Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was safe to self-administer a medication for one of 28 residents in the survey sample, Resident #169. The findings include: For Resident #169 (R169), the facility staff failed to complete an assessment to determine if the resident was safe to self-administer a nebulizer medication. A review of R169's clinical record revealed a physician's order dated 8/13/24 for ipratropium 0.5 mg (milligrams)-albuterol (1) 3 mg- 3 ml (milliliters) via nebulization two times per day for aspiration pneumonia. On 8/20/24 at 8:56 a.m., R169 was observed holding a mask to his face and self-administering a nebulizer medication. On 8/21/24 at 10:27 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the nurses complete a self-assessment form for residents who self-administer medications. RN #1 stated the self-assessment consists of determining if the resident is alert and oriented, and determining if it is safe for the resident to self-administer medications. On 8/21/24 at 1:22 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Self-Administered Medications--HCC (Health Care Center) documented, It is the responsibility of the Interdisciplinary Team to determine that it is safe for a resident residing in HCC to self-administer medications before the resident may exercise that right. Assessment will be documented on the EHR (Electronic Health Record). No further information was presented prior to exit. Reference: (1) Ipratropium-albuterol inhalation solution is used to treat lung diseases. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000006.htm.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the baseline care plan for one of 28 residents in the survey sample, Resident #169. The findings include: For Resident #169, the facility staff failed to implement the resident's baseline care plan for a fall mat. R169's baseline care plan dated 8/9/24 documented, (R169) will remain safe during treatments and care while in the facility. (A) (R169) needs these safety measures: Floor Mat x1 . A review of R169's clinical record revealed a physician's order dated 8/9/24 that documented, Fall mat x1. On 8/20/24 at 8:56 a.m., 8/20/24 at 3:39 p.m., and 8/21/24 at 8:47 a.m., R169 was observed lying in bed. There was no fall mat down on either side of the bed. A fall mat was observed folded up, against the wall. On 8/21/24 at 10:27 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the purpose of the care plan is to track treatments, so residents have better care. RN #1 stated any nurse has access to the care plan to make sure it is being implemented. RN #1 stated fall mats are used because if a resident falls, the impact is going to be less. RN #1 stated a resident's need for fall mats is communicated to nurses via physicians' orders and also shows up in the CNAs' (certified nursing assistants') computer system too. On 8/21/24 at 1:22 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Care Plans- Baseline documented, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews facility document review and clinical record review, it was determined the facility staff failed to implement the care plan for two of 28 residents in the survey sample, Resident #53 and Resident #319. The findings include: 1. The facility staff failed to implement the comprehensive care plan for anticoagulation monitoring for Resident #53. Resident #53 was admitted to the facility on [DATE] with diagnosis that included but were not limited to toxic hyponatremia, CHF (congestive heart failure), CKD (chronic kidney disease and atrial fibrillation. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/25/24, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and eating. A review of the comprehensive care plan dated 6/7/24 revealed, FOCUS: Resident is at risk for complications from blood thinning medication: Eliquis for atrial fibrillation. INTERVENTSIONS: Monitor for presence or absence of signs of hemorrhage under the skin, oral mucosa, and/or conjunctiva, active bleeding, bloody stools, declining hemoglobin and hematocrit. Notify physician if side effects noted. A review of the physician orders dated 5/20/24 revealed, Eliquis 5 milligram twice a day. A review of the MAR (medication administration record) for June, July and August revealed that Eliquis 5 milligram twice a day was administered. No evidence of anticoagulation side effect monitoring was found. An interview was conducted on 8/21/24 at 10:00 AM with Resident #53, when asked if they are monitoring her for bleeding/bruising, Resident #53, stated, no, not that I know of. An interview was conducted on 8/21/24 at 10:25 AM with LPN (licensed practical nurse) #2. When asked where evidence of anticoagulation side effect monitoring was located, LPN #2 stated, we look for the side effects, but there is nowhere to document it in this system. When asked if the care plan had been implemented, LPN #2 stated, no, it was not. On 8/21/24 at 1:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and LPN (licensed practical nurse) #1, the infection prevention nurse was made aware of the finding. The facility's Care Plan, Comprehensive Person Centered policy revealed the following, The comprehensive, person-centered care plan includes measurable objectives and timeframes; reflects currently recognized standards of practice for problem areas and conditions. No further information was provided prior to exit. 2. The facility staff failed to implement the comprehensive care plan for anticoagulation monitoring for Resident #319. Resident #319 was admitted to the facility on [DATE] with diagnosis that included but were not limited to venous thrombosis, hypertension and gout. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 8/5/24, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/toileting and supervision for bed mobility, transfer, dressing and eating. A review of the comprehensive care plan dated 8/16/24 revealed, FOCUS: Resident is at risk for complications from blood thinning medication: Eliquis for post-surgery, fracture of femur and history of venous thrombosis. INTERVENTSIONS: Monitor for presence or absence of signs of hemorrhage under the skin, oral mucosa, and/or conjunctiva, active bleeding, bloody stools, declining hemoglobin and hematocrit. Notify physician if side effects noted. A review of the physician orders dated 7/29/24 revealed, Eliquis 2.5 milligram twice a day for deep vein thrombosis. A review of the MAR (medication administration record) for July and August revealed that Eliquis 2.5 milligram twice a day was administered. No evidence of anticoagulation side effect monitoring was found. An interview was conducted on 8/21/24 at 10:10 AM with Resident #319, when asked if they are monitoring him for bleeding/bruising, Resident #319, stated, they may be. I do not really know and do not have much healthcare knowledge. An interview was conducted on 8/21/24 at 10:25 AM with LPN (licensed practical nurse) #2. When asked where evidence of anticoagulation side effect monitoring was located, LPN #2 stated, we look for the side effects, but there is nowhere to document it in this system. When asked if the care plan had been implemented, LPN #2 stated, no, it was not. On 8/21/24 at 1:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and LPN (licensed practical nurse) #1, the infection prevention nurse was made aware of the finding. The facility's Care Plan, Comprehensive Person Centered policy revealed the following, The comprehensive, person-centered care plan includes measurable objectives and timeframes; reflects currently recognized standards of practice for problem areas and conditions. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement a fall intervention for one of 28 residents in the survey sample, Resident #169. The findings include: For Resident #169 (R169), the facility staff failed to implement a physician ordered floor mat. A review of R169's clinical record revealed a physician's order dated 8/9/24 that documented, Fall mat x1. On 8/20/24 at 8:56 a.m., 8/20/24 at 3:39 p.m., and 8/21/24 at 8:47 a.m., R169 was observed lying in bed. There was no fall mat down on either side of the bed. A fall mat was observed folded up, against the wall. On 8/21/24 at 10:27 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated fall mats are an intervention used in the facility. RN #1 stated fall mats are used because if a resident falls, the impact is going to be less. RN #1 stated a resident's need for fall mats is communicated to nurses via physicians' orders and also shows up in the CNAs' (certified nursing assistants') computer system too. On 8/21/24 at 1:22 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Fall Protocol documented, It is the policy of (name of facility) to provide an environment that is free from fall and accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents and injuries .Implementation includes communicating the interventions to all relevant staff, assigning responsibility, providing training as needed, documenting interventions and ensuring the interventions are put into place. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide respiratory care and services for one of 28 residents in the survey sample, Resident #169. The findings include: For Resident #169 (R169), the facility staff failed to store an incentive spirometer in a sanitary manner. A review of R169's clinical record revealed an admission nursing assessment dated [DATE] that documented the resident was oriented. Further review of R169's clinical record revealed a physician's order dated 8/15/24 for an incentive spirometer three times a day. On 8/20/24 at 8:56 a.m., an uncovered incentive spirometer with the mouthpiece exposed to air was observed sitting on R169's overbed table. On 8/20/24 at 3:39 p.m., an incentive spirometer with the mouthpiece exposed to air was observed sitting on R169's bed. R169 stated he uses the incentive spirometer whenever he can, and he has not been offered a bag or covering for it. On 8/21/24 at 8:47 a.m., an uncovered incentive spirometer with the mouthpiece exposed to air was observed sitting on R169's overbed table. On 8/21/24 at 10:27 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated an incentive spirometer should be stored in a Ziplock bag to avoid any microbes and protect it, so it's not exposed to germs. On 8/21/24 at 1:22 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Oxygen Administration, Storage, & Safety documented, 11. Incentive Spirometer. b. After each use, clean the mouthpiece and place the spirometer and mouthpiece in a plastic bag within the resident's reach. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure residents were free of unnecessary medications for two of 28 residents in the survey sample, Resident #53 and Resident #319. The findings include: The facility staff failed to ensure Resident #53 and Resident #319 were free from unnecessary meds by providing monitoring for anticoagulation side effects. 1. Resident #53 was admitted to the facility on [DATE] with diagnosis that included but were not limited to toxic hyponatremia, CHF (congestive heart failure), CKD (chronic kidney disease and atrial fibrillation. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/25/24, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and eating. A review of the comprehensive care plan dated 6/7/24 revealed, FOCUS: Resident is at risk for complications from blood thinning medication: Eliquis for atrial fibrillation. INTERVENTSIONS: Monitor for presence or absence of signs of hemorrhage under the skin, oral mucosa, and/or conjunctiva, active bleeding, bloody stools, declining hemoglobin and hematocrit. Notify physician if side effects noted. A review of the physician orders dated 5/20/24 revealed, Eliquis 5 milligram twice a day. A review of the MAR (medication administration record) for June, July and August revealed that Eliquis 5 milligram twice a day was administered. No evidence of anticoagulation side effect monitoring was found. An interview was conducted on 8/21/24 at 10:00 AM with Resident #53, when asked if they are monitoring her for bleeding/bruising, Resident #53, stated, no, not that I know of. An interview was conducted on 8/21/24 at 10:25 AM with LPN (licensed practical nurse) #2. When asked where evidence of anticoagulation side effect monitoring was located, LPN #2 stated, we look for the side effects, but there is nowhere to document it in this system. On 8/21/24 at 1:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and LPN (licensed practical nurse) #1, the infection prevention nurse was made aware of the finding. The facility's Anticoagulation-Clinical Protocol policy revealed the following, The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. No further information was provided prior to exit. 2. Resident #319 was admitted to the facility on [DATE] with diagnosis that included but were not limited to venous thrombosis, hypertension and gout. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 8/5/24, coded the resident as scoring a 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/toileting and supervision for bed mobility, transfer, dressing and eating. A review of the comprehensive care plan dated 8/16/24 revealed, FOCUS: Resident is at risk for complications from blood thinning medication: Eliquis for post-surgery, fracture of femur and history of venous thrombosis. INTERVENTSIONS: Monitor for presence or absence of signs of hemorrhage under the skin, oral mucosa, and/or conjunctiva, active bleeding, bloody stools, declining hemoglobin and hematocrit. Notify physician if side effects noted. A review of the physician orders dated 7/29/24 revealed, Eliquis 2.5 milligram twice a day for deep vein thrombosis. A review of the MAR (medication administration record) for July and August revealed that Eliquis 2.5 milligram twice a day was administered. No evidence of anticoagulation side effect monitoring was found. An interview was conducted on 8/21/24 at 10:10 AM with Resident #319, when asked if they are monitoring him for bleeding/bruising, Resident #319, stated, they may be. I do not really know and do not have much healthcare knowledge. An interview was conducted on 8/21/24 at 10:25 AM with LPN (licensed practical nurse) #2. When asked where evidence of anticoagulation side effect monitoring was located, LPN #2 stated, we look for the side effects, but there is nowhere to document it in this system. On 8/21/24 at 1:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and LPN (licensed practical nurse) #1, the infection prevention nurse was made aware of the finding. The facility's Anticoagulation-Clinical Protocol policy revealed the following, The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide monitoring for fluid restriction and intake for one of 28 residents, Resident #53. The findings include: The facility failed to provide monitoring for fluid restriction and intake for Resident #53. Resident #53 was admitted to the facility on [DATE] with diagnosis that included but were not limited to toxic hyponatremia, CHF (congestive heart failure), CKD (chronic kidney disease and atrial fibrillation. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/25/24, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bathing/transfer/dressing/toileting and eating. A review of the comprehensive care plan dated 6/7/24 revealed, FOCUS: Resident has a potential for fluid imbalance related to CHF. INTERVENTIONS: Administer medications per orders, assess for edema, abnormal breath sounds and advise physician as needed. A review of the physician orders dated 6/27/24 revealed, 1500 milliliter fluid restriction daily. A review of the June, July and August MAR-TAR (medication administration record-treatment administration record) revealed 1500 milliliter fluid restriction at 7:00 AM, 3:00 PM and 12:00 AM, with initials by each shift. There was no specification of amounts of fluids designated for each shift, nor any specific allocation of amount to dietary. An interview was conducted on 8/21/24 at 10:25 AM with LPN (licensed practical nurse) #2. When asked where evidence of fluid restriction/intake monitoring was located, LPN #2 stated, we have taken her water pitcher out of her room and give her multiple medications with applesauce. We do not have any specific documentation place for amounts. On 8/21/24 at 1:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and LPN (licensed practical nurse) #1, the infection prevention nurse was made aware of the finding. On 8/21/24 at approximately 1:55 PM, ASM #1 stated, we do not have fluid restriction amounts documented, but we do weigh her daily. ASM #2 stated, we started working on this yesterday 8/20/24. The facility's Intake/Output policy revealed the following, It is the facility policy to maintain accurate fluid intake and output amounts on a resident who is on fluid restriction or as a nursing measure for assessing hydration. No further information was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain one of one kitchen in a sanitary manner. The findings include: On 8/20/24 at 7:25 AM, an observation was conducted in the main kitchen. Two employees were observed coming from the kitchen without hair nets, OSM (other staff member) #3, the cook and OSM #5, dining services. When told I was there for the kitchen inspection and requested a hair net, OSM #3, the cook, went back into the kitchen to obtain a hair net. OSM #3 put a hairnet on at this time. Hair nets were located inside the kitchen and around a corner near another entrance, but not outside of the kitchen area. During the inspection of the dry storage room, OSM #4, dining services, came into the dry storage room. When asked about her hair covering, OSM #4 stated, I do not work in the kitchen. When asked if you are in the kitchen are you to wear a hair net, she stated, yes, I should have one on. OSM #5 was observed back in the kitchen without hair net and at 7:45 AM, OSM #5 was coming back into the kitchen and when asked if there were any items she was to wear in the kitchen, OSM #5 stated, yes, a hair net. I am going to go get one now. I just got to work. On 8/20/24 at 7:40 AM, flowers were observed in the 'dessert' refrigerator. On 8/20/24 at 10:20 AM, on second trip to the kitchen, OSM #7, the executive staff introduced herself. I asked her to come with me to the 'dessert' refrigerator and asked her about the flowers stored with the food. OSM #7 stated, they just are there for a short while, they are for the table vases. I informed OSM #7, that I had observed them at 7:40 AM in the refrigerator, OSM #7 stated, I will have them moved now. On 8/21/24 at 1:05 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and LPN (licensed practical nurse) #1, the infection prevention nurse was made aware of the finding. The facility's Dining Services-Personal Appearance and Personal Hygiene policy revealed the following, Hair coverings will be worn at all times while working in the kitchen. No further information was provided prior to exit.

