**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure that medical records were accurately documented for four (4) of thirteen (13) residents (Resident #6, Resident #8, Resident #12, Resident #13) reviewed for accurate clinical records, in that: The facility failed to ensure Resident #6, Resident #8, Resident #12, and Resident #13's EMARs were accurately reflecting narcotic medications administered. This deficient practice could result in errors in care and treatment. Findings included: Resident #6 Review of Resident #6's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Cirrhosis of the Liver (scarring of the liver), Muscle Weakness, Pain in unspecified joint, Femur fracture (large upper leg bone), unsteadiness on feet and repeated falls. Review of Resident #6's MDS assessment, dated 07/11/2023, reflected a BIMS of 5, indicating severe cognitive impairment. Review of Resident #6's EMAR reflected on 7/15/2023 and 7/16/2023 the 4:00 PM a dose of Tramadol HCL 50 mg tablet was checked off by medo and AMP respectively. Review of Resident #6's July Narcotic count sheet reflected no entries on 7/15/2023 and 7/16/2023 at 4:00 PM for the Tramadol HCL 50 mg tablet. Resident #8 Review of Resident #8's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Dementia (progressive memory impairment), Glaucoma (eye diseases that can cause vision loss), Type 2 Diabetes Mellitus, Malignant Neoplasm of Colon (cancer of the Colon), repeated falls, lack of coordination and muscle weakness. Review of Resident #8's MDS assessment, dated 05/18/2023, reflected a BIMS of 8, indicating moderate cognitive impairment. Review of Resident #8's EMAR reflected on 6/6/2023 the 10:00 PM dose of Tramadol HCL 50 mg tablet was checked off by VNR. Review of Resident #8's June narcotic count sheet reflected no entries on 6/6/2023 at 10:00 for the Tramadol HCL 50 mg tablet. Resident #12 Review of Resident #12's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Dementia, Major Depressive Disorder, Insomnia, and Disorientation. Review of Resident #12's MDS assessment, dated 05/5/2023, reflected a BIMS of 5 indicating severe cognitive impairment. Review of Resident #12's EMAR reflected on 5/22/2023 the 8:00 PM dose of Lorazepam 0.5 mg tablet was checked off by VNR. Review of Resident #12's May Narcotic count sheet reflected no entries on 5/22/2023 at 8:00 pm for the Lorazepam 0.5 mg tablet. Resident #13 Review of Resident #13's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Dementia (progressive memory impairment), Type 2 Diabetes Mellitus, Major Depressive Disorder, Pain in left shoulder, Pain in right knee, Pain in left ankle, unsteadiness on feet, hear Failure, Pulmonary Hypertension (high blood pressure affecting the lungs) and chronic kidney disease. Review of Resident #13's MDS assessment, dated 06/16/2023, reflected a BIMS of 3 indicating severe cognitive impairment. Review of Resident #13's EMAR reflected on 5/5/2023 and 5/14/2023, the HS dose of Tramadol HCL 50 mg tablet was checked off by tr and ML respectively. Review of Resident #13's May narcotic count sheet reflected no entries for 5/5/2023 or 5/14/2023 at HS for the Tramadol HCL 50 mg tablet. During an interview on 8/3/2023 at 1:05 PM, Resident #6 stated she did not remember missing any doses of medication in July of 2023 She states she was in pain all the time and did not remember if she had more pain on those days or not. During an interview on 8/3/2023 at 1:12 PM, Resident #8 stated she did not remember missing and medications in June of 2023, but she had no idea what medications they give her anyway, so she would not know if one was missing. She stated she was in pain all the time but did not recall if it was worse back in June. During an interview on 8/3/2023 at 1:25 PM, Resident #12 stated she did not remember any issues with her medications back in May of 2023 and does not remember if she felt more anxious that usual at that time, as it was several months back. During an interview on 8/3/2023, 1:30 PM, Resident #13 stated she did not recall any issues with medications back in Ma y of 2023 but that was too long to remember. She stated she would not know if they left out her pain medication anyway, because she could not identify it. She did not recall whether she was in pain back in May, it was too long ago. During an interview with the DON on 8/3/2023 at 11:30 am, she provided a list of names and phone numbers of the staff that had EMAR discrepancies. She identified AMP as LVN #1, medo as LVN #2, VNR as LVN#3, tr as agency nurse #1 and ML as agency nurse #2. During an interview on 8/3/2023 at 12:20 PM, LVN #1 stated her initials in the EMAR were AMP. When shown the EMAR check off on Resident #6 for the 4:00 PM dose of Tramadol HCL 50 mg tablet on 7/16/2023 and the July narcotic count book, she stated There is no entry there referring to the narcotic count book. She stated, I have no idea what happened; I guess I was in a hurry. She stated she had been working a double shift that day and she may have clicked it off in the EMAR before she gave the medication. She stated the resident could have been sleeping and that is why she had not given it. When asked if she followed the facility policy on