealed Ziploc bag that was stored inside the large plastic bag that contained crushed Chocolate Chips dated 02/08/21. Food Director stated, The Dietary staff should not be storing anything inside the opened bag of Chocolate Chips. They should store the crushed Chocolate Chips separately in sealed Ziploc bag and not inside the box. -Large, unsealed Ziploc bag dated as opened on 02/04/22 contained an opened bag of LasagneLasagna Pasta was not sealed. -Dusty opened large box of Grill bricks stored in metal rack -5 Lb. opened box of [NAME] Cake Mix was not sealed, opened package inside the box not sealed or dated when opened. Rack #4 -Dusty large, opened box of Zero Calorie Sweetener packets. -Opened box of Iodized salt packets, had multiple opened salt packets, and salt particles in the bottom of the box. Rack #6 -5 Lb. plastic container of Honey had white residual on cap and sides of bottle. -Opened 5 Lb. plastic container of Honey with dried dripping on sides of bottle and around lid. Observation &and iInterview on 02/13/22 at 9:30 AM, with Food Director revealed there were dried white stains on the floor in the Dry Storage Rooms and food particles under metal racks. Food Director stated, The Dry Storage room is cleaned once a week according to cleaning schedules. I have been understaffed and have been working as the Cook, so I have not had time to be checking that cleaning is being done according to cleaning schedules. B. Dishwashing Area: Observation and Interview on 02/13/22 at 9:32 AM, with Food Director reported that the Garbage Disposable in the 3 compartments sink was not working. Food Director stated, It has not been working for about a week, the Maintenance man ordered the part and is still pending delivery. So, we are only using the Sanitize and Rinse sinks to wash pots, pans, plastic bins, and rinse blender cups, then they are put in the Dish Washer. We use the Diversity J512 Test Paper to check pH solution in the Rinse sink. Diversity J512 Test Paper expiration date 09/15/23. Sanitize-300 and Rinse-164. Observation and Interview 02/13/22 at 1:30 PM , Food Director reported that they used a Low Temperature Dishwasher and used Chloride Test Strips to measure the level of sanitizer strength in the dishwasher water. It was observed that the Chloride Test Strips expired July 1, 2021. Food Director stated, I have a new bottle in my office, let me go get it. Food Director brought new bottle of Chloride Test Strips that did not have an expiration date. Food Director stated, I called the Vendor, and he said that the Chloride Test Strips do not need to have an expiration date. Food Service Director check the Chloride Level in the Dishwasher at was at 200 P.P.M. Interview on 2/16/22 at 5:19 PM, Food Director informed surveyor that the Vendor had called him back to inform him that the Chloride Test Strips did need to have an expiration date. C. Puree Food Prep Area: -Dried Food stains on the wall by Large Gray Trash Can next to metal table -Large metal rack had multiple opened Large Gray Plastic Storage Containers that had kitchen utensils, plates, bowls, and cups; There was a can of Germ-Bac Disinfectant Spray stored in the metal rack. Food Director stated, I don't know who put the can there, because we do not use this in the kitchen. D. Food Preparation Area -Three Large [NAME] Slant Top Ingredient Bins with clear lids that contained Sugar, Panko Breadcrumbs, and Flour had white powder residual and dried food stains on lids. Food Director stated, These Bins should be cleaned after each use. Metal Rack to the side of food preparation table revealed the following: -Opened 2 qt. Bottle Soy Sauce not dated when opened. Manufacture label documented Refrigerate After Opening. -Kitchen Bouquet Browning & Seasoning Sauce 32 Fl. Oz. was opened and not dated -Opened Gallon 128 fl. oz. Fine [NAME] Cooking Wine was not dated when opened -Opened Gallon Olive Oil was not dated when opened had a loose lid -Opened Gallon of Cooking Wine was not dated when opened -Opened Gallon of Sesame Oil was not dated when opened -Eighteen 30 oz. Plastic Spice Bottles that had sticky greasy substance on sides of bottles, and small food particles on top of lids and sides of bottles -Opened 21 oz. bottle of Flavoring Seasoning was not dated when opened -Opened 6.25 oz. Italian Seasoning was not dated when opened -Opened 24 oz. bottle of Oregano Leaves, had light powder on the lid and sides of bottle -Five opened spice bottles (Parsley Flakes, Garlic Powder, Whole Bay leaves, Cracked Black Pepper) were not dated when opened. The spice bottles had grease residual on top and sides of bottles -Large opened, box of Iodized Salt was not sealed -Dusty opened box of Grill bricks