Based on staff interview and clinical record review, the facility staff failed to honor a preference for twice weekly showers for one of thirty residents in the survey sample (Resident #112). The findings include: According to the clinical record, diagnoses for R112 included left femur fracture, osteoarthritis, malnutrition, and anxiety. The most current MDS (minimum data set) was a an admission assessment with an ARD (assessment reference date) of 11/12/24, which assessed R12 as being moderately cognitively impaired. Review of R112's admission MDS, Section F Preferences for Customary Routine-Activities, documented that R112 felt it to be very important to choose how to bathe. Review of shower records documented that R112 only received a shower on 11/10/24. On 5/1/25 at 9:45 a.m. license practical nurse (LPN #4, unit manager) provided a shower schedule for R112 and indicated R112 was supposed to receive a shower every Tuesday and Friday. When asked to evidence that R112 received the showers as scheduled, LPN #4 reviewed bathing logs and indicated that R112 received a bed bath on 11/12/24 and 11/15/24. LPN #4 was unable to find any other evidence to show R112 was received a shower. On 5/1/25 at 5:30 p.m., the above finding was presented to the administrator and director of nursing. No other information was presented prior to exit conference on 5/1/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #110 (R110), the facility failed to notify the physician and responsible party of the dislodgement of a enteral feeding tube. Review of the Face Sheet found in R110's EMR under the Profile tab revealed R110 was admitted to the facility on [DATE] with diagnoses of intracranial injury with loss of consciousness of unspecified duration, gastrostomy status, dysphagia, and protein-calorie malnutrition. Review of R110's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/09/24 revealed the resident had short- and long-term memory problems and the resident's cognitive decision making was severely impaired. Further review revealed the resident was dependent on staff for eating and required a feeding tube. Review of R110's Care Plan Report found under the care plan tab revised 07/17/24 revealed .Alteration in nutrition tube feeding provides nutrition & hydration. Risk for malnutrition . Review of the Clinical Physician Orders found in R110's EMR under the Order tab dated 01/27/23 revealed .Enteral Feed Order two times a day Turn on at 1800 [6:00 PM] and off at 0600 [6:00 AM]. Flush before and after hanging . Review of R110's Progress Notes found in the EMR under the Progress note tab dated 06/28/24 at 7:15AM revealed .Res [resident] left for Neuro [neurology] appt [appointment] via transport. Peg tube noted out and dried blood noted on stomach This documentation did not mention that emergency measures had been attempted to replace the feeding tube. Review of R110's Progress Notes found in the EMR under the Progress Note tab, dated 06/28/24 at 9:53 AM, revealed .Patient has returned from Neuro appointment, peg tube noted to be dislodged. This nurse attempted foley placement into peg tube site, attempted x [times] 3 with family at bedside, attempt unsuccessful. NP [Nurse Practitioner] updated; family wants resident sent out for peg tube placement. Call to [named transportation], to provide transportation, [named transport] in route. Call to [named hospital], spoke with ER nurse to give report, nurse verbalize understanding. Medical DX [diagnosis] sheet, and med list sent with resident and family to [named hospital] . Review of the EMR revealed no documented evidence the family was notified R110's peg tube dislodged. During a telephone interview on 05/01/25 at 7:30 AM, Family Member 1, who was was present for the appointment, stated she found out at a neurology appointment that R110 did not have a peg tube and called the facility. Family Member 1 stated that the CNA that was getting her dress that morning kicked it under the bed and that she had been sent out to the appointment without the peg tube. Family Member 1 stated that it was discovered stoma bleeding at the neurology appointment. Family Member 1 stated that after returning to the facility the Director of Nursing (Former DON) made two attempts to place a foley catheter, an 18 and 16 gauge, but was unsuccessful. When she failed to do that, the DON called the ambulance we had her taken to the emergency room (ER). During an interview on 05/01/25 at 8:56 AM, the Former DON stated, The nurse did not let us know. Transport was at the facility to take the resident to the appointment and they noticed the peg tube on the floor. They did not notify or tell us the peg tube was out. The nurse should have let us know the peg tube was out, and we educated the nurse at that time. During an interview on 05/01/25 at 3:43 PM, the Former Administrator stated, I do recall the incident the peg tube was dislodged. Recall the history with [Family Member 1 name redacted], she did not want her to go the hospital and the hospital did not have the right size enteral feeding tube. When questioned further, the Administrator stated that the expectation was that staff would notify the physician, obtain orders, notify family, and notify administration. Review of the facility's undated policy titled, Change In a Resident's Condition revealed .The facility will promptly notify the resident, his or her physician /practitioner, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes of level of care, billing/payments, resident rights, etc.) . No additional information was provided prior to survey exit. Based on responsible party interview, staff interviews, clinical record reviews, and facility documents, the facility staff failed to inform the physician and resident or representative timely of a change in condition for two of thirty residents in the survey sample, (Residents #109 and Resident #110). The findings include: 1. For Resident #109 (R109), the facility staff failed to inform the resident or representative timely of a change in condition for one of thirty residents in the survey sample, (Residents #109). According to the clinical record, diagnoses for R109 included urinary tract infection, urine retention, pressure ulcers, and renal insufficiency. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 10/11/24. R109 was assessed with a cognitive score of 13 out of 15, indicating cognitively intact. Review of R109's clinical record revealed the following via progress notes: 10/3/24 - order to obtain urinalysis due to [R109] complaining of urine frequency and burning and overall not feeling well. 10/6/24 - results of urine lab indicates [R109] does have a urinary tract infection with Extended spectrum beta-lactamases (ESBL), will start on intravenous antibiotics and placed on contact isolation. 10/7/24 - PICC [peripheral insertion central catheter] inserted and antibiotic medication started. 10/10/24 - unstageable pressure ulcer to right gluteal fold and and unstageable pressure ulcer to right and left heels. Treatment to heels were betadine dressing daily and apply protective boots. Treatment to gluteal fold was wound cleanser, apply Medihoney, fill with Calcium Alginate and cover with foam dressing daily and as needed, apply air mattress. Until 10/11/24, there was no documentation to evidence that R109 or the responsible party (RP) was informed of the four changes in condition or treatment. A progress note dated 10/11/24 documented the following, Communication with Family/NOK/POA Note Text : This writer spoke with [name of RP/ emergency contact redacted], update on resident current status given, all questions answered at this time. On 5/1/25 at 1:00 p.m., license practical nurse (LPN #2, nurse that wrote the progress note) was interviewed in regards to notification of the family. LPN #2 verbalized that the family was notified via telephone of the wounds and intravenous antibiotics for a urinary tract infection, adding that the family member voiced concerns of not being notified timely. LPN #2 verbalized that typically the nurses would notify family members as soon as a change in condition happens. On 5/1/25 at 4:00 p.m. the director of nursing (DON) was made aware of the above finding. The DON presented a form indicating that R109 was her own RP. It was that pointed out that according to the clinical record the daughter was the RP, that the form that was shown was not noted in the clinical record, and that, according to the clinical record, R109 had not been made aware of the changes in condition. No other information was presented prior to exit conference on 5/1/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to follow abuse prevention policies for reporting an injury of unknown origin for one of thirty residents in the survey sample (Resident #111). The findings include: Resident #111 (R111) was admitted to the facility with diagnoses that included dementia with psychotic disturbance, hypertension, hypothyroidism, affective mood disorder, depression, gastroesophageal reflux disease, dysphagia, insomnia, chronic kidney disease and protein-calorie malnutrition. The minimum data set (MDS) dated [DATE] assessed R111 with short and long-term memory problems and severely impaired cognitive skills. R111's clinical record documented a nursing note on 12/2/23 stating, .CNA [certified nurses' aide] alerted this nurse that [R111] had bruising around her neck and face at approximately 0930 [9:30 a.m.]