documentation for medication administration she stated, Of course not. She stated they are not supposed to click it off on the EMAR until they give the medication She stated if residents did not get their pain medication they could be in severe pain. During an interview on 8/3/2023 at 12:25 PM, LVN #2 stated her initials in the EMAR were medo. When shown the EMAR check off on Resident #6 for the 4:00 PM dose of Tramadol HCL 50 mg tablet on 7/15/2023 and the July narcotic count book, she stated I clicked it off, but didn't give it. I made a mistake. She stated, I don't normally pass meds and she did not have a definite answer as to why there was a discrepancy. She stated she would normally click it off in the EMAR after she had given it, but stated she probably had not given it, ifit if it was not signed out on the narcotic count sheet. She also stated she did not follow facility policy for medication administration, and she really did not remember what happened that day, but she probably had not given it. When asked what could happen if residents did not get their pain medications she stated, the resident could be in pain. During an interview on 8/3/2023 at 1:45 PM, Agency Nurse #1 stated her initials in the EMAR were tr. When shown the EMAR check off on Resident #13 for the HS dose of Tramadol HCL 50 mg tablet on 5/5/2023 and the May narcotic count sheet, she stated that she did not remember what happened that day but if I clicked it in the EMAR, I probably gave it; maybe I put it on the wrong count sheet. She stated, I can't defend myself, but I'm pretty sure I gave it. She stated if residents did nott get their pain medication they could be in pain, and their blood pressure could go up if their pain wasn't alleviated. During an interview on 8/3/2023 at 2:15 PM, LVN #3 stated her initials in the EMAR are VNR. When shown the EMAR check off on Resident #8 on 6/6/2023 for the 10:00 PM dose of Tramadol HCL 50 mg tablet and Resident #12 on 5/22/2023 for the 8:00 PM dose of Lorazepam 0.5 mg tablet and the May and June narcotic count sheets, she stated she thought she had given it but did not remember. She stated she did not know if there was another count sheet but if she had given it she would have signed out for it on the narcotic count sheet where the others were. She said there was a possibility that she did not give the medications, but she did not know where else it would be documented. She stated she was supposed to give the medications then click it off in the EMAR and sign it out on the narcotic count sheets. She stated if residents did not get their pain meds they could have pain and if they do nott get their anti-anxiety meds (Lorazepam) they could get anxious. Agency Nurse #2,ML was contacted by phone three times on 8/3/2023 but had never returned any calls prior to exit on 8/3/2023. During an interview with the DON and the AD on 8/3/2023 at 10:21 am regarding the discrepancies between the EMAR and the narcotic count sheets, the DON stated, I'm thinking they just signed off on it and didn't give it. She further stated a checkmark on the EMAR indicated a medication was given, but if there was no entry on the narcotic count sheets, it had not been given. The DON stated her expectation was staff would give meds as ordered. The AD stated she didn't know too much about EMARs and narcotic count sheets. She stated her and the DON had previously conducted an audit of the narcotic count sheets after a staff expressed a concern and had not found any discrepancies. During an interview on 8/3/2023 at 4:15 PM, the MD stated he was not aware of any discrepancies between EMARS and narcotic count sheets at the facility. He stated they would have discussed discrepancies during their QAPI meetings, and these had not been previously discussed. He started his expectations were that staff would follow orders as given and if they do not it is a med error and should be reported. He stated he had not been notified of any med errors or meds not given. He stated if a resident did not get their prescribed Lorazepam they could have withdrawal symptoms, could have jitters, increased anxiety, or other side effects. He further stated if residents did not get their pain medications as ordered they could have increased pain and possible withdrawal symptoms if they take it on a regular basis. Review of facility policy Administering Medications revised April 2019 reflected 4. Medications are administered in a safe and timely manner, and as prescribed. Also reflected, 22. The individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 1 (200 hall medication aide cart) of 2 medication carts reviewed for pharmacy services in that: The facility failed to ensure medications in unsecured containers were immediately removed from the 200 hall MA cart. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: An observation on 06/27/2023 at 12:20 PM of the MA Cart for Hall 200 revealed the blister pack for Resident #43's tramadol 50 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill was still inside the broken blister and taped over. In an observation and interview on 06/27/23 at 12:20 PM, MA A stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister. She stated the risk of a damaged blister would be a potential for drug diversion. She stated the nurses and medication aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated the count was done at shift change and the count was correct. She stated she did not see the broken blisters during the count. She stated when a broken seal was observed, tow nurses should discard the medication. At this time the surveyor checked the medication; the count was compared to the blister packs and the count was correct. Interview on 06/28/23 at 2:31 PM, the DON stated if a blister pack medication seal was broken the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be losing the medication because the seal was broken. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated she supposed to check the carts randomly. Review of the facility's policy Storage of Medications, revised April 2019 reflected the following: . 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a medication error rate below 5%. There were 2 errors out of 27 opportunities, resulting in a facility had a 7.4 percent (%) medication error rate for one (Resident #45) of 6 residents reviewed for medication administration. The facility failed to ensure MA A administered medications per the physician orders for Resident #45. MA A administered the wrong dose of Eliquis (anticoagulant medication used to treat and prevent blood clots) and ropinirole HCl (used to treat restless leg syndrome). This failure could place residents at risk for not receiving therapeutic effects of their medications. The findings included: A record review of Resident #45's Quarterly MDS assessment dated [DATE], revealed Resident #45 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot), restless legs syndrome, and dementia. Resident #45 had a BIMS of 08 which indicated Resident #45 was cognitively moderately impaired. A record review of Resident #45's physician's orders dated 6/28/23 revealed Resident #45 was to receive Eliquis tablet 2.5 milligrams (Apixaban), give 5 milligrams by mouth two times a day related to pulmonary embolism. Give 2 of 2.5 milligrams. And to receive ropinirole HCl tablet 1 milligram, give 1 tablet by mouth two times a day related to restless legs syndrome. Take total of 1.5 milligram (1tablet of 1 milligram and 1 tablet of 0.5 milligram) A record review of Resident #45's medication administration record dated 6/28/23 revealed Resident #45 was to receive Eliquis tablet 2.5 milligrams (Apixaban), give 5 milligrams by mouth two times a day related to pulmonary embolism. Give 2 of 2.5 milligrams. And to receive ropinirole HCl tablet 1 milligram, give 1 tablet by mouth two times a day related to restless legs syndrome. Take total of 1.5 milligram (1tablet of 1 milligram and 1 tablet of 0.5 milligram). During an observation of the medication pass on 6/28/23 at 7:47 AM, revealed MA A administered to Resident #45 the following medications: Eliquis tablet 2.5 milligrams and ropinirole HCl tablet 1 milligram. In an interview of on 6/28/23 at 12:33 PM, MA A stated she overlooked the two orders. MA A stated she did not administer the right dose. MA A stated she gave less than the ordered dose, the risk would be ineffective medication. MA A stated she was to follow the five rights of medications: right patient, right order, right time, right dose, and right route. In an interview on 6/28/23 at 02:31 PM, the DON stated she expected the medications to be administered per the physician orders and for the staff to follow the five rights of medication administration, which included the right dose. The DON stated by giving a dose less than the order, the risk would be failure to give a therapeutic dose. The DON stated nursing staff were to complete in-service regarding the 5 rights of medication administration. On 3/28/23 at 02:40 PM, this surveyor attempted to call the physician, a message was left. Record review of the facility policy revised April 2019, titled Administering Medications reflected, . Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 10. The individual administering the medication checks the label 3 times to verify the right resident, right medication, right dosage, right time and right method (route of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #20, Resident #213 and Resident #42) of 15 residents reviewed for ADLs. The facility failed to ensure: -Resident#20 had her fingernails cleaned and trimmed. -Resident#213 had her fingernails cleaned and trimmed. -Resident #42 had his facial hair and fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1. A record review of Resident #20's Quarterly MDS assessment dated [DATE] reflected Resident #20 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus and dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Resident #20 was unable to complete the cognition assessment. Resident #20 required total dependence of one-person physical assistance with transfer, dressing, and personal hygiene. A record review of Resident #20's Comprehensive Care Plan, revised 01/12/23, reflected Focus: I have an ADL self-care performance deficit related to dementia, impaired physical mobility related to weakness. Goal: I will receive necessary assistance to maintain clean and neat appearance. Interventions: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. An observation on 06/28/23 at 11:15 AM revealed Resident #20 was laying in her bed. The nails on both hands were approximately 0.3 centimeter in length extending from the tip of her fingers. Resident # 20 was unable to answer questions. 