stored on bottom rack Food Director confirmed that metal rack had dried white substance on bottom rack and the floor by the metal rack had grease build-up and food particles Freezer: Temperature -10 degrees Fahrenheit -Individually wrapped Pizzas stored in freezer were full of crumbs. Food Director stated, They are crumbs that fall when the staff gets chicken strips from the freezer. -Bottom Freezer shelf was full of food particles E. Walk in Refrigerator - Temperature 37 degrees Fahrenheit Observation on 2/13/22 at 9:40 AM, with Food Director revealed: Metal Rack #1: - Large Plastic Food Storage Container that was unsealed contained 6 bunches of Cilantro, that had dried food stains and food particles in the bottom of the container - Large Plastic Food Storage Container that was unsealed contained an opened plastic bag that contained onions, a Cucumber full of white mole, large unsealed, plastic bag of chopped celery that was not dated, large bag of chopped carrots dated 2/12/22 was not sealed, large openedlarge, opened bag with grated carrots was unsealed and not dated, there were dried food stains and food particles in the bottom of the container Metal Rack #2: -Medium size metal container with Gravy dated 02/13/22 stored in metal rack covered with Saran Wrap was not completely sealed -Plastic Container that contained canned peaches was not sealed;sealed. -Plastic Container that contained Red Chile Sauce dated 2/11/22 was not sealed, lid was sticky and had dried food particles. E.F. Beverage Station Refrigerator #1 -Observation and Interview on 2/13/22 at 9:50 AM, with Food Director revealed small refrigerator used to store nourishments was at 32 degrees Fahrenheit; There were multiple undated covered containers that contained individual servings of Vanilla/Chocolate Pudding, slices of Lemon Pie, cups of Tea & Lemonade that were not dated. Food Director stated, All of the containers should be dated prior to putting them in the refrigerator. We do not date the Tea & Lemonade because they are going to be served today with the lunch meal. G. Cooking Tray Line Grill: Observation and& Interview at 9:52 AM, Food Director revealed the Grill had splattered grease on the sides, GrillgratesGrill grates had white food particles and residue buildup, grease, and fat accumulation; Grill drip tray was covered with aluminum foil and had dried dark brown stains, was full of food particles, and Grill knobs had accumulation of grease. There was a missing knob on the Grill. Food Director stated, They cooked chicken last night and it was cleaned by the [NAME] with a metal brush. The Grill is cleaned once a week, that is why it looks like this. I don't know when it was last cleaned. Combination (Combi) Ovens: One of Two Combination (Combi) Ovens was not working. Food Director stated, The Combi Oven has been broken for several months. The working Combi Oven had dark brown grease accumulation on the inner doors, racks, and bottom of oven. There was dark brown grease dripping from the Combi Oven down to the side of stainless steelstainless-steel oven leg. The Combi Oven is cleaned once a week, that is why it looks like this. I don't know when it was last cleaned. Stove: Stove knobs were full of grease accumulation and food particles; Drip Trays covered with aluminum foil and had dried green stains and were full of food particles. The stove is cleaned once a week, that is why it looks like this. I don't know when it was last cleaned. There a cooking pan stored under the stove rack with clean pots and pans, that had oil residual and food particles. Observation and interview on 02/13/22 at 10:35 PM, Administrator confirmed drip trays in the stove had had dried green stains and were full of food particles. GrillgratesGrill grates had white food particles and residue buildup, grease, and fat accumulation; Grill drip tray was covered with aluminum foil and had dried dark brown stains, was full of food particles, and Grill knobs had accumulation of grease. There was a missing knob on the Grill. The working Combi Oven had dark brown grease accumulation on the inner doors, racks, and bottom of oven. There was dark brown grease dripping from the Combi Oven down to the side of stainless steelstainless-steel leg. Fryer: Accumulation of grease and food particles and fat accumulation on sides of Fryer and full of food particles. Wall behind the Fryer had dark green stains. Telephone Interview on 02/16/22 at 5:14 PM, with Dietitian Consultant and Food Director, reported that her main responsibility was to provide dietary consultation to the residents. Dietitian reported that she conducted on site sanitization inspections of the kitchen once a month and had not identified any