Based on observation, staff interview and facility document review, it was determined the facility staff failed to store food in a sanitary manner in one of one main kitchens. The findings include: Observation was made of the main kitchen on 4/25/2023 at 11:00 a.m. accompanied by OSM (other staff member) #1, the registered dietitian/manager, and OSM #2, the executive chef. The walk-in freezer contained a plastic box approximately two feet long and one foot wide. It contained chopped frozen carrots. There were two blue plastic bags in the box. The carrots were sitting in the box, not in plastic. There was no lid on the box so the carrots in the box were exposed to air. OSM #1 stated she believed they had just taken some carrots out of the box for the lunch meal soup. The lid was not in the freezer. When asked if it should be covered, OSM #2 stated, yes. The dry storage area contained a large plastic white container with a lid. The container contained brown rice in it. There was a scoop in the container with the handle touching the rice. OSM #1 stated, the scoop must have fallen out of the slot for it. When asked if the scoop should be in the rice, OSM #1 stated, no. The facility policy, Storage of Food Products, documented in part, All food will be covered, labeled and dated when stored. OSM #1 presented another policy, Safe Food Handling, and stated this was the only thing she could find about the scoop needing to be out of the stored product. The policy documented in part, Safe storage: the safe sanitation of counters, cutting boards, and utensils, and proper cooking temperatures are all important factors in the prevention of food-borne disease. ASM (administrative staff member) #1, the associate executive director, was made aware of the above concern on 4/26/2023 at 2:44 p.m. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to notify the physician of a potential need to alter treatment for one of 29 residents in the survey sample, Resident #11. The facility staff failed to notify the physician (or nurse practitioner) when the physician ordered medication divalproex (1) was not available for administration to Resident #11 on 10/1/21, 10/2/21 and 10/3/21. The findings include: Resident #11 was admitted to the facility on [DATE]. Resident #11's diagnoses included but were not limited to dementia, major depressive disorder and high blood pressure. Resident #11's quarterly minimum data set with an assessment reference date of 8/3/21, coded the resident's cognitive skills for daily decision making as severely impaired. Review of Resident #11's clinical record revealed a physician's order dated 9/30/21 for divalproex 250 mg (milligrams) - two tablets (500 mg) three times a day for Alzheimer's dementia. Review of Resident #11's October 2021 MAR (medication administration record) revealed a physician's order dated 9/30/21 for divalproex 250 mg- two tablets three times a day. Further review of the October 2021 MAR revealed the medication was not administered to Resident #11 at all on 10/1/21 or 10/2/21, and twice on 10/3/21. A nurse's note dated 9/30/21 documented Resident #11 was refusing divalproex 500mg tablets because the tablets were too big. The note further documented a new order was received for divalproex 250mg- two tablets three times a day. A late entry nurse's note dated 10/2/21 for 10/1/21 documented, On 10/1/2021, late entry; divalproex medications, was not delivered; and a call was placed to pharmacy staff; spoke to (name) who stated that divalproex meds [medications] was re-ordered too soon. Writer-nurse related that dosage was changed to 250mg; to give 2 tabs three times a day and that divalproex 500 mg has been discontinued, and on med card next re-order date will be 10/7/2021. She said resident's insurance will not pay or process it at this time. Shift supervisor made aware to notify MD (medical doctor). A nurse's note dated 10/2/21 documented, Divalproex medications, still not delivered; shift supervisor updated . Further review of nurses' notes dated 10/1/21, 10/2/21 and 10/3/21 failed to reveal the physician or nurse practitioner was made aware divalproex was not administered to Resident #11 on those dates. Review of the facility STAT box (a box containing various medications) list revealed three tablets of divalproex 250 mg was available in the box. On 11/4/21 at 10:24 a.m., an interview was conducted with RN (registered nurse) #1, the nurse who documented the 10/1/21 and 10/2/21 notes, regarding the process staff follows for medications that are not available for administration. RN #1 stated nurses should check the STAT box for the medication and take the medication from there if available. RN #1 stated nurses should call the pharmacy if the medication is not available in the STAT box. RN #1 stated the shift supervisor is responsible for notifying the physician when an ordered medication is not administered. In regards to the above notes, RN #1 stated Resident #11 was complaining that she could not swallow divalproex 500 mg pills so the physician's order was changed to two tablets of divalproex 250 mg. RN #1 stated divalproex 250 mg tablets for Resident #11 had not arrived on 10/1/21 so she called the pharmacy. RN #1 stated the pharmacy staff said they had already sent divalproex 500 mg tablets and for insurance purposes the medication could not be sent until a specific date. RN #1 stated she told the pharmacy staff the dose had changed then she reported the situation to the shift supervisor. RN #1 stated she did not check the STAT box for divalproex 250 mg tablet because she thought the last time she looked, the medication was not available in the STAT box. On 11/4/21 at 10:48 a.m., a telephone interview was conducted with RN #2, the shift supervisor RN #1 stated she reported to. RN #1 stated Resident #11 was refusing divalproex 500 mg tablets so she told the nurse practitioner who changed the medication to a smaller dose then the pharmacy sent the medication. RN #2 stated she did not know when the pharmacy sent the medication. RN #2 stated she remembered RN #1 making her aware the 500 mg tablet was too big for Resident #11 but she did not recall RN #1 making her aware the pharmacy would not send the 250 mg tablets so she did not notify the physician. RN #2 stated the medication was in the STAT box and RN #1 could have obtained it from there. On 11/4/21 at 11:25 a.m., ASM (administrative staff member) #1 (the director of nursing) and ASM #2 (the administrator) were made aware of the above concern. The facility pharmacy policy titled, 7.0 Medication Shortages/Unavailable Medications documented, If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions. No further information was presented prior to exit. Reference: (1) Divalproex is used to treat seizures, mania and prevent migraine headaches. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682412.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility document review, it was determined that the facility staff failed to maintain a safe and homelike environment for one of 57 resident rooms on the health care unit, room [ROOM NUMBER]. The facility staff failed to maintain the carpet in room [ROOM NUMBER] in good repair. The findings include: On 11/3/2021 at 1:24 p.m., an observation was made of current resident rooms in the facility. Observation of room [ROOM NUMBER] revealed the current resident lying in bed asleep, a carpet covered the bedroom floor. The carpet leading from the doorway to the resident bed was observed to have visible buckling in two areas near the center of the carpet. Additional observations on 11/4/2021 at 8:25 a.m. revealed the findings above. On 10/4/2021 at 10:15 a.m., an interview was conducted with CNA (certified nursing assistant) #3. CNA #3 stated that they reported any environmental repairs needed to their environmental services department by telephone. CNA #3 stated that they also reported any repairs or issues to the nurse assigned to the area. CNA #3 stated that the maintenance and housekeeping departments were in the same area. CNA #3 stated that any buckling in the carpet was reported right away because it was a safety hazard for the residents, the staff and visitors. CNA #3 stated that buckling carpet did not make rooms look homelike. On 10/4/2021 at 10:20 a.m., an interview was conducted with CNA #2. CNA #2 stated that they reported any environmental problems to environmental services and they would come up to fix things. CNA #2 stated that they had a few areas on the unit with the carpet buckling. CNA #2 stated that they knew the environmental services department was notified of the carpet buckling about a week ago and they had come up to look at it. CNA #2 stated that they knew that they had to schedule people from the outside to come in to fix the areas. CNA #2 stated that the carpet buckling could be a hazard for falls or tripping. On 10/4/2021 at 10:25 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they reported any repairs needed to the environmental services department and put in a help ticket for them to assess the issue. LPN #1 stated that someone had been up to assess the carpet and advised them that they were going to have to replace it all but they did not remember exactly when they came. LPN #1 observed the buckled carpet in room [ROOM NUMBER] and stated that the carpet in the room was already planned to be replaced. LPN #1 stated that the buckled carpet was a potential safety hazard for residents, staff and visitors. On 11/4/2021 at 11:10 a.m., an interview was conducted with OSM (other staff member) #3, director of facilities management. OSM #3 stated that they had a designated staff member who conducted all of the inspections and rounded on the unit to observe any environmental problems. OSM #3 stated that they were in the process of replacing all of the carpet and wallpaper on the unit. OSM #3 stated that staff placed work orders for them for any environmental concerns for them to assess and repair. OSM #3 stated that they were unsure if there were any active work orders for room [ROOM NUMBER] but they would check on it. OSM #3 stated that when they find problems with the carpet buckling they contacted the carpet company who would come out to flatten out the areas for them until they could replace the carpet. OSM #3 observed the carpet in room [ROOM NUMBER] and stated that the buckling could be a trip hazard for residents and staff. At that time a request was made to OSM #3 for documentation of any active work orders for the buckled carpet in room [ROOM NUMBER] and the progress for repairs in place. On 11/4/2021 at 11:54 a.m., ASM (administrative staff member) #2, the director of nursing stated that they were notified by maintenance that a contractor would be coming today to repair the carpet in room [ROOM NUMBER]. ASM #2 stated that there was not any evidence of a work order or any repairs for room [ROOM NUMBER] prior to today. On 11/4/2021 at approximately 1:37 p.m., a request was made to ASM #2 for the facility policy for maintaining a homelike environment. The facility policy, Homelike Environment dated February 2021 documented in part, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible . On 11/4/2021 at 1:55 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide notification of a hospital transfer for one of 29 residents in the survey sample, Resident #62. Resident #62 was transferred to the hospital on 9/24/21. The facility staff failed to provide notification of the transfer to the ombudsman. The findings include: Resident #62 was admitted to the facility on [DATE]. Resident #62's diagnoses included but were not limited to muscle weakness, joint disorders of the right hand and joint disorders of the left hand. There was no minimum data set assessment completed for Resident #62. An admission nursing assessment dated [DATE] documented the resident was disoriented to time. Review of Resident #62's clinical record revealed the resident was transferred to the hospital on 9/22/21 due to a fever and status post hip repair a week before that date. Further review of Resident #62's clinical record failed to reveal the facility provided notice of the transfer to the ombudsman. On 11/4/21 at 1:30 p.m., an interview was conducted with OSM (other staff member) #1 (social worker). OSM #1 stated that typically she receives resident transfer paperwork from the assistant director of nursing, faxes transfer notification to the ombudsman and keeps a copy of the fax confirmation. OSM #1 stated she could not find a fax confirmation to evidence the ombudsman was notified regarding Resident #62's transfer to the hospital on 9/22/21. On 11/4/21 at 1:37 p.m., ASM (administrative staff member) #1 (the director of nursing) was made aware of the above concern. The facility policy titled, Facility-Initiated Transfer (Hospital) Required Documentation for HCC (health care center) Residents documented, 6. The Social Worker is responsible for notifying the State Ombudsman of facility-initiated transfers . No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure treatment and care in accordance with professional standards of practice, and the comprehensive plan of care for one of 29 residents in the survey sample, Resident #11. The facility staff failed to administer the physician ordered medication divalproex (1) to Resident #11 on 10/1/21, 10/2/21 and 10/3/21. The findings include: Resident #11 was admitted to the facility on [DATE]. Resident #11's diagnoses included but were not limited to dementia, major depressive disorder and high blood pressure. Resident #11's quarterly minimum data set with an assessment reference date of 8/3/21, coded the resident's cognitive skills for daily decision making as severely impaired. Review of Resident #11's clinical record revealed a physician's order dated 9/30/21 for divalproex 250 mg (milligrams) - two tablets (500 mg) three times a day for Alzheimer's dementia. Review of Resident #11's October 2021 MAR (medication administration record) revealed a physician's order dated 9/30/21 for divalproex 250 mg- two tablets three times a day. Further review of the October 2021 MAR revealed the medication was not administered to Resident #11 at all on 10/1/21 or 10/2/21, and twice on 10/3/21. Resident #11's comprehensive care plan with a start date of 8/13/21 failed to document specific information regarding divalproex administration. A nurse's note dated 9/30/21 documented Resident #11 was refusing divalproex 500mg tablets because the tablets were too big. The note further documented a new order was received for divalproex 250mg- two tablets three times a day. A late entry nurse's note dated 10/2/21 for 10/1/21 documented, On 10/1/2021, late entry; divalproex medications, was not delivered; and a call was placed to pharmacy staff; spoke to (name) who stated that divalproex meds was re-ordered too soon. Writer-nurse related that dosage was changed to 250mg; to give 2 tabs three times a day and that divalproex 500 mg has been discontinued, and on med card next re-order date will be 10/7/2021. She said resident's insurance will not pay or process it at this time. Shift supervisor made aware to notify MD (medical doctor). A nurse's note dated 10/2/21 documented, Divalproex medications, still not delivered; shift supervisor updated . Review of the facility STAT box (a box containing various medications) list revealed three tablets of divalproex 250 mg was available in the box. On 11/4/21 at 10:24 a.m., an interview was conducted with RN (registered nurse) #1 (the nurse who documented the 10/1/21 and 10/2/21 notes), regarding the process for medications that are not available for administration. RN #1 stated nurses should check the STAT box for the medication and take the medication from there if available. RN #1 stated nurses should call the pharmacy if the medication is not available in the STAT box. In regards to the above notes, RN #1 stated Resident #11 was complaining that she could not swallow divalproex 500 mg pills so the physician's order was changed to two tablets of divalproex 250 mg. RN #1 stated divalproex 250 mg tablets for Resident #11 had not arrived on 10/1/21 so she called the pharmacy. RN #1 stated the pharmacy staff said they had already sent divalproex 500 mg tablets and for insurance purposes the medication could not be sent until a specific date. RN #1 stated she told the pharmacy staff the dose had changed then she reported the situation to the shift supervisor. RN #1 stated she did not check the STAT box for divalproex 250 mg tablet because she thought the last time she looked, the medication was not available in the STAT box. On 11/4/21 at 10:48 a.m., a telephone interview was conducted with RN #2 (the shift supervisor RN #1 stated she reported to). RN #1 stated Resident #11 was refusing divalproex 500 mg tablets so she told the nurse practitioner who changed the medication to a smaller dose then the pharmacy sent the medication. RN #2 stated she did not know when the pharmacy sent the medication. RN #2 stated she remembered RN #1 making her aware the 500 mg tablet was too big for Resident #11 but she did not recall RN #1 making her aware the pharmacy would not send the 250 mg tablets. RN #2 stated the medication was in the STAT box and RN #1 could have obtained it from there. On 11/4/21 at 11:25 a.m., ASM (administrative staff member) #1 (the director of nursing) and ASM #2 (the administrator) were made aware of the above concern. ASM #1 stated the current STAT box list (that documented divalproex 250 mg tablets were in the box) held the same contents during the beginning of October 2021. The facility pharmacy policy titled, 7.0 Medication Shortages/Unavailable Medications documented, 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy . No further information was presented prior to exit. Reference: (1) Divalproex is used to treat seizures, mania and prevent migraine headaches. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682412.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility document review, it was determined that the facility staff failed to ensure a safe environment free of accident hazards in one of 57 resident rooms on the health care unit, room [ROOM NUMBER]. The facility staff failed to maintain the carpet in room [ROOM NUMBER] in good repair. The findings include: On 11/3/2021 at 1:24 p.m., an observation was made of current resident rooms in the facility. Observation of room [ROOM NUMBER] revealed the current resident lying in bed asleep, a carpet covered the bedroom floor. The carpet leading from the doorway to the resident bed was observed to have visible buckling in two areas near the center of the carpet. Additional observations on 11/4/2021 at 8:25 a.m. revealed the findings above. On 10/4/2021 at 10:15 a.m., an interview was conducted with CNA (certified nursing assistant) #3. CNA #3 stated that they reported any environmental repairs needed to their environmental services department by telephone. CNA #3 stated that they also reported any repairs or issues to the nurse assigned to the area. CNA #3 stated that the maintenance and housekeeping departments were in the same area. CNA #3 stated that any buckling in the carpet was reported right away because it was a safety hazard for the residents, the staff and visitors. On 10/4/2021 at 10:20 a.m., an interview was conducted with CNA #2. CNA #2 stated that they reported any environmental problems to environmental services and they would come up to fix things. CNA #2 stated that they had a few areas on the unit with the carpet buckling. CNA #2 stated that they knew the environmental services department was notified of the carpet buckling about a week ago and they had come up to look at it. CNA #2 stated that they knew that they had to schedule people from the outside to come in to fix the areas. CNA #2 stated that the carpet buckling could be a hazard for falls or tripping. On 10/4/2021 at 10:25 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they reported any repairs needed to the environmental services department and put in a help ticket for them to assess the issue. LPN #1 stated that someone had been up to assess the carpet and advised them that they were going to have to replace it all but they did not remember exactly when they came. LPN #1 observed the buckled carpet in room [ROOM NUMBER] and stated that the carpet in the room was already planned to be replaced. LPN #1 stated that the buckled carpet was a potential safety hazard for residents, staff and visitors. On 11/4/2021 at 11:10 a.m., an interview was conducted with OSM (other staff member) #3, director of facilities management. OSM #3 stated that they had a designated staff member who conducted all of the inspections and rounded on the unit to observe any environmental problems. OSM #3 stated that they were in the process of replacing all of the carpet and wallpaper on the unit. OSM #3 stated that staff placed work orders for them for any environmental concerns for them to assess and repair. OSM #3 stated that they were unsure if there were any active work orders for room [ROOM NUMBER] but they would check on it. OSM #3 stated that when they find problems with the carpet buckling they contacted the carpet company who would come out to flatten out the areas for them until they could replace the carpet. OSM #3 observed the carpet in room [ROOM NUMBER] and stated that the buckling could be a trip hazard for residents and staff. At that time a request was made to OSM #3 for documentation of any active work orders for the buckled carpet in room [ROOM NUMBER] and the progress for repairs in place. On 11/4/2021 at 11:54 a.m., ASM (administrative staff member) #2, the director of nursing stated that they were notified by maintenance that a contractor would be coming today to repair the carpet in room [ROOM NUMBER]. ASM #2 stated that there was not any evidence of a work order or any repairs for room [ROOM NUMBER] prior to today. On 11/4/2021 at 1:55 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and clinical record review, it was determined that the facility staff failed to store respiratory equipment in a clean and sanitary manner for two of 29 residents in the survey, Residents #1 and #26. The findings include: 1. The facility staff failed to store Resident #1's incentive spirometers (1) in a clean and sanitary manner. Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses included but were not limited to chronic kidney disease, acute respiratory failure and high cholesterol. Resident #1's five day Medicare assessment with an assessment reference date of 6/14/21, coded the resident as being cognitively intact. Review of Resident #1's clinical record revealed a physician's order dated 10/18/21 for incentive spirometry use every shift. Resident #1's comprehensive care plan with a start date of 10/27/21 failed to document information regarding the storage of an incentive spirometer. On 11/3/21 at 12:32 p.m., an uncovered incentive spirometer was observed on Resident #1's over bed table and another incentive spirometer was observed on the resident's nightstand. Both incentive spirometers were uncovered and the mouth pieces were exposed. On 11/3/21 at 2:09 p.m., an interview was conducted with Resident #1. The resident stated he uses the incentive spirometers multiple times each day. On 11/3/21 at 4:31 p.m., both incentive spirometers remained uncovered with the mouth pieces exposed. On 11/4/21 at 9:57 a.m., another interview was conducted with Resident #1. The resident stated no employee had ever offered a bag or anything else to cover the incentive spirometers. On 11/4/21 at 10:24 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated incentive spirometers should be stored in a plastic bag to prevent contamination from dirt, germs and bacteria. On 11/4/21 at 11:25 a.m., ASM (administrative staff member) #1 (the director of nursing) and ASM #2 (the administrator) were made aware of the above concern. The facility policies titled, Oxygen Administration & Safety and Oxygen Storage in Nursing Areas failed to document information regarding the storage of incentive spirometers. No further information was presented prior to exit. Reference: (1) An incentive spirometer is A device used to help you keep your lungs healthy. Using the incentive spirometer teaches you how to take slow deep breaths. This information was obtained from the website:https://medlineplus.gov/ency/patientinstructions/000451.htm 2. The facility staff failed to Resident #26's oxygen tubing/nasal cannula (1) in a clean and sanitary manner. Resident #26 was admitted to the facility on [DATE]. Resident #26's diagnoses included but were not limited to chronic obstructive pulmonary disease (lung disease), urinary tract infection and chronic kidney disease. Resident #26's quarterly minimum data set assessment with an assessment reference date of 8/31/21, coded the resident's cognition as severely impaired. Review of Resident #26's clinical record revealed a physician's order dated 6/1/21 for continuous oxygen at three liters per minute via nasal cannula. Resident #26's comprehensive care plan with a start date of 9/9/21 failed to document information regarding the storage of oxygen tubing. On 11/3/21 at 12:35 p.m., Resident #26 was out of the room. The oxygen tubing/nasal cannula connected to the oxygen concentrator was uncovered and was hanging over the arm rest of a chair. On 11/3/21 at 1:42 p.m., Resident #26 was in a wheel chair in the room receiving oxygen from tubing via a portable tank. The oxygen tubing/nasal cannula connected to the oxygen concentrator was uncovered and laying on the bed. On 11/3/21 at 1:49 p.m., an employee entered Resident #26's room, assisted the resident with combing her hair and exited the room. On 11/3/21 at 1:51 p.m., the oxygen tubing/nasal cannula remained uncovered on the bed. On 11/4/21 at 10:24 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated oxygen tubing should be stored in a plastic bag to prevent contamination from dirt, germs and bacteria. On 11/4/21 at 11:25 a.m., ASM (administrative staff member) #1 (the director of nursing) and ASM #2 (the administrator) were made aware of the above concern. The facility policies titled, Oxygen Administration & Safety and Oxygen Storage in Nursing Areas failed to document information regarding the storage of oxygen tubing. No further information was presented prior to exit. Reference: (1) A nasal cannula is the part of oxygen tubing that is placed into the nostrils. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000048.htm

Based on observation, resident interview, staff interview and facility document review, it was determined that the facility staff failed to evidence an assessment and consent for the use of side rails for one of 29 residents in the survey sample, Resident #214. The findings include: Resident #214 was admitted to the facility with diagnoses that included but were not limited to acute respiratory failure with hypoxia (1) and severe sepsis (2). Resident #214's MDS (minimum data set) was not due at the time of the survey. The admission nursing assessment for Resident #214 dated 11/2/2021 coded Resident #214 being alert and oriented. The admission nursing assessment coded Resident #214 as requiring assistance of one person for transfers and two persons for ambulation. The admission nursing assessment coded Resident #214 as being oriented to side rails on admission. On 11/3/2021 at 3:02 p.m., an observation was conducted of Resident #214 in bed with bilateral upper side rails in the up position on the bed. At that time an interview was conducted with Resident #214, when asked about the side rails, Resident #214 stated that he was admitted the day before and was able to grab on to turn in bed and position himself. Resident #214 stated that he did not remember if he had signed anything about the side rails or not. An additional observation on 11/4/2021 at approximately 8:35 a.m., revealed the same observation as stated above. The comprehensive care plan for Resident #214 dated 11/3/2021, documented, Safety, [Name of Resident #214] preference is to have upper 1/4 siderails on his bed to aid in bed mobility. Under interventions it documented in part, Obtain consent for use of siderails from resident and/or POA (power of attorney). Discuss risks involved with use of siderails . The physician's orders for Resident #214 documented in part, Side rails up at all times when in bed to aid in bed mobility. Order Date: 11/02/21; Start Date: 11/02/21. The physician's orders further documented, 2 (two) Upper 1/4 (quarter) side rails. [Name of physician] Order Date: 11/02/21; Start Date: 11/02/21. Review of Resident #214's clinical record failed to evidence a consent for the use of side rails or a side rail assessment. On 11/3/2021 at approximately 6:00 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing for the bed inspection for Resident #214's bed. On 11/4/2021 at approximately 8:30 a.m., ASM #2 provided a book of bed inspections from maintenance documenting a bed inspection completed on 9/15/2021 for the bed in Resident #214's room. On 11/4/2021 at approximately 10:58 a.m., a request was made to ASM #2, the director of nursing for evidence of a use of side rail assessment and consent for Resident #214. On 11/4/2021 at 1:35 p.m., ASM #2 stated that they did not have a side rail assessment or consent for Resident #214 and they had asked the staff to complete it today. On 11/4/2021 at 1:40 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident required side rails they obtained an order from the physician, performed an assessment to ensure that the side rails were appropriate for the resident and obtained a consent. LPN #1 stated that the assessment should be completed prior to installing the side rails on the bed or the resident using them. On 11/4/2021 at 1:50 p.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the staff were expected to complete a side rail assessment and obtain a consent for the use of the side rails. ASM #2 stated that they expected this to be done the day of admission. On 11/4/2021 at approximately 1:37 p.m., a request was made to ASM #2 for the facility policy for side rails. The facility policy, Bed Rail Safety Program dated 7/24/2018 documented in part, .Side Rail and Entrapment Risk Evaluation Form: This form is used to determine appropriate side rails use for each resident. An analysis of the information gathered in the Bed Safety Inspection and the Entrapment Assessment is performed with a determination of appropriate side rail use of each resident. The analysis is performed with each MDS assessment and subsequently care planned. Consent form: This form is used for residents/resident representatives to be fully informed of the risks and benefits of side rails use. Upon completion of the above assessments, evaluations, and forms, an MD (medical doctor) order will be obtained for the appropriate side rail usage, and the correct information will be care planned . On 11/4/2021 at approximately 1:50 p.m., ASM #2 provided a side rail consent for Resident #214 dated 11/04/2021 at 1:47 p.m. and a side rail & entrapment risk evaluation dated 11/04/2021 at 1:51 p.m. On 11/4/2021 at 1:55 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. References: 1. Respiratory failure: When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. 2. Sepsis: An illness in which the body has a severe, inflammatory response to bacteria or other germs. The symptoms of sepsis are not caused by the germs themselves. Instead, chemicals the body releases cause the response. This information was obtained from the website: <https://medlineplus.gov/ency/article/000666.htm>.