2. A record review of Resident #213's Comprehensive MDS assessment, dated 06/20/2023, reflected Resident #213 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, lack of coordination and legal blindness. Resident #213 had a BIMS of 09 which indicated Resident #213's cognition was moderately impaired. Resident#213 required extensive assistance of one-person physical assistance with dressing and personal hygiene. A record review of Resident #213's Comprehensive Care Plan dated 06/13/23 did not indicate personal hygiene and grooming. Observation and interview on 06/28/23 at 11:35 AM, revealed Resident #213 was sitting in her wheelchair. The nails on both hands were discolored tan and chipped. Resident #213 stated she could not clean and trim her nails. Resident #213 stated the chipped nails bothered her when they hanged to things. Interview on 06/28/23 at 12:35 AM, CNA B stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA B stated she would talk to the nurse about Resident #20 and Resident #213 long nails because they were both diabetic. CNA B stated fingernail care was provided for the residents during daily care. CNA B stated she did not notice long nails on Resident #20 and chipped nails on Resident #213. Interview on 06/28/23 at 12:45 PM, LVN D stated CNAs were responsible to clean and trim residents' nails as needed. LVN D stated only nurses cut residents' nails if they were diabetic. LVN D stated no one notified her Resident #20 and Resident #213's nails were long and chipped, and she had not noticed the nails herself. LVN D stated Resident #20 and Resident #213 were diabetic, she would clean and trim their nails. Interview on 06/28/23 at 2:31 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and chipped nails could be a skin break down and infection control issue. The DON stated she was responsible to do routine rounds for monitoring. The DON stated she had not noticed the nails herself. 3. A record review of Resident #42's Quarterly MDS assessment dated [DATE] reflected Resident #42 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Leukemia (cancer), hypertension, generalized muscle weakness, unsteadiness on feet, abnormalities of gait and mobility and lack of coordination. Resident #42 had a BIMS of 11 indicating he was moderately cognitively impaired. Resident #42 required limited assistance with hygiene and dressing. He required extensive assistance with bathing. A record review of Resident #42's Comprehensive Care Plan last revised 03/19/23 reflected Resident #42 had limited physical mobility related to weakness, decreased functional mobility, leukemia, cataracts and history of falls. Invention included to provide supportive care, assistance with mobility as needed. Document assistance as needed. Observation and interview on 06/27/23 at 12:05 PM, with Resident # 42 revealed he was lying in bed with an unkempt beard hair of about an inch length covering both cheeks below the mouth and under his chin and mustache about ½ inch length of facial hair. Resident #42 revealed his shower schedule was on the 2 pm to 10 pm shift. He stated he sometimes would get his shower, but he had not gotten his facial hair trimmed in 2 weeks. He stated he had been asking to get his facial hair trimmed for 2 weeks and CNAs make promises they will later come to trim it but do not. He stated sometimes he did refuse his showers when offered to him during an inconvenient time like meals, med pass time or too late on evening shift. Resident #42 stated he was not provided facial trimming for 2 weeks and preferred to have no facial hair including the beard and mustache. Observation on 06/28/23 at 2:00 PM, with Resident #42 revealed he was lying in bed with a beard hair of about a inch length below the mouth and under his chin and mustache about ½ inch of hair. Interview with Resident #42 revealed yesterday was his shower day and he did not get a shower or shaved. He stated his fingernails needed to be trimmed. Observation revealed fingernails on right hand were about ¼ inch on each of his finger nails on right hand. He trimmed his own on one hand left hand because he was tired of waiting for them to be trimmed. He stated he felt like the CNAs did not want to be bothered and just wanted him to sign the shower sheet for refusal. Interview on 06/28/23 at 2:03 PM, Hospitality Aide H revealed she worked with Resident #42 along with another CNA who had not arrived yet on the 2 pm to 10 pm shift. She stated Resident #42 did refuse a shower one time for her because he had lost his belt to his pants. She stated she did not ask residents if they wanted their facial hair trimmed unless it was one of the two residents on 200 hall who she knew wanted their facial hair trimmed. She stated she was not aware Resident #42 wanted his facial hair of his beard and mustache trimmed. She did not ask Resident #42 if he would like his fingernails