problems. Dietitian stated, The Grill should be cleaned after each use using a wire brush, cleaned with soapy water and dry well. Review of facility's policy and procedure on Maintaining a Sanitary Tray Line 08/16/17 documented in part: Policy: To provide an organized tray line that provides food at proper temperature, of nutritious value and in a manner to prevent the spread of bacteria that may cause food borne illness. Compliance Guidelines: -Thermal bottoms, dome lids and equipment designed to maintain temperatures should be used -Appropriate, sized bowls, dishes, lids, cups; and/or glasses should be used for servings 4.) Sanitation Inspection dated 08/16/17 documented in part: Policy: It is the policy of this facility to maintain a food service area that is clean and sanitary. Policy Explanation and Compliance Guidelines: 1. All kitchen and kitchen areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. 2. Sanitation inspections will be conducted weekly and as needed by the dietary manager or designee. 3. Inspections will include the following: a. Dry Storage b. Freezer c. Refrigerator d. Dish Room e. Pot Wash f. Main production area g. Food preparation area h. General dietary observations Review of facility's policy and procedure on Food Preparation Guidelines dated 08/16/17 documented in part: Policy: To assure that the nutritive value of food is not compromised because of prolonged food storage, light, and air exposure. Policy Explanation and Compliance Guidelines: The cook, or designee, should prepare menu items following the written menus and standardized recipes. Foods should be cut, chopped, pureed or ground to meet the individual needs of the residents. Each meal should be presented in an attractive and appetizing manner: Servings should be placed on plates to prevent running together with other food items. Food should be protected from contamination, while being stored, prepared and transported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to 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 2 (Residents #33 and #34) of 15 residents reviewed for a sanitary environment to help prevent the development and transmission of communicable disease and infections. A. Resident #33 and Resident #34 had catheter bags and tubing resting on the floor with no protective bag on the catheter bag. B. Surveyors had to ask to get temperature taken and get asked questions regarding Covid-19 exposure and symptoms upon entrance. C. A family member was not screened upon entrance for Covid-19 exposure/symptoms. These failures could have placed all residents at risk for Covid-19 exposure, and residents with catheters at increased risk for infection. Findings include: Record review of Resident #33's admission Record dated 02/16/2022 documented that she was [AGE] years old and was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #33's History and Physical dated 02/01/2022 documented that she had sepsis, a urinary tract infection (UTI), diabetes, incontinence of urine and depression. She had a urinary catheter in place. Record review of Resident #33's Baseline Care Plan dated for admission [DATE] documented that she had a urinary catheter. Record review of Resident #33's physician's orders dated 01/31/2022 documented that she was to have a Foley Catheter for urinary retention. Catheter care was to be provided every shift including cleaning of the catheter tubing. The catheter tubing and drainage bag were to be changed if needed for infection, obstruction or when the closed system was compromised. Record review of Resident #33's admission MDS dated [DATE] documented that she had a BIMS of 6 (Severe cognitive impairment). She was totally dependent on two people for use of the toilet. Urinary continence was not rated because she had a urinary catheter. She was always incontinent of bowel. She had a urinary tract infection in the last 30 days. Record review of Resident #33's MAR for February 2022 (printed 02/16/2022) documented that she had a Foley Catheter for urinary retention. Catheter care was provided every shift from 02/01/2022 through the morning of 02/16/2022 except for the night shift on 02/13/2022. As needed change of the catheter tubing and drainage bag had not occurred. Observation and interview on 02/13/22 at 11:35 AM Resident #33 was observed sitting at the nurse's station in a wheelchair. She did not respond when greeted. Observation of Resident #33 revealed that her urinary drainage bag contained medium amber clear urine and was lying directly on the floor without a protective cover. The urinary drainage tube extending down from the side of the resident's wheelchair was also lying directly on the floor. When the positioning of