Based upon interview and record review, the facility failed to provide care and services according to accepted standards of clinical practice regarding Physician Orders and notification for 2 residents [Res.#6 and #17] of 18 sampled residents. Findings include: Per review of the Lippincott Manual of Nursing, Common Departures from the Standards of Nursing Care include: failure to follow physician orders, follow appropriate nursing measures, communicate information about the patient. [Lippincott Manual of Nursing Practice-11th Edition 2018] 1.) Per record review, Physician Orders for Res.#6 include: Azithromycin Ophthalmic Solution 1 % -Instill 1 drop in both eyes two times a day for Severe Blepharitis. [According to the Mayo Clinic: Blepharitis is inflammation of the eyelids that can cause irritation, redness, crusting and stickiness. Azithromycin ophthalmic solution belongs to a group of medicines called macrolide antibiotics and works by killing the bacteria causing the infection .To help clear up your eye infection completely, keep using this medicine for the full treatment time .Your infection may not clear up if you stop using the medicine too soon. Do not miss any doses.] (https://www.mayoclinic.org/diseases-conditions/blepharitis/symptoms-causes/syc-20370141) (https://www.mayoclinic.org/drugs-supplements/azithromycin-ophthalmic-route/description/drg-20070979) Review of the Medication Administration Record [MAR] of Res.#6 reveals the Azithromycin Ophthalmic Solution was not administered as ordered 7 times over 9 days [6/24/24 - 7/2/24] including 5 consecutive times over 3 days [6/24-6/26/24]. Nursing Notes regarding the missed doses record Medication not available, on order, medication unavailable, pharmacy sending tonight [later when the medication did not arrive] Medication not available, Not available, pharmacy is aware, no eyedrops available, reordered. Further review revealed no documentation that Res.#6's physician was notified that the eye medication was not given as ordered on any of the instances. An interview was conducted with a staff Registered Nurse [RN] on 7/30/24 at 8:14 AM. The RN stated that if the medication is not available through the medication cart or through the back up supply, Nursing notifies the provider that the ordered medication cannot be given as ordered and see if an alternative can be used or if the physician wants to hold or discontinue the medication. The RN reported that missing or unavailable medications are prompted to be documented in the medical record along with physician notification. The RN also stated that the pharmacy can be contacted through the resident's electronic medical record system and Nursing can call the pharmacy to confirm if a medication order was received. 2.) Per record review, Physician Orders for Res.#17 include: Erythromycin Ophthalmic Ointment- Instill 1 centimeter in both eyes two times a day for Blepharitis for 30 Days. [Blepharitis is inflammation of the eyelids that can cause irritation, redness, crusting and stickiness Erythromycin ophthalmic preparations are antibiotics used to treat infections of the eye.] (https://www.mayoclinic.org/drugs-supplements/erythromycin-ophthalmic-route/description/drg-20068673) Review of the Medication Administration Record [MAR] of Res.#17 reveals the Erythromycin Ophthalmic Ointment was not administered as ordered 9 times over 18 days [6/8-6/25/24], including 6 consecutive times over 3 days [6/23-6/25/24]. Nursing Notes regarding the missed doses record waiting for pharmacy, on order, Medication not available, eye ointment not available, reordered, Medication unavailable, Unavailable Pharmacy has been made aware, eyedrops unavailable. Further review revealed no documentation that Res.#17's physician was notified that the eye medication was not given as ordered on any of the instances. An interview was conducted with the Director of Nursing [DON] on 7/30/24 at 2:30 PM. The DON confirmed the Medication Administration Records [MARs] and progress notes of Res.#6 & #17 demonstrated multiple dates where medication was not given as ordered. Review of the facility's Medication Administration policy [2024] reads Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The DON further stated the facility's process is to contact the resident's provider for missed/unavailable medication[s]. Per review of the facility's Notification of Changes policy [2023], Circumstances requiring notification include: .circumstances that require a need to alter treatment. The DON confirmed the Medication Administration Records [MARs] and progress notes of Res.#6 & #17 demonstrated multiple dates where medication was unavailable and not given as ordered and the physician was not notified. Further record review revealed that regarding the missed medications between the two residents [Res.#6 & #17], five different nurses, including the DON, failed to administer medications as ordered and failed to notify the physician as required.