trimmed. Interview on 06/28/23 at 2:28 PM, Resident #42 revealed he told LVN G he had trimmed his left-hand fingernails himself and still needed his right hand fingernails trimmed. He told LVN G he was tired of waiting for staff to trim them. Resident #42 told LVN G he would like to have a shower or bed bath whichever he could get and would like his facial hair trimmed. Interview on 06/28/23 at 2:28 PM, LVN G revealed Resident #42 had refused showers before. She stated the CNAs should be trimming fingernails for Resident #42 on shower dates and trim his facial hair if resident wanted it trimmed. She stated CNAs should have been offering to Resident #42 facial trimming of his beard and mustache along with fingernail trimming. Interview on 06/28/23 at 2:35 PM, the DON revealed Resident #42 should be offered shower or a bed bath. The DON stated the CNAs should offer to Resident #42 facial trimming and fingernail trimming on shower days at least. Review of the facility's policy titled, Fingernails/Toenails, Care, revised February 2018, reflected, . The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed . 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting revised March 2018 reflected Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain .grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming and oral care) .

Based on observations, interviews, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen for 2 of 2 (Freezer #1 and #2) reviewed for kitchen sanitation. The facility failed to ensure items in Freezer #1 and #2 were sealed properly. This failure could place residents at risk for food contamination and food-borne illness. Findings included: Observations on 06/27/23 for Freezer #1 revealed: - at 11:16 AM revealed a box of bacon was open, not sealed about 2 inches with bacon not sealed. - at 11:18 AM revealed a box of biscuits was open, not sealed about 1.5 inches. Interview on 06/27/23 at 11:19 AM, with Dietary Aide F revealed she did not use the biscuits today so she was not sure how long they had been unsealed. She stated she used the bacon this morning. She stated the items should be sealed. Observation on 06/27/23 at 11:26 AM, for Freezer #2 revealed a box of pork patties, dated 05/12/23 open about 2 inches not sealed. Interview on 06/27/23 at 11:27 AM, with Dietary Manager revealed the freezer items should be sealed right after being used. He stated they had limited space in the freezer so when they are moving items around the boxes could have opened more. He stated they had a small amount of dietary staff in the kitchen and was working in the kitchen as staff so he had not had an opportunity to look to see if freezer items were sealed properly. Review of facility's policy Food Receiving and Storage revised October 2022 reflected foods shall be received and stored in a manner that complies with safe food handling practices.

**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 designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 5 (Resident #22, Resident #27, Resident #31, Resident #40, and Resident #45) of 6 residents reviewed for infection control. The facility failed to ensure MA A disinfected the blood pressure cuff in between blood pressure checks for Residents #22, #27, #31, #40, and #45. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #22's Quarterly MDS assessment, dated 05/12/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses included elevated blood pressure, and hyperlipidemia (high levels of fat in the blood). He had a BIMS of 03 indicating his cognition was severely impaired. Record review of Resident #22's physician orders dated 06/28/23 reflected, carvedilol tablet 3.125 mg, give 1 tablet by mouth two times a day - Special instruction: Hold for systolic blood pressure less than 100, diastolic blood pressure less than 60 or heart rate less than 60. Cozaar tablet 25 mg, give 1 tablet by mouth one time a day - Special instruction: Hold for systolic blood pressure less than 100, diastolic blood pressure less than 60, or heart rate less than 60. Record review of Resident #27's Quarterly MDS, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included history of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hyperlipidemia (an abnormal high concentration of fats or lipids in the blood), and shortness of breath. He had a BIMS of 12 indicating he was moderately impaired. Record review of Resident #27's physician orders dated 06/28/23 reflected, metoprolol tartrate 50 mg, give 1 tablet by mouth, two times a day - Special instruction: Hold for systolic blood pressure less than 110, diastolic blood pressure less than 60, or when the heart rate is less than 60. Record review of Resident #31's Comprehensive MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hyperlipidemia (an abnormal high concentration of fats or lipids in the blood), and dementia. She had a BIMS of 08 indicating her cognition was moderately impaired. Record review of Resident #31's physician orders dated 06/28/23 reflected, amlodipine tablet; 10 mg, give 1 tablet by mouth, one time per day - Special instruction: Hold for systolic blood pressure less than 110 and or diastolic blood pressure less than 60. Carvedilol tablet 25 mg, give 1 tablet by mouth two times a day - Special instruction: Hold for systolic blood pressure less than 110 and or diastolic blood pressure less than 60. Record review of Resident #40's Quarterly MDS, dated [DATE], revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and hyperlipidemia (an abnormal high concentration of fats or lipids in the blood). She had a BIMS of 03 indicating her cognition was severely impaired. Record review of Resident #40's physician orders dated 06/28/23 reflected, carvedilol tablet; 3.125 mg, give 1 tablet by mouth, two times per day - Special instruction: Hold for systolic blood pressure less than 110 and or heart rate less than 60. Enalapril maleate tablet 5 mg, give 1 tablet by mouth two times a day - Special instruction: Hold for systolic blood pressure less than 100 or diastolic blood pressure less than 60. Record review of Resident #45's Quarterly MDS assessment dated [DATE], revealed Resident #45 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included elevated blood pressure, pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot), and hyperlipidemia (an abnormal high concentration of fats or lipids in the blood). Resident #45 had a BIMS of 08 which indicated Resident #45's cognition was moderately impaired. Record review of Resident #45's physician orders dated 06/28/23 reflected, amlodipine tablet; 2.5 mg, give 1 tablet by mouth, two times per day - Special instruction: Hold for systolic blood pressure less than 110 and or diastolic blood pressure less than 60. Observation on 06/28/23 at 7:30 AM, revealed MA A performing morning medication pass, during which time she checked the blood pressures on Resident #40. MA A did not sanitize the blood pressure cuff before or after using it on Resident #40. MA A put the blood pressure cuff on top of the medication cart after use. Observation on 06/28/23 at 7:47 AM, revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #45. MA A used the same blood pressure cuff right after using it on Resident #40. MA A did not sanitize the blood pressure cuff before or after using it on Resident #45. She left the blood pressure cuff on top of the medication cart. Observation on 06/28/23 at 7:57 AM, revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #31. MA A used the same blood pressure cuff right after using it on Resident #45. MA A did not sanitize the blood pressure cuff before or after using it on Resident #31. Observation on 06/28/23 at 8:09 AM, revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #22. MA A used the same blood pressure cuff right after using it on Resident #31. MA A did not sanitize the blood pressure cuff before or after using it on Resident #22. Observation on 06/28/23 at 8:15 AM, revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #27. MA A used the same blood pressure cuff right after using it on Resident #22. MA A did not sanitize the blood pressure cuff before or after using it on Resident #27. Interview on 06/28/23 at 12:33 PM, MA A stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting an infection from one resident to another. She stated she forgot to wipe the cuff this time. Interview on 06/28/23 at 2:33 PM, the DON stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She said she was responsible for training staff on infection control. She said that she did routine rounds in the floor to ensure the nurses and med aids were following proper infection control procedures. Record review of facility's policy Cleaning and Disinfection of Resident-Care Items and Equipment, reviewed March 2023, reflected . 6. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions. 9. Durable medical equipment is cleaned and disinfected before reuse by another resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the facility's only kitchen, dining room and one of three halls (Hall 200) reviewed for pest control. The facility failed to keep an effective pest control program to ensure kitchen, dining room and residents' rooms on Hall 200 were free of flies. This failure could place residents at risk for reduced quality of life. Findings included: Observation on 06/27/23 at 11:04 AM revealed four flies were in the dish area of kitchen while Dietary Aide F wash using the dish machine. Observations on 06/27/23 at 11:10 AM and 11:15 AM revealed fly light had no light on it and was not plugged in the kitchen. Interview on 06/27/23 at 11:20 AM with Dietary Aide F and the Dietary Manager revealed the electronic fly light did not work to their knowledge. Observation on 06/27/23 at 11:23 AM revealed three flies in food prep area of kitchen while two dietary staff were doing food prep for lunch. Observation on 06/27/23 at 11:02 AM and 11:29 AM revealed an open full trash can with vegetables, food snack packages, cups and used condiment containers with no lid in dining room about 3 feet away from closed kitchen door. Interview on 06/27/23 at 11:30 AM with Maintenance Supervisor revealed the electronic bug light in the kitchen in the dish area should be plugged in so it kept the flies and gnats down. He stated he did have issues with dietary staff unplugging it so they can plug in something else. He stated the trash can in the dining room should be covered to keep the flies and gnats out of it. Observation and interview on 06/27/23 at 11:45 AM revealed three flies were in his room (resident room [ROOM NUMBER]). Resident #21 stated the flies were bad in the facility and saw the flies in his room constantly. Observation on 06/27/23 at 12:18 PM revealed there were four flies in resident's room (resident room [ROOM NUMBER]). Interview with Resident # 10 revealed the flies bothered her all the time and used the fly swatter in her hand to try to get rid of them. She stated there were some flies in her room now and had a lot of flies in her room on a daily basis. Observation on 06/27/23 at 12:28 PM revealed Resident #41 had two flies landing on her dining table during lunch. Observation on 06/27/23 at 12:30 PM with Resident #34 revealed she shooed two flies away from her lunch plate. Interview on 06/27/23 at 12:33 PM with Resident # 34 revealed the facility did have flies in dining room especially during meals. She stated the flies bothered her a lot when she is eating. Observation on 06/27/23 at 2:32 PM in resident room [ROOM NUMBER] revealed Resident #43's walker had two flies landing on his walker. Observation on 06/28/23 at 2:17 PM revealed fly light had no light on it and was not plugged in the kitchen. Interview on 06/28/23 at 2:19 PM with Maintenance Supervisor revealed he was not aware of the kitchen electronic fly light not working in the kitchen and should have been plugged in so it can help with flies. He stated he had new electronic fly lights which needed to be put up but was waiting for pest control to put them up. He stated the electronic fly light on 200 hall was not working well, was older and needed to be replaced with a new one. He stated he had put up one new electronic bug light on 100 hall so far. Observation on 06/28/23 at 2:21 PM revealed fly light on 200 hall had light on and about 4 flies were stuck to glue board. Interview on 06/29/23 at 9:50 AM with Administrator revealed pest control came out regularly at least once a month to service the facility for pests. She stated she was not aware of the fly light in the kitchen being unplugged or if it was not working properly. Review of email communication between the facility and pest control reflected the following: - dated 04/28/23 reflected Facility had 4 fly lights broken and needed to be replaced. Facility requested to order 4 bug lights sent to Pest Control company. - dated 04/28/23 reflected Pest Control company would order them and have them shipped. - dated 05/11/23 Maintenance emailed Pest Control company reflected .The bug lights that we received, 2 do not work. When we took them out of the box and plugged them in, they did not come on. What do we need to do to get them replaced? - dated 05/11/23 Pest Control company emailed Maintenance Supervisor back reflected Go ahead and set them those to the side. I'll have the tech check the starters and bulbs when he comes and if he can't get them working then he will take them and I will have new ones sent. It looks like we are scheduled for 5/23. - Dated 06/14/23 from Maintenance Supervisor to Pest Control company reflected We still have two of the new bug/fly lights that we ordered from you that do not work. I thought .was going to look at them on the 23rd of May but he did not. This month they have already come and serviced us. Can we please see about getting these lights replaced or repaired? We are in need of them at this time of year. - Dated 06/14/23 from Pest Control to Maintenance Supervisor reflected pest control reached out to vendor and will be shipping out two replacement lights today. Review of pest control visits for April to June 2023 reflected the following about flies: - dated 05/23/23 fly lights inspected and 3 glueboard (3 each) were replaced. - dated 06/08/23 fly lights glueboard (7 each) - dated 06/16/23 facility requested additional service on-site for emergency service regarding flies. Staff reported flies throughout the facility mainly the 200 hallway and resident room [ROOM NUMBER]. Upon inspection several flies were observed I applied a liquid resident fly bait to the tops (6 ft) of hallways 99-108, 200, 300 and dining area to help reduce fly pressure. Fly lights were inspected and insect monitors replaced as necessary. Resident room [ROOM NUMBER] was treated as well with liquid residual product by applying product to Swiffer head in the hallway, then wiping it to the top perimeter of the room. The exterior entrances and exits were treated with a repellant liquid residual product to deter flies from doorways. The dumpster area was treated with a liquid residual fly bait also. During the inspection of the exterior I found a hole in the wall outside of the kitchen door. I patched it temporarily with duct tape. This area is most likely how some flies are getting into the facility and needs proper repairs. This is a fly hot spot as it is close to dumpsters. Review of facility's pest control log for March to June 2023 reflected no documentation of flies. Review of facility's policy Pest Control revised May 2008 reflected this facility maintains an on-going pest control program to ensure that the building is free of insects and rodents.