the urinary drainage bag and tubing was pointed out to LVN C she stated it should not be on the floor because it posed an infection control issue. She stated that it might have gotten there when Resident #33 was moved by the CNAs from her room to the nurse's station. She stated that she would go get a privacy bag for the urinary drainage bag and did return several minutes later with a cover for the drainage bag. In an interview on 02/14/22 at 09:30 AM CNA G stated that she had received training on positioning of the urinary catheter bag and tubing. She stated that the drainage bag should be in a bag for privacy and the tubing should not be on floor because it could get contaminated. She stated regarding catheter drainage bags that the CNAs did the work, but the nurses had to make sure that it was is ok. In an interview on 02/15/22 at 02:49 PM ADON E stated that Resident #33 did have orders to monitor the catheter because of the risk for infection. She stated that the catheter bag or tubing should not be on the floor because of risk for infection. ADON E stated the floor nurse was responsible for monitoring the CNA's handling of resident's catheters. She did not know how or why the catheter was on the floor but stated that it could have been because the resident moves around in her wheelchair. Record review of Resident #34's admission Record dated 02/16/2022 documented that he was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #34's History and Physical dated 2/4/2022 documented that he had diagnoses including history of hypertension, renal failure and congestive heart failure. He had a colostomy, was receiving dialysis and had a urinary catheter. He was alert and oriented. Record review of Resident #34's admission MDS dated [DATE] documented that his BIMS was 6 (Severe Cognitive Impairment). He had a urinary catheter and colostomy. was totally dependent on one staff member for using toilet use. Record review of Resident #34's IDT admission Evaluation with Baseline Care Plan for admission on [DATE] with most recent admission of 12/23/2021 did not document he had a urinary catheter. Record review of Resident #34's Comprehensive Care Plan dated 01/31/2022 documented that he had an indwelling urinary catheter. The catheter tubing was to be checked for kinks every shift. It was to be placed below the level of the bladder and away from the entrance door to the resident's room. Record Review of Resident #34's Physician Orders dated 01/31/2022 documented that he was to have a urinary catheter for chronic urinary retention. Catheter care including cleaning of the tubing with soap and water every shift. The catheter tubing and drainage bag were to be changed as needed for infection, obstruction or when the closed system was compromised. Observation on 02/13/2022 at 12:00 PM revealed that Resident #34 was lying in bed. An interview was attempted but he could not be understood. Observation of Resident #34's catheter revealed that the urinary drainage bag was lying directly on the floor without a protective cover as was the urinary drainage tube. In an interview on 02/13/2021 at 12:05 PM ADON E was asked to come to Resident #34's room. She observed the placement of the urinary drainage bag and catheter tubing. She stated that the urinary drainage bag needed to be in a privacy bag and the tubing needed to be off the floor for reasons of infection control. She also stated that the catheter tubing on the floor presented a fall risk. She stated that the nurses and the CNAs were responsible for catheter bag and tube care. Review of the facility policy Catheter Care Policy dated 2017 documented in part that the facility would provide catheter care in an effort to reduce bladder and kidney infections. The policy described the process for providing catheter care to males and females. It mentioned nothing regarding covering or placement of the drainage bag or of the catheter tubing. During observation and interview on 02/13/22 at 9:05 AM, Surveyor H, Surveyor I, and Surveyor J entered the facility. Approximately 5 min after all surveyors entered, Surveyor H asked Receptionist L if he needed to take our temperatures. Receptionist L stated yes, he needed to take out temperatures then proceeded to take surveyors temporal temperatures, he then wrote down surveyors' temperatures in a separate screening sheet for each. After Receptionist L took surveyors temporal temperatures, approximately 5 minutes later, Surveyor H asked Receptionist L if he needed to ask us any questions regarding Covid-19, Receptionist L stated yes and proceeded to ask Covid-19 exposure and symptoms. During interview on 02/13/22 at 09:51 AM Resident #8's Family Member stated she had not been