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program related to behavioral health or trauma informed care and services, as determined by resident needs and the facility assessment for 7 of 8 sampled staff. Review of the 2024 Facility Assessment indicates that the facility has had 27 residents with the diagnosis of anxiety disorder, 37 residents with depression, 2 residents with manic depression, 2 residents with psychiatric disorder, and 1 resident with Post Traumatic Stress Disorder. Review of employee training and competency files revealed that 4 Licensed Nursing Assistants and 3 Registered Nurses had no documented evidence that they received behavioral health and trauma informed care training on hire or annually for 2024. During an interview on 7/31/24 at 12:31 PM the Director of Nursing (DON) confirmed that there was no documented evidence that staff had received behavior health or trauma informed care training. The facility Administrator was able to produce a training log for behavioral health and trauma completed on 7/27/23 however, only one of sampled staff members had attended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that resident environments were free of accident hazards related to safe handwashing water temperatures. Findings include: During unit observations on 7/29/2024 at 2:45 PM, the hot water was assessed from a faucet in an unlocked, common area bathroom, accessible to all residents. The water was too hot to hold a hand under comfortably, so a thermometer was used to take the temperature of the water. The highest reading was 124.1 degrees Fahrenheit (F). The sample was then expanded to include other common areas sinks and resident rooms. The left hallway sink read 121.8 degrees F, a right hallway sink read 121.7 degrees F, a second common area bathroom read 121.1 degrees F. The Resident in room [ROOM NUMBER] is independent with care and uses the bathroom for toileting and bathing. The water temperature in their bathroom sink read 123.4 degrees F. The above temperatures were confirmed by the facility Dietary Manager who was accompanying the surveyors at the time. Per interview with the facility Administrator (LNHA) on 7/29/24 at 3:45 PM there have been no issues with water temperatures throughout the facility. The LNHA was able to produce a water temperature monitoring log that that s/he maintains. There were no documented water temperatures above 119 degrees F. At 3:49 PM the water temperatures were rechecked by the surveyor and the LNHA using the thermometer that they use to monitor the water temperatures for the logs. The water temperature from the Hall 1 bathroom sink read 121.2 degrees F. Room number #7 read 123 degrees F, and the Hall 2 bathroom read 121.8. The LNHA confirmed all of the above water temperatures.

Based on observation, interview, and record review, the facility failed to ensure that food was stored in accordance with professional standards for food safety. The facility failed to document the temperatures of 1 of 3 freezers and the temperatures of 2 of 3 refrigerators, served food items to residents outside of the facility's standard for food temperatures, and failed to discard expired food items. Findings include: A Meat Freezer log was provided to surveyors. Per the facility's Equipment Temperature Log the accepted freezer temperature is -10 [degrees Fahrenheit] to 0 [degrees Fahrenheit]. In addition to one abnormal temperature of -12 [degrees Fahrenheit] recorded there was no month documented for the Meat Freezer log. An interview was conducted with the Dietary and Housekeeping Manager on 7/30/24 at 1:35 PM. The Dietary and Housekeeping Manager confirmed on 7/30/24 that there was no documentation identifying the month where temperature of -12 [degrees Fahrenheit] was recorded. The Dietary and Housekeeping Manager confirmed s/he did not know the month of the Meat Freezer log provided. Per the facility's Equipment Temperature Log the facility's accepted refrigerator temperatures are 33 [degrees Fahrenheit] to 41 [degrees Fahrenheit]. Per record review of the milk refrigerator for May 2024 revealed ten temperatures for the refrigerator that were below accepted limits. The milk refrigerator had abnormally high temperatures on 6/3/24 and 7/11/24 with no intervention documented. In addition to the milk refrigerator, the facility also utilizes what is labeled a Milk Cooler. Per record review of the Milk Cooler temperatures for May 2024, there were seventeen Milk Cooler temperatures that were abnormally low with no intervention corrective action documented on the Equipment Temperature Log. On 7/30/24 at 1:35 PM the Dietary and Housekeeping Manager confirmed that the temperatures of the milk refrigerator and milk cooler temperatures were out of the facility's accepted range for the internal temperature of the refrigerator. 2.) Per the facility's Temperature Log and Checklist, Ground entrees are to be 170 [degrees Fahrenheit]. Entrees, Meats, Starch, Soup, Vegetables should be at 160 [degrees Fahrenheit]. Per record review from March 2024 to July 2024 there were thirteen abnormally low temperatures for ground entrees. From March 2024 to July 2024 there were twelve entrees, and three vegetable temperatures documented that were below the accepted temperature. 3.) On 7/29/24 a facility assessment of the kitchen was conducted. Per observation, one of two freezers in the basement had thirty Magic Cup ice cream cups that were expired on 12/2/23. On 7/30/24 at 1:35 PM the Dietary and Housekeeping Manager confirmed the box of 30 Magic Cup ice cream cups that expired on 12/2/23 should have been discarded but were not.