. At this time full nursing assessment performed. Moderate amount of bruising noted on left and right side of face and neck. Skin tear on right cheek. resident is able to turn head left and right .Resident unable to state what happened due to baseline confusion .Supervisor DON [director of nursing] notified .[emergency contact] notified . The clinical record documented no recent fall and/or incident involving R111. The record included no known cause of R111's facial bruising and skin tear documented on 12/2/23. There was no immediate report to the state agency or adult protective services (APS) of R111's injury of unknown origin that occurred on 12/2/23. The facility's documentation included an initial facility synopsis form describing the bruising of unknown origin, listing the incident date as 12/2/23, and the report date as 12/3/24. There was no evidence of fax confirmation and/or emails that this form/report was sent to the state agency. The state agency had no record of receiving this initial report. This form documented that APS and department of health professions (DHP) were notified of the injury of unknown origin on 12/2/24. There was no evidence of fax confirmation and/or emails indicating notification to APS or DHP. It was unclear who or what was reported to the department of health professions. The facility's final synopsis findings were documented on 12/8/23 with fax confirmation to the state agency on 12/9/23. A letter dated 1/2/24 from the local APS, that investigated the injuries, documented R111's unexplained injury was reported to APS on 12/6/23. The administrator and DON employed at the time of R111's injury of unknown origin were not available for interview, as they no longer worked at the facility. On 5/1/24 at 9:21 a.m., the current administrator and DON were interviewed about R111's injury of unknown origin. The administrator and DON reviewed the facility documentation and presented no evidence that the initial report had been sent to the state agency. The administrator stated that the initial form was completed indicating the incident occurred on 12/2/23 with a report date documented as 12/3/23. The administrator stated that he found no confirmations indicating notification to the state agency, APS or DHP. The DON stated the incident should have been reported immediately to the state agency and APS, with the findings reported to the state agency within five days. The administrator stated that there was no record of what was sent to DHP. The administrator stated he found no explanation about the conflicting report dates to local APS (12/2/23 vs. 12/6/23). On 5/1/25 at 10:30 a.m., the administrator stated he searched again, reviewed the investigation documents, and found no further evidence of immediate reporting of R111's injury of unknown source to the state agency, APS or DHP. The administrator stated he was not sure why notification to the stage agency and APS was not done on the day of the incident (12/2/23). The administrator stated there were no faxes, digi-fax or email confirmations about an initial notification to the state agency, APS or DHP. The administrator stated he only had evidence that the investigation/findings were submitted to the state agency on 12/9/23. The facility's policy titled Abuse (revised 10/20/22) documented, .The facility is committed to developing and operationalizing policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property .The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures . These findings were reviewed with the administrator and DON on 5/1/25 at 9:30 a.m. and with the administrator on 5/1/25 at 10:30 a.m., with no further information presented prior to the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to immediately report to the state agency and adult protective services (APS), an injury of unknown origin suspicious of abuse for one of thirty residents in the survey sample (Resident #111). The findings include: Resident #111 (R111) was admitted to the facility with diagnoses that included dementia with psychotic disturbance, hypertension, hypothyroidism, affective mood disorder, depression, gastroesophageal reflux disease, dysphagia, insomnia, chronic kidney disease and protein-calorie malnutrition. The minimum data set (MDS) dated [DATE] assessed R111 with short and long-term memory problems and severely impaired cognitive skills. R111's clinical record documented a nursing note on 12/2/23 stating, .CNA [certified nurses' aide] alerted this nurse that [R111] had bruising around her neck and face at approximately 0930 [9:30 a.m.]. At this time full nursing assessment performed. Moderate amount of bruising noted on left and right side of face and neck. Skin tear on right cheek. resident is able to turn head left and right .Resident unable to state what happened due to baseline confusion .Supervisor DON [director of nursing] notified .[emergency contact] notified . The clinical record documented no recent fall and/or incident involving R111. The record included no known cause of R111's facial bruising and skin tear assessed on 12/2/23. There was no immediate report to the state agency or adult protective services (APS) of R111's injury of unknown origin that occurred on 12/2/23. The facility's documentation included an initial facility reported incident form describing the bruising of unknown origin, listing the incident date as 12/2/23 and the report date as 12/3/24. There was no evidence that this form/report was sent to the state agency. The state agency had no record of receiving this initial report. This form documented APS and department of health professions (DHP) were notified of the injury of unknown origin on 12/2/24. There was no evidence of fax confirmation and/or emails indicating notification to APS or DHP. It was unclear who or what was reported to the department of health professions. The facility's investigation findings were documented on 12/8/23 with fax confirmation to the state agency on 12/9/23. A letter from the local APS that investigated the injuries dated 1/2/24 documented R111's unexplained injury was reported to APS on 12/6/23. The administrator and DON employed at the time of R111's injury of unknown origin were not available for interview as they no longer worked at the facility. On 5/1/24 at 9:21 a.m., the current administrator and DON were interviewed about R111's injury of unknown origin. The administrator and DON reviewed the facility documentation and presented no evidence that the initial report was sent to the state agency. The administrator stated the initial form was completed indicating the incident occurred on 12/2/23 with a report date documented as 12/3/23. The administrator stated he found no confirmations indicating notification to the state agency, APS or DHP. The DON stated the incident should have been reported immediately to the state agency and APS and the findings reported to the state agency within five days. The administrator stated there was no record of what was sent to DHP. The administrator stated he found no explanation about the conflicting report dates to local APS (12/2/23 vs. 12/6/23). On 5/1/25 at 10:30 a.m., the administrator stated he searched again and reviewed the investigation documents and found no further evidence of immediate reporting of R111's injury of unknown source to the state agency, APS or DHP. The administrator stated he was not sure why notification to the stage agency and APS was not done on the day of the incident (12/2/23). The administrator stated there were no faxes, digi-fax or email confirmations about an initial notification to the state agency, APS or DHP. The administrator stated he only had evidence that the investigation/findings were submitted to the state agency on 12/9/23. The facility's policy titled Abuse (revised 10/20/22) documented, .The facility is committed to developing and operationalizing policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property .The organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures . These findings were reviewed with the administrator and DON on 5/1/25 at 9:30 a.m. and with the administrator on 5/1/25 at 10:30 a.m. with no further information presented prior to the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to provide the resident and/or resident representative with a baseline care plan summary for one of thirty residents in the survey