screened upon entrance. Resident #8 Family Member stated she entered the facility approximately 10-15 minutes ago. Resident #8 Family Member stated when she entered the facility the male receptionist handed her a N95 mask to wear and called the nurse in the back to let them know she was here and was then let in the building. Resident #8 Family Member stated this was the first time she had not been screened. Record review of Covid-19 visitors screen sheets for 02/13/2022 morning visitors revealed Resident #8 Family Member name was not found on any of the Covid-19 visitor screenings for the morning of 02/13/2022. During interview on 02/15/22 at 10:11 AM Receptionist K stated she was trained to screen everybody that comes in through the front door. Receptionist K stated she screens all visitors and employees. Receptionist K stated the front door is always locked, she opens the door once the doorbell rings and will ask employee or visitor to disinfect hands and will provide new N95 if they need one. Receptionist K stated she takes temporal temperature and will record the temperature on Covid-19 visitor or employee screening sheet and will then ask questions regarding Covid-19 exposure and symptoms. Receptionist K stated she was trained to screen all visitors upon hire and will daily get reminders from Administrator and DON. Receptionist K stated if a visitor was not screened the facility would be exposed to contracting Covid-19. During interview on 02/15/22 at 10:26 AM DON stated receptionists are in charge of screening all visitors and employees upon entering the building. DON stated once the receptionist opens the door for the visitors and employees, the receptionist will ask to disinfect hands and hand a new N95 mask if they need one; then the receptionist will take their temporal temperature and record the temperature either on Covid-19 visitor or employee screening sheet and proceed to ask Covid-19 exposure and symptoms questions. DON stated receptionist are trained of screening process upon hire and get at least once a month daily reminder. DON stated the Administrator and DON will do random screening checks, they will look at the Covid 19 screening sheets and make sure temperature and all questions have been answered. Surveyor J asked if there was a system in place to verify that everyone entering the double doors to the resident's hall have been screened, DON did not have an answer. DON stated by not screening a visitor the residents and all facility would be exposed to contracting Covid-19. During interview on 02/15/22 at 01:01 PM Receptionist L stated he worked on Sunday 02/13/2022. Receptionist L stated he remembers surveyors asking to be screened. Receptionist L stated he should have had taken all surveyors temperature and asked Covid 19 exposure and symptoms questions as soon as they had walked in. Receptionist L stated he had been trained to screen everybody that walks into the building. Receptionist L stated he was trained about screening process upon hire and gets daily reminders on daily basis from Administrator and DON. Receptionist L stated when a visitor or employee walk in the building, he had been trained to take their temperature, record the temperature on either Covid 19 visitor or employee screening sheet; he then is to ask Covid 19 exposure and symptoms questions and provide new N95 mask if they need one. Receptionist L stated by not screening a visitor the facility is exposed to contracting Covid 19. During interview on 02/16/22 at 09:45 AM Administrator stated all receptionists are in charge of screening all visitors and employees. Administrator stated receptionist are trained of screening process upon hire and get daily reminders. Administrator stated receptionists have been trained to take temperature and ask Covid 19 exposure and symptoms to everyone that walks into the building. Administrator stated DON and Administrator are in charge of doing random screening checks, will check that temperature is recorded, and all questions have been answered on screening sheets. Surveyor J asked if there was a system in place to verify that everyone entering the double doors to the resident's hall have been screened, Administrator did not have an answer. Administrator stated by not screening a visitor the entire facility could be exposed to Covid-19. Record review of Infection Control and Prevention Covid-19 Mitigation Plan policy dated 12/1/21 revealed page 11 of 24 Visitors: for facilities allowing visitation, at a minimum must be screened with questionnaire related to their symptoms, have a temperature check with temperature of 100F below and wear a mask and perform hand hygiene prior to visiting. FACILITY Infection Control