Based on interview and record review, the facility failed to address in their facility assessment what the staff competencies that are necessary to provide the level and types of care needed for the resident population identified in the assessment. This deficient practice has the potential to affect all 20 residents residing in the facility. Findings include: Per review of the 2024 Facility Assessment does not indicate what specific competencies are necessary to provide care to the Residents who reside in the facility. The facility assessment also fails to indicate which competencies will be evaluated. Per interview on 7/31/24 at 2:37 PM with the Licensed Nursing Home Administrator (LNHA) the licensed staff are evaluated for competency during orientation and annually. Additional training is provided to staff when a skill is needed that is not something that they routinely care for. The LNHA confirmed that the facility assessment does not identify the specific training or competencies to be evaluated that are needed to provide care to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of five applicable residents of the sampled 16 residents (Resident #14) was free from any significant medication errors. Findings include: Per record review, Resident #14 was administered an incorrect dose of an ordered medication daily from 5/14/23-5/22/23. On 5/14/23 Resident #14 was admitted to the facility following a hospital stay for weakness/falls, additional diagnosis include myasthenia gravis (a neuromuscular disease) and congestive heart failure (weakened heart muscle). On 5/22/23 Resident #14 was acutely sent to the emergency room with swelling in the right hip and thigh and shortness of breath at rest as well as with exertion. Per hospitalist Discharge summary dated [DATE] although he had an exacerbation of this congestive heart failure on this dose of diuretics (medication to reduce fluid excess), suspect his prednisone may be contributing to fluid retention and may improve as prednisone is tapered. University of [NAME] discharge note indicated that he should resume his prior admission dose of 12.5 mg, taper to 12.5 mg by decreasing 5 mg every 3-4 days . During review of Resident #14's medications, it was noted that the hospital discharge orders dated 5/14/23 included Prednisone 5 milligram (mg) tablet take 2.5 tablets by mouth daily (this would equal a total of 12.5 mg daily). Per the facility medication administration record, Resident #14 had been administered 25 mg of prednisone daily from 5/15/23-5/22/23. Per interview with the Director of Nursing (DON) at 10:30 AM on 6/6/23, s/he was aware of this situation and stated, there was a transcription error on the dosing for prednisone and s/he was being given a double dose. It was clarified by the DON that the transcription error had occurred in the facility by the nurse on duty at the time. Based on corrective actions completed prior to the onsite, this citation is designated as past non-compliance. Following the incident, the Interdisciplinary Team Members (IDT) met to discuss the incident and completed the following corrective actions. 1. Re-education with all nurses was conducted regarding the transcription of orders. 2. A triple check of orders is conducted by the nurse doing the transcription and two other nurses. The DON receives confirmation of the triple check having been done on all new orders. 3. A change in workflow was made regarding transmitting orders to the pharmacy. In place of sending the transcribed orders the pharmacy receives a copy of the orders as originally written by the provider. 4. This specific error was discussed by the quality team (QAPI) and medication errors remain on the monthly QAPI meeting schedule.