sample (Resident #37). The findings include: Resident #37 (R37) was admitted to the facility with diagnoses that included Parkinson's, sepsis, urinary tract infection, pressure ulcer, respiratory failure, and history of hip fracture. The minimum data set (MDS) dated [DATE] assessed R37 with severely impaired cognitive skills. R37's clinical record documented an admission assessment dated [DATE]. This assessment included a baseline care plan that addressed care areas of catheter care, constipation prevention, hospice services, diet, pressure ulcer care, fall prevention and assistance with activities of daily living. The clinical record documented no evidence that the baseline care plan was reviewed with the resident's representative or that the representative was given a summary or copy of the plan. The sections on the 3/28/25 admission assessment indicating completion of the baseline plan, review of the plan with the resident's representative and provision of the plan summary and medications were not completed. On 4/30/25 at 2:41 p.m., the licensed practical nurse unit manager (LPN #2) was interviewed about R37's baseline care plan. LPN #2 reviewed the clinical record and stated she found nothing indicating the resident's representative received a copy of the plan or that the plan was reviewed with the representative. LPN #2 stated the baseline care plan items auto-populated based upon the assessments entered. LPN #2 stated the baseline plan should have been reviewed with the resident's family with the family provided a summary/copy of the plan. LPN #2 stated nurses were able to print the baseline plan from the electronic health record. The facility's policy titled Baseline Care Plans (undated) documented, .The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to .initial goals of the resident .summary of the resident's medications and dietary instructions .Any services and treatment to be administered by the facility and personnel acting on behalf of the facility . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 4/30/25 at 5:00 p.m. with no further information presented prior to the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of thirty residents in the survey sample (Resident #91). The findings include: Resident #91 (R91) was admitted to the facility with diagnoses that included spinal stenosis, cardiomyopathy, chronic respiratory failure, diabetes and depression. The minimum data set (MDS) dated [DATE] assessed R91 as cognitively intact. On 4/29/25 at 12:20 p.m., R91 was interviewed about quality of care/life in the facility. R91 stated during this interview that she preferred female caregivers to provider her personal care and that the facility had honored this preference. R91's plan of care (revised 3/28/25) documented the resident required assistance with activities of daily living that included toileting, incontinence care, and assistance with bathing/dressing. The care plan made no mention of the resident's preference for a female caregiver. On 5/1/25 at 8:13 a.m., the licensed practical nurse unit manager (LPN #2) was interviewed about R91's care plan. LPN #2 stated the MDS coordinators usually updated care plans after assessments and/or discussions from morning meetings. LPN #2 stated the resident's preference for female caregivers should have been added to the plan of care. On 5/1/25 at 8:30 a.m., the registered nurse (RN #7) MDS coordinator responsible for care plan updates was interviewed. RN #7 reviewed the plan of care and stated she found nothing on the care plan about female caregivers. RN #7 stated the resident's last care plan review was completed on 4/3/25. RN #7 stated the female caregiver preference should have been added to the plan. This was reviewed with the administrator and director of nursing on 5/1/25 at 5:45 p.m. with no further information provided prior to the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to provide incontinence care for in a timely manner for two of three residents (Resident (R) 36 and R41) reviewed for activities of daily living (ADLs) out of a total sample of 30. Failure to provide timely incontinence care places residents at increased risk of urinary tract infections and skin breakdown. Findings include: 1. For R36, facility failed to provide timely incontinent care, as needed. Review of R36's Profile tab of the electronic medical record (EMR) revealed R36 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, adult failure to thrive, and unspecified sequelae of cerebral infarction. Review of R36's Care Plan, dated 01/08/25 and located under the Care Plan tab of the EMR revealed, . the resident is incontinent of bladder and bowel and is not a candidate for a toileting program . The goal was, . the resident will remain clean and dry as possible thru [sic] the review period . Interventions included, . provide toileting hygiene as needed for incontinent episode . Review of R36's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/25 and located under the MDS tab of the EMR, revealed R36 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident was severely cognitively impaired. The MDS documented that R36 had functional limitation in range of motion on both upper and lower extremities, was dependent on staff for transfers and repositioning, and was always incontinent of bladder and bowel. During an observation on 04/29/25 at 10:25 AM, R36 was observed sitting in a Broda (a cushioned and tilting chair that is used for supportive positioning) chair. During observations at 11:04 AM and 11:31 AM, R36 remained in his Broda chair. Beginning at 12:34 PM through 1:09 PM, R36 was observed continuously in his Broda chair. He was not checked for incontinence. At 1:09 PM, Certified Nurse Aide (CNA) 1, who was assigned to R36, pushed a meal tray cart through the unit's dining room and began to deliver meal trays. CNA1 did not check R36 for incontinence while she was delivering meal trays. CNA1 delivered meal trays from 1:09 PM until 1:22 PM, when she sat down by R36 and began to feed him. CNA1 did not check R36 for incontinence before she began to feed him. From 1:22 PM through 2:26 PM, R36 remained in the unit's dining room and was observed continuously. Staff did not check R36 for incontinence. At 2:26 PM, CNA1 transported R36 to his room, transferred the resident to his bed, and provided incontinent care. R36 had been incontinent of bowel. CNA1 described R36's stool as thick and sticky. During an interview on 04/29/25 at 2:41 PM, CNA1 stated that she transferred R36 from his bed to his Broda chair at approximately 8:00 AM on this day. She stated R36 was normally placed at the table after getting out of bed and stayed there until the noon meal was completed. She stated he was taken back to bed and checked for incontinence at that time. CNA1 stated she had taken R36 to the shower room at approximately 11:30 AM to check him for incontinence. CNA1 stated she checked for incontinence by pulling the front of his pants down to see if the wetness indicator on the incontinent brief had changed colors. CNA1 stated that she relied on smells to determine if the resident was incontinent of bowel. CNA1 confirmed that she did not transfer the resident from the Broda chair to check for incontinence or visually look for fecal incontinence. R36 had not been checked for fecal incontinence from 11:30 AM to 2:26 PM, three hours and was found to have had a bowel movement that was thick and sticky per CNA1. 2. For R41, facility failed to provide timely incontinent care, as needed. Review of R41's Profile tab of the EMR revealed R41 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease with late onset, muscle weakness, and bipolar disorder. Review of R41's quarterly MDS, with an ARD of 04/01/25 and located under the MDS tab of the EMR, revealed R41 had long and short-term memory problems and was severely impaired in cognitive skills for daily decision making. It was recorded that R41 was dependent on staff for toileting hygiene, and transfers and was always incontinent of bladder and bowel. Review of R41's Care Plan, revised on 04/03/25 and located under the Care Plan tab of the EMR, revealed, . the resident is incontinent of bladder and bowel and is not a candidate for a toileting program . The goal was, . the resident will remain clean and dry as possible thru [sic] the review period . Interventions included, . provide toileting hygiene as needed for incontinent episodes . During an observation on 04/29/25 at 10:25 AM, R41 was observed sitting in her Broda chair in the unit's dining room. Observationa at 11:00 AM, 11:04 AM, and 11:31 AM revealed that R41 remained in the dining room. Beginning at 12:34 PM through 1:09 PM, R41 was observed continuously in her Broda chair. She was not checked for incontinence. At 1:09 PM, CNA1, who was assigned to R41, pushed a meal tray cart through the unit's dining room and began to deliver meal trays. CNA1 delivered meal trays from 1:09 PM through 1:22 PM. R41 was not checked for incontinence during this time. At 1:22 PM, R41 was provided with her noon meal tray. She was not checked for incontinence. From 1:22 PM through 2:26 PM, R41 remained in the unit's dining room and was observed continuously. Staff did not check R4 for incontinence. R41 remained in the dining room until 2:50 PM. During an interview and observation on 04/29/25 at 2:50 PM, CNA1 stated that after she had helped R41 out of bed, she had taken her to the unit's dining room for breakfast. She stated she had taken R41 to the shower room to check for incontinence around 11:30, at around the same time she had taken R36. CNA1 was asked how often residents were to be checked for incontinence. CNA1 stated, Every two hours. CNA1 propelled R41 to the shower room and showed the surveyor how she checked the residents for incontinence. CNA1 pulled the front of R41's pants down, exposing the upper portion of the front of the resident's brief. CNA1 stated she looked to see if the stripe on the brief had changed color from wetness. CNA1 was asked how she checked for bowel incontinence. CNA1 stated that she could smell if the resident had been incontinent of bowel. CNA1 confirmed that she had not opened the resident's brief to check for urine or bowel incontinence. According to CNA1, R41 was checked by at 11:30 AM and then again at 2:50 PM, indicating it had been 3 hours and 20 minutes since being for incontinent care. During an interview on 04/30/25 at 2:36 PM, Registered Nurse (RN) 4, who was the Unit Manager for R36 and R41's unit, stated her expectation was for staff to make rounds every two hours and check for incontinence. RN4 stated that sometimes staff took residents to the shower room, pulled their pants down to check for incontinence and sometimes, staff transferred the resident back to bed to check for incontinence. RN4 stated a visual check must be completed for both urinary and bowel incontinence. RN4 stated that she did not know if the residents were transferred from the chairs in order to check for incontinence when they were taken to the shower room. During an interview on 04/30/25 at 3:17 PM, the Director of Nursing (DON) stated that her expectation was for residents to be checked for incontinence at least every two hours. The DON confirmed that residents should be visually checked for both urinary and bowel incontinence. The DON confirmed that residents could be incontinent of urine, and the wetness indicator on the brief would not change color due to how the urine could flow. Review of the facility's undated policy titled, Urinary Continence and Incontinence - Assessment and Management revealed, . The staff and practitioner will appropriately . manage individuals with urinary and/or fecal incontinence . will provide appropriate services and treatment to . prevent infections to the extent possible . Facility staff will provide and/or assist the resident with incontinence care as needed . No additional information was provided prior to survey exit.

Based on interview, record review, and job description review, the facility failed to have a certified Activity Director to direct the provision of activities for 114 of 114 residents, as required. Findings include: During an interview on 05/01/25 at 9:03 AM, when asked if she was certified as an Activities Director, the Activity Director (Other Staff (OS) 4) said, No. OS4 stated that she was not informed she needed to be certified when she took the position two years ago. OS4 stated that she had been working at another facility as the Activity Director previously. OS4 stated the previous Administrators had not talked with her about it, but that the current Administrator had informed her certification was necessary. OS4 stated the Administrator had been pushing her to get the certification completed. OS4 stated that she had signed up for the class and was told due to her years of experience she only needed to write an essay. OS4 stated that she had received the book for the class during the previous week, and that the class had been paid for. OS4 stated that she had written the essay, but she had not turned it in yet. During an interview on 05/01/25 at 9:30 AM, when asked if the Activity Director was certified, the Administrator stated, No. The Administrator stated that she had been enrolled in class. The Administrator confirmed knowing that the facility must have a certified Activity Director. The Administrator provided documentation of the Activity Director's enrollment in the certification class. Review of the facility's job description for the Activities Director revealed, . To promote, plan, organize and staff activities and opportunities for facility's residents which best fit their needs to enhance their quality of life and the philosophy of the facility . Appropriate training and/or certification is highly advantageous . No additional information was provided prior to survey exit.

Based on observation, staff interview and clinical record review, the facility staff failed to ensure a wound dressing was intact for one of thirty residents in the survey sample, (Residents #19). Resident #19's (R19) did not have a wound dressing in place. The Findings Include: Diagnoses for R19 included non-pressure chronic ulcer to left calf, adult failure to thrive, and peripheral vascular disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/19/25. R19 was assessed with a cognitive score of 15 out of 15, indicating cognitively intact. On 4/29/25 at 12:55 p.m., R19 was interviewed and was asked about having any wounds. R19 verbalized that he had a wound on the left calf that has been there before being admitted and the nurses are taking care of it. At this time, the wound was observed without a dressing and with scant drainage. When asked what happened to the dressing, R19 verbalized it came off when the aides had helped him to get dressed in the morning. On 4/29/25 at 1:16 p.m., registered nurse (RN #6) also observed R19's wound open to air and without a dressing. RN #6 verbalized that no one had reported to her regarding the dressing not being in place and that it should be covered at all times. RN #6 then dressed the wound according to physician orders. Review of physician orders for R19 included: Clean wound with Dakins 1/4 strength, pat dry, apply dermblue to wound bed, and cover with boarded gauze. Every day shift for wound care. On 4/30/25 at 5:00 p.m. the above information was presented to the administrator and director of nursing. No other information was presented prior to exit conference on 5/1/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to implement interventions to aid in the prevention of pressure ulcers for one of three residents (Resident (R) 36) reviewed for pressure ulcers out of a total sample of 30. Failure to implement interventions placed R36 at increased risk of developing pressure ulcers. Findings include: Review of the facility's undated policy titled, Pressure Injury Prevention and Management revealed, . The intent of this organization is to develop and maintain systems and processes to ensure that the resident does not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice . Frequent encouragement and assistance with turning, repositioning, shift of weight . Assistance with incontinence care, and application of moisture barrier ointments to protect the skin from contact with urine and/or feces . Review of R36's Profile tab of the electronic medical record (EMR) revealed R36 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, adult failure to thrive, and unspecified sequelae of cerebral infarction. Review of R36's Care Plan, dated 01/08/25 and located under the Care Plan tab of the EMR, revealed . The resident is at risk for pressure ulcers and skin impairment related to history of pressure ulcer development, inability to turn and reposition, incontinence, dx [diagnosis] failure to thrive, impaired healing from PVD [peripheral vascular disease], protein calorie malnutrition. Res [resident] has dry skin. refuses to lie down at times . The documented care plan goal was that R36 would not have any skin impairment through the review period. R36's care plan interventions included assisting the resident in turning and repositioning often and keeping the skin as clean and dry as possible. Review of R36's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/25 and located under the MDS tab of the EMR, revealed R36 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident was severely cognitively impaired. The MDS recorded R36 had functional limitation in range of motion on both upper and lower extremities, was dependent on staff for transfers and repositioning, and that R36 was at risk for the development of pressure ulcers but did not have one. During an observation on 04/29/25 at 10:25 AM, R36 was observed sitting in a Broda (a cushioned and tilting chair that is used for supportive positioning) chair. At 11:04 AM and 11:31 AM, R36 remained in the same position in his Broda chair. Beginning at 12:34 PM through 1:09 PM, R36 was observed continuously in his Broda chair. He was not repositioned by staff. At 1:09 PM, Certified Nurse Aide (CNA) 1, who was assigned to R36, pushed a meal tray cart through the unit's dining room and began to deliver meal trays. CNA1 delivered meal trays from 1:09 PM through 1:22 PM, when she sat by R36 and began to feed him. CNA1 did not reposition R36 before she began to feed him. From 1:22 PM through 2:26 PM, R36 was observed continuously. Staff did not reposition R36. At 2:26 PM, CNA1 transported R36 to his room, transferred the resident to his bed, and provided incontinent care. During an interview on 04/29/25 at 2:41 PM, CNA1 confirmed she had not repositioned R36 at any other time on this day. During an interview on 04/30/25 at 2:36 PM, Registered Nurse (RN) 4, who was the Unit Manager for R36's unit, stated her expectation was for staff to make rounds every two hours, and reposition the resident if they are unable to reposition themselves. During an interview on 04/30/25 at 3:17 PM, the Director of Nursing (DON) confirmed that R36 was at high risk for pressure ulcers, was unable to reposition himself, and should be repositioned at least every two hours in an effort to prevent pressure ulcer development. No additional information was provided prior to survey 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 failed to ensure the environment was free of accident hazards for one resident (Resident #88) and failed to provide adequate supervision to prevent accidents for two residents (Resident #36 and Resident #69), in a sample of thirty residents. The findings include: 1. For Resident #88, the facility failed to provide safe water temperature at a room sink. Resident #88's room had water temperature at the bathroom sink above the recommended range of 110 degrees (F) to less than 120 degrees (F). Resident #88 (R88) was admitted to the facility with diagnoses that include atrial fibrillation, hypertension, diabetes, hypothyroidism, hypercholesterolemia, edema, rosacea, osteoarthritis and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed R88 as cognitively intact. On 4/29/25 at 1:32 p.m., R88 was interviewed about quality life/care in the facility. When asked about any safety concerns, R88 stated the water at her bathroom sink gets really hot. R88 stated she usually bathed at the sink and ran hot/cold water to get a comfortable water temperature. R88 stated she had experienced no issues with the hot water as she adjusted the temperature, but she thought the hot water seemed hot. On 4/29/25 at 1:38 p.m., accompanied by the maintenance director (other staff #8), the water temperature at R88's bathroom was measured. After allowing the hot water to run for approximately one minute, the maintenance director's digital thermometer read and maintained at 121.3 degrees (F). The maintenance director stated at this time that the desired range for resident room water temperatures was from 110 degrees (F) to 120 degrees (F). The maintenance director stated R88's water temperature . needs to be adjusted a little to be below 120 degrees. On 4/29/25 at 3:00 p.m., the maintenance director (other staff #8) was interviewed by the survey team about the 121.3 degree reading in R88's room. The maintenance director stated the mixing valve was working properly and temperature at the mixing valve could be adjusted if needed. The maintenance director stated the state regulations required water temperatures to be 120 degrees (F) or less. The maintenance director stated seasonal adjustments were required to maintain desired temperatures. The maintenance director stated water temperatures in fifteen resident rooms were checked weekly as part of the preventive maintenance program. The maintenance director presented copies of weekly water temperature checks from 4/1/25 through 4/28/25. All temperatures during this time were below 120 degrees (F). room [ROOM NUMBER] was last checked on 4/15/25 with water temperature recorded at 117.3 degrees (F). On 5/1/25 at 10:54 a.m., the administrator was interviewed about the water temperature in R88's room above 120 degrees (F). The administrator stated he talked with the regional maintenance director and the regional director stated outside temperatures had some effect on water temperatures because the water pipes were in the ceiling area that had no temperature control and that boiler temperatures and mixing valve set points had to be adjusted seasonally to maintain desired temperatures. The administrator stated he agreed that the water temperature in rooms needed to be maintained below 120 degrees (F). The facility's instructions for testing water temperatures (Tels - undated) documented, .Test the water at various locations throughout your facility .federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 4/30/25 at 5:00 p.m. with no further information presented prior to the end of the survey. The DON stated at this time there had been no complaints from residents about hot water and no incidents/injuries involving hot water in the facility. Based on observation, interview, record review, and review of facility policy, the facility failed to: 1.) complete 2. For R36, facility staff failed to follow needed supervision during a transfer to reduce the risk of resident injury. Review of R36's Profile tab of the electronic medical record (EMR) revealed R36 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, adult failure to thrive, and unspecified sequelae of cerebral infarction. Review of R36's Care Plan, dated 01/18/25 and located under the Care Plan tab of the EMR, revealed, . the resident is a long term care resident and requires assistance with their ADL's [activities of daily living] related to chronic obstructive pulmonary disease (COPD), hemiplegia of the left side, residual effects from cerebrovascular disease, toes have been amputated to left foot, decreased ROM [range of motion] to both arms/shoulders and legs/knees . Interventions included, . Dependent for transfers requiring two people Date Initiated: 01/18/2025 . Hoyer lift [mechanical lift] for all transfers x 2 staff Date Initiated: 01/18/2025 . Review of R36's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/25 and located under the MDS tab of the EMR, revealed R36 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident was severely cognitively impaired. The MDS recorded R36 had functional limitation in range of motion on both upper and lower extremities and was dependent on staff for transfers. Review of R36's undated Visual/Bedside Kardex Report, located under the Care Plan tab of the EMR, revealed, . Dependent for transfers requiring two people . Hoyer lift for all transfers x 2 staff . During an observation on 04/29/25 at 2:26 PM, Certified Nurse Aide (CNA) 1 propelled R36 to his room. CNA3 entered the room. CNA1 and CNA3 stood on each side of R36, placed an arm under R36's arms, and transferred him to his bed. During an observation and interview on 04/30/25 at 3:00 PM, CNA1 and CNA2 were observed transferring R36 from his chair to his bed. CNA1 stood on R36's right side, and CNA2 was on his left side. The CNAs placed an arm under R36's arms and started to transfer him. As they began to raise the resident from his chair, CNA2 stated she could not complete the transfer. CNA1 instructed her to back away, and CNA1 completed the transfer by herself. The CNAs were asked how they knew which transfer method was to be used for a resident. CNA2 stated there was a sheet of paper on the inside of the residents' closets that recorded what transfer method was to be used. CNA2 reviewed the sheet for R36 and stated it was recorded the resident was to be transferred with two people and a Hoyer lift. CNA1 and CNA2 stated that they never used the Hoyer lift to transfer R36. During an interview on 04/30/25 at 3:24 PM, the Director of Nursing (DON) was asked how the method of transfer for a resident was determined. The DON stated that it was through a collaboration between the Interdisciplinary Team and therapy. The DON was asked if she expected a resident's method of transfer to be accurately reflected on the resident's Care Plan and Kardex. The DON stated, Yes. When asked if R36 should be transferred with a Hoyer lift, as per his Care Plan and Kardex, the DON stated, Yes, and added that injury could occur to R36 and the staff members, if he was not transferred using the Hoyer lift. Review of the facility's undated policy titled, Activities of Daily Living (ADLs), revealed, . Residents will be assisted with transfer and mobility as ordered by the physician/practitioner and/or as instructed in the resident's care plan . 3. For Resident #69, facility staff failed to complete an assessment/order related to elopement risks and a wandering device, before applying the wanderguard. Review of the Face sheet found in R69's electronic medical record (EMR) under the Profile tab revealed R69 was admitted to the facility on [DATE] with a diagnosis of dementia without behavioral disturbances. Review of R69's Elopement Risk Assessment found under the Assessment tab dated 12/23/24 revealed the resident was at risk for elopement and was assigned a wander guard bracelet. Further review revealed R69 did not have a current Elopement Risk Assessment Review of R69's Care Plan Report found under the Care plan tab revised 12/23/24 revealed .Elopement: the resident is at risk for elopement related to confusion and disorientation, dementia, exit seeking . Assess elopement risk as needed . wander guard to (SPECIFY) . Review of R69's Significant Change MDS assessment with an ARD date of 03/25/25 revealed the resident had a BIMS score of 00 out of 15, which indicated severe cognitive impairment. Review of the Clinical Physician Orders found in the EMR under the Orders tab revealed that R69 did not have physician orders for the wander guard. Observation on 04/29/25 at 1:16 PM on the River Unit revealed revealed that R69 had a wander guard to right ankle, wandered around unit with no purpose with a walker, and required staff redirection back to her room. During an interview on 05/01/25 at 1:07 PM, the Director of Nursing (DON) stated, The resident should have a wander guard physician order that describes the location to check placement and expiration date. There should be an elopement assessment, we do them on admission and quarterly and as needed. Review of the facility's policy titled, Medication and Treatment Orders dated 10/01/21 revealed .Drug and biological orders must be recorded on the physician's order sheet in the resident's medical record. Such orders are reviewed by the consultant pharmacist on a monthly basis . Review of the facility's policy titled, Elopement/Unsafe Wandering Risk Evaluations revised 04/18/23 revealed .The Elopement Risk Evaluation in PCC be completed by licensed nurse/designee in admission, readmission, and quarterly and as needed for a change in resident status . No additional information was provided prior to survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #84, facility staff failed to verify the resident's name on a pharmacy supply card prior to preparation for the adminisration of medications during a medication pass observation on The Gardens unit. The medication torsemide 40 mg (milligrams) was pulled for Resident #84 from a pharmacy supply card labeled for Resident #159. On 4/30/25 at 8:00 a.m., a medication pass observation was conducted with licensed practical nurse (LPN #7) administering medications to Resident #84 (R84). Among the medications prepared for R84 were two tablets of torsemide 20 mg. LPN #7 accessed the torsemide tablets from a pharmacy supply card labeled for Resident #159 (R159). The medication pass was paused prior to the administration to R84 and LPN #7 was questioned about the torsemide obtained from R159's supply card. LPN #7 verified that R84 had a current order for torsemide 20 mg - two tablets once daily. LPN #7 stated that she verified the medication dose but did not verify the name on the pharmacy supply card. LPN #7 stated that R159's card was in the medication cart section with R84's other medications. LPN #7 stated, I did not pay attention to the resident name. I just looked at the med [medication] and dose. LPN #7 stated that she should have made sure the medication was obtained from the correct card. On 4/30/25 at 8:56 a.m., the unit manager (LPN #2) was interviewed about LPN #7 obtaining medication for R84 from a card labeled for R159. LPN #2 stated R159 discharged on 4/29/25 and all the resident's other medications had been returned to pharmacy at the time of discharge. LPN #2 stated it was possible that R159's torsemide card got misplaced in the room slots in the medication cart. LPN #2 stated that she reviewed the incident with LPN #7 and stated that LPN #7 reported she looked at the medication and dosage and did not pay attention to the resident name on the card. LPN #2 stated nurses were expected to verify the correct medication, dose and resident name when giving medications. On 4/30/25 at 9:40 a.m., accompanied by LPN #2 and LPN #7, R84's supply card for torsemide 20 mg tablets was located in the bottom drawer of the medication cart. LPN #7 stated again that she looked at the medication and dose but did not realize the medication was from another resident's card. R84's clinical record documented a physician's order dated 4/8/25 for torsemide 20 mg - two tablets once daily for edema. R159's clinical record documented a physician's order dated 4/21/25 for torsemide 20 mg - two tablets once daily for edema. The facility's policy titled General Guidelines for Medication Administration (revised 8-2020) documented, .Medications are administered as prescribed in accordance with good nursing principles and practices .Medications supplied for one resident are never administered to another resident . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 4/30/25 at 5:00 p.m. with no further information presented prior to the end of the survey. Based on staff interviews, record review, and facility documents, the facility failed to ensure that nursing services met the professional standards of quality for five of 30 sampled residents (Resident (R) 11, R70, R76, R84, R159). Findings included: 1. For Residents #84 and Resident #159, the facility failed to ensure that licensed nursing services were not delegated to and performed by an unlicensed staff member. Registered Nurse (RN) 9 delegated administration of oral medications and the performance of a fingerstick blood glucose check to Certified Nurse Aide (CNA) 10. Review of R11's Census and Med Diag (Medical Diagnosis) tabs of the electronic medical record (EMR) revealed R11 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, essential hypertension, and unspecified hypertension. Review of R70's Census and Med Diag tabs of the EMR revealed R70 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, major depressive disorder, and essential hypertension. Review of R76's Census and Med Diag tabs of the EMR revealed R76 was admitted to the facility on [DATE] with diagnoses that included paroxysmal atrial fibrillation, chronic pain, and vascular dementia. Review of a facility synopsis dated 04/22/25 revealed, Report date: 4/22/25 . Incident Date 4/19/25 . Residents involved: [R70] Injuries: [No circled] . Incident Type: . ['Other' written on form] . Describe incident, including location, and action taken: April 21st 4:30 pm CNA reported that on Sat [Saturday] April 19th a nurse delegated a CNA to passed [sic] medication [and] take a blood sugar . Name of employee(s) involved and their positions: RN [RN9][,] CNA [CNA10][,] CNA who reported event [CNA1] . Employee action initiated or taking: RN [and] CNA suspended [and] investigation started . The FRI recorded that the responsible party, physician, Adult Protective Services (APS), and Department of Health Professions (DHP) had been notified on 04/22/25. Review of the facility's investigative file of the incident revealed a letter to the Virginia Department of Health, Office of Licensure and Certification, dated 04/28/25, that recorded, . Incident/Investigation: On 4/21/25 at 4:30 PM, the Director of Nursing [DON] received a report that a RN was allowing a CNA to pass medications and check blood sugars on the unit [NAME] Square on Saturday 4/19/25. The RN pulled the medications and allowed the CNA to pass them to the residents. CNA [CNA1] observed this with several of the residents on 4/19/25 and reported it to her charge nurse on 4/21/25. The director [sic] of nursing reported to the administrator [sic] and notified the provider. Statements were obtained from CNA [CNA1], CNA [CNA10], and RN [RN9]. The director of nursing and administrator spoke with [R70] and [family member name withheld], [R11] and [family member name withheld], and [R76] and [family member name withheld] to inform them of the incident. The provider assessed all residents on [NAME] Square with no adverse effects noted. The RN and CNA involved were put on suspension and educated on delegation and scope of practice. Facility documentation included the following: Action Plan: 1. DON and Administrator notified residents, family members, and provider of RN allowing CNA to administer medications and obtain blood sugars. 2. Statements obtained from staff, residents, and family members. 3. OLC, AOS, and Ombudsman notified. 4. Notified Department of Health Professions. 5. Staff members involved suspended. 6. Provider saw all residents to assess for adverse effects. 7. All responsible parties notified of the 3 residents involved. Conclusion: Facility conducted a thorough investigation through interviews. Interviews with staff members involved confirmed that the RN allowed the CNA to pass out medications and obtain blood sugar checks. Interviews with family members could not confirm that it was the CNA giving medication or doing blood sugar checks due to it being different staff on the unit the day this occurred. The provider saw and assessed all of the residents on [NAME] Square with no adverse effects noted. The report of the RN allowing the CNA to pass out medications and obtain blood sugar checks is substantiated as evidenced above . The facility will review this concern to remain preventative and proactive, considering all opportunities to ensure the safety of our residents and any opportunities for improvement . This document was signed by the DON. 2. A copy of an email from RN9 to the DON, dated 04/21/25, which indicated, . On Saturday 4/19, I was working as a nurse on Town Square 7am-7pm. During this time, I did ask a CNA, [CNA10], to check some blood sugars via glucometer. I did not realize this was out of their scope. At another point I did pull some medications for [R70], no narcotics were pulled. I had to go and assist with another patient complaining of difficulty breathing. I handed [R70]'s medication to [CNA10] asking her to take it to the resident for me. I do understand this is unacceptable and will not repeat the poor decisions made that shift . 3. A copy of an email from CNA10 to the DON, dated 04/21/25, which indicated, . On Saturday, I was working with [RN9]. She had mentioned having to take blood sugars, and I said I would do it for you. She said, 'Yeah, that's fine.' So I went in and took [R11]'s blood sugar. The [RN9] pulled the meds and put them in the cups. I did hand them off. I know [R70] said [I can't move my arms, I need you to dump them in my mouth. One of the aides said, 'Don't leave them on the table because of her [family member],' so I went ahead and dumped them in her mouth. I helped [RN9] in the morning and afternoon with medication, helping pass them out. Due to her having to run downstairs to help them, and next door. I did take [R11]'s blood sugar once, and that was in the afternoon, as well as [R70]'s medication. [R76]'s [family member] had come in and mentioned that her mom was complaining about her legs hurting, and I had told her she refused medication; she said it was too late. I told her I'll go ask the nurse, she told me to go and handed me her medication. I took it to her daughter, and she took it from me. That is when [R76] took her meds. I do not remember all the patients that I gave meds to, but it was two that I was 100% sure of. 4. Progress Notes, dated 04/22/25, detailed the provider's assessments of R11, R70, and R76, with no concerns noted. 5. An In-Service/Education Record, dated 04/22/25, for Delegating and Scope of Practice. The record contained the signatures of nursing staff members who received the education. 6. A copy of an email from RN9 to the DON, dated 04/26/25, which indicated, . please accept this as my resignation from employment immediately . 7. A Notice of Disciplinary Action, dated 04/29/25, which indicated, . CNA [CNA10] gave two residents their medications and took blood sugars of another resident. This is practicing outside of your scope of service as you are not a licensed nurse . The notice indicated CNA10's employment had been terminated by the facility. During an interview on 04/30/25 at 3:27 PM, the DON stated that it was out of the scope of practice for a CNA to administer medications in Virgina. She stated that an RN should not delegate the task to a CNA. The DON stated it was not the policy of the facility to allow CNAs to administer medications and that both CNA10 and RN9 should have known the scope of their practices. The DON stated after she had learned on 04/21/25 of the incident, both CNA10 and RN9 were contacted. The DON stated that CNA10 stated that she had given R70 and R76 their medications and had completed a fingerstick blood glucose check for R11. The DON stated that when she spoke with RN9, RN9 reported that she had allowed CNA10 to administer medications to one resident and perform one fingerstick blood glucose check. The DON stated both staff members were suspended immediately pending investigation, and the investigation was started. The DON stated because of the conflicting information from the emails and the staff's statements, she had asked the provider to complete assessments on all the residents on the Town Square unit, because everyone had the potential to be affected. The DON stated nursing staff had been educated on delegating and scope of practice. The DON stated RN9 had resigned her position and CNA10's employment had been terminated. The DON stated that regional administration, Human Resources, the Administrator, and the physician had been involved determining and implementing corrective measures. Review of the Virginia Administrative Code revealed When staff administers acting as a medication aide, revealed, . Qualifications and supervision of staff administering medications . When staff administers medications to residents, the following standards shall apply . All staff responsible for medication administration shall . Be licensed by the Commonwealth of Virgina to administer medications; or b. Be registered with the Virginia Board of Nursing as a medication aide . https://law.[NAME].virginia.gov/admincode/title22/agency40/chapter73/section670/#:~:text Qualifications and supervision of staff administering medications. Review of the Virginia Administrative Code revealed, . Delegation shall be made only if . Delegated tasks and procedures are within the knowledge, area of responsibility, and skills of the delegating nurse . https://law.[NAME].virginia.gov/admincode/title18/agency90/chapter19/section250/#:~:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, clinical record review, and facility policy review, 1.) the facility failed to implement enhanced barrier precautions (EBP) during high contact resident care for two residents (Resident (R) 86 and R63) ; 2.) the facility failed to implement contact precautions measure in posting appropriate signage and ensuring appropriate PPE was readily available in the care of one resident (R7); 3.) the facility staff failed to perform the standard precautions of appropriate hand hygiene with incontinent care and with handling clean linen to prevent risk of cross contamination for one of one resident (R36); and 4.) facility staff failed to perform the required hand hygiene with meal service to prevent cross contamination for seven residents (R66, R22, R51, R70, R23, R35, and R36), out of a total sample of 30 residents, increasing the risk of hospital-acquired infections for all residents. Findings include: 1. For Residents #86 and Resident #7, facility staff failed to implement enhanced barrier precautions (EBP) during high contact resident care. a. Review of R86's Profile and Med Diag (Medical Diagnosis) tab of the electronic medical record (EMR) revealed R86 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis and reflux uropathy. Review of R86's Physician Orders, dated 10/02/24 and located under the Orders tab of the EMR, revealed . Infection precautions - enhanced barrier d/t [due to] foley [urinary catheter]. every shift for infection control per protocol remainder of resident's stay or until foley is removed. Staff is to wear gown/gloves when engaging in high contact activities . Review of R86's Care Plan, dated 01/13/25 and located under the Care Plan tab of the EMR, revealed a focus of, . the resident requires a urinary (Foley) catheter related to obstructive uropathy, urinary retention . Res now has new suprapubic cath [catheter] site . Interventions included, . enhanced barrier precautions . During an observation and interview on 04/29/25 at 12:29 PM, R86 was observed lying in bed. A sign stating to use EBP was observed on the wall in the resident's room, near the head of her bed. No PPE was observed in the resident's room or in her bathroom. The resident had a urinary catheter bag hanging from the left side of her bed. R86 stated she had a suprapubic catheter. R86 was asked if staff wore PPE of gowns and gloves when providing care. She stated, Sometimes they do; depends on what they are doing. No PPE, signage, or markings noting the resident was on EBP were noted near the outside of the resident's room. During an observation and interview on 05/01/25 at 10:50 AM, Licensed Practical Nurse (LPN) 3 was observed providing suprapubic catheter care for R86. LPN3 performed the care without donning a gown. At 11:04 AM, after completing the care, LPN3 was asked if R86 was supposed to be on EBP. She stated, Yes. LPN3 stated she forgot to wear a gown. LPN3 was asked where the PPE was kept. LPN3 showed the surveyor a package of gowns and a supply of gloves located in the supply room behind the nurses' station at the middle of the unit. During an interview on 05/01/25 at 1:20 PM, the Director of Nursing (DON) stated it was the facility's policy for EBP signage to be inside the resident's room and for PPE to be in the central supply closet. She stated there was supposed to be a colored dot outside the door to indicate the resident was on EBP. The DON stated her expectation was that staff would wear a gown and gloves for suprapubic catheter care. When asked what color of dot should be outside a resident room to indicate the resident was on EBP, the DON said that she did not know, but the Unit Mangers would know. During an observation and interview on 05/01/25 at 1:24 PM, Certified Nurse Aide (CNA) 3 was asked to show the surveyor the colored dot or other indication that R86 was on EBP. CNA3 looked outside of R86's room and confirmed that there was no colored dot or anything in place to indicate in any way that R86 was on EBP. On 05/01/25 at 1:30 PM, the DON was informed that the surveyor could not find a colored dot outside of R86's room. The DON stated, Yes and acknowledged that the Unit Managers had told her that there were not any dots posted. b. Review of the Face sheet found in R63's EMR under the Profile tab revealed R63 was admitted to the facility on [DATE] with a diagnosis of anoxic brain damage and gastrostomy. Review of R63's Care Plan Report found under the care plan tab revised 02/25/25 revealed the resident is at risk for weight loss, malnutrition or poor hydration status related to need for supplemental enteral nutrition . Provide enteral feedings as ordered . Review of R63's Quarterly MDS assessment with an ARD date of 04/15/25 revealed the resident had a BIMS score of 14, which indicated no cognitive impairment. Further review revealed R63 required a feeding tube while in the facility. Review of the Clinical Physician Orders found in R63's EMR under the Order tab dated April 2025 revealed .Infection precautions- enhanced barrier every shift for infection . guaifenesin (expectorant medication) tablet 400 mg [milligrams] give 1 tablet via PEG [percutaneous endoscopic gastrostomy]-Tube every 6 hours for cough and congestion .Sennosides-Docusate (laxative and stool softener) Sodium Tablet 8.6-50 mg give 1 tablet via PEG-Tube three times a day for Constipation . acetaminophen (pain and reduce fever) Tablet 325 mg Give 2 tablet via PEG-Tube three times a day for right shoulder pain . Per observation on 04/30/25 at 1:05 PM, Registered Nurse (RN) 1 washed hands donned gloves but did not put on a PPE gown. Per observation on 04/30/25 at 1:07 PM, RN1 assessed for enteral tube placement on R63. Per observation 04/30/25 from 1:08 PM to 1:15 PM, RN1 prepared medications and administered them to R63. Observation on 04/30/25 at 1:17 PM in R63's room revealed signage for enhanced barrier precautions hanging in on the cork board. Further observation revealed no other PPE besides gloves were near the door or in the room. During an interview on 04/30/25 at 1:17 PM, when asked if R63 was on any precautions RN1 stated, She is not on enhanced barrier precautions. When questioned further, RN1 stated that she did not notice signage in the room. When asked if signage was placed somewhere else would she notice it, RN1 stated that she would she look to the door where she was used to seeing that. When questioned about available PPE, RN1 confirmed that there were gloves in the bathroom but did not see any gowns available. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP) Policy, dated 03/28/24, revealed, . The purpose of this policy is to outline the guidelines for implementing Enhanced Barrier Precautions (EBP) in order to reduce the transmission of multidrug-resistant organisms (MDROs) within our facility. EBP will be utilized in conjunction with standard precautions to provide targeted gown and glove use during high-contact resident care activities . EBP should be employed in the following scenarios: . Has a wound or indwelling medical device, without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO . High-Contact Resident Care Activities Requiring EBP . Device Care or use (e.g., . urinary catheter, feeding tube .PPE [personal protective equipment] and alcohol-based hand rub should be readily accessible to staff, and their placement may be adjusted as needed . 2. For Resident R7, being treated for a contagious, multiple drug resistant urinary tract infection, the facility staff failed to follow contact precautions with posting the required signage and ensuring PPE was readily available near the doorway. Review of the Face sheet found in R7's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. Review of R7's Significant Change MDS assessment with an ARD date of 04/13/25 revealed the resident had a BIMS score of 15 out of 15, which indicated no cognitive impairment. Further review revealed R7 required touch assistance for toileting while in the facility. Review of the Clinical Physician Orders found in R7 EMR under the Orders tab dated 04/29/25 revealed .contact precautions related to ESBL [Extended-Spectrum Beta-Lactamases] (enzymes that render certain antibiotics ineffective) every shift . Review of R7's Care Plan Report found under the care plan tab revised 04/29/25 revealed UTI [Urinary Tract Infection] The resident has developed a urinary tract infection, ESBL Observation and interview on 04/29/25 at 1:35 PM, revealed no signage on R7's door to describe the type of precautions the resident was on or to see the nurse. Neither was a supply of gloves, gowns, or masks observed readily available near the room entrance. LPN 8 stated that the facility had orange signage to let someone know if the resident is on precautions. LPN 8 stated that R7 had ESBL and that EBP signage was posted in the room, but no contact precautions signage was posted on the door or in the room. During an interview on 05/01/25 at 10:52 AM, ADON stated, We typically put the precaution signage outside the door with the cart and the gowns. I notify the managers and set up precautions. From what I was taught, we put the EBP signage in the room for privacy and dignity purposes. 3. For R36, the facility failed to provide standard precautions in performing the required hand hygiene with the provision of incontinent care and handling of linen to decrease the risk of cross-contamination. Review of R36's Profile tab of the EMR revealed R36 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and adult failure to thrive. During an observation on 04/29/25 at 2:26 PM, Certified Nurse Aide (CNA) 1 was observed performing incontinent care for the resident. Without performing hand hygiene, CNA1 donned gloves and provided incontinent care to R36, who had notably been incontinent of bowel. CNA1 cleaned R36, placed a clean brief on the resident, and adjusted the resident's clothing. She then removed her gloves, and without performing hand hygiene, left the room to retrieve a clean incontinent pad for the bed. CNA1 returned to the room, placed the incontinent pad under the resident, adjusted the pillows and bed linens, and then adjusted the height of the bed. CNA1 retrieved the trash from the trash can and the soiled linens and left the room. CNA1 placed the soiled linens in the soiled linen closet at the nurses' station and then washed her hands. During an interview on 04/29/25 at 2:41 PM, CNA1 was asked if she had changed her gloves or performed hand hygiene after performing incontinent care for R36. CNA1 confirmed she had washed her hands after she had placed the soiled linens in the soiled linen cart but not after cleaning the resident or prior to obtaining a pad from the clean linen. CNA1 stated that she had not observed her gloves to be contaminated, and if she had, she would have changed her gloves. During an interview on 04/30/25 at 2:41 PM, Registered Nurse (RN) 4 stated that staff was expected to perform hand hygiene with incontinent care after cleaning bowel movement. RN4 stated staff should remove their gloves, perform hand hygiene, and then reglove. During an interview on 04/30/25 at 3:17 PM, the Director of Nursing was asked what the expectation was for staff performing hand hygiene during incontinent care. The DON stated that the expectation was for staff to remove their gloves, perform hand hygiene, and reglove when moving from a contaminated area to a clean area. 4. For R66, R22, R51, R70, R35, R23, and R36, the facility staff failed to perform the required hand hygiene to prevent cross-contamination during meal tray delivery. During an observation on 04/29/25 at 1:03 PM, CNA1 was observed passing meal trays on the Town Square unit. CNA1 entered R66's room, placed the meal tray on the overbed table, repositioned the resident's overbed table, helped the resident with her sweater, and then left the room. Without performing hand hygiene, CNA1 retrieved a meal tray for R22. CNA1 entered R22's room, uncovered the resident's food and left the room. At 1:06 PM, CNA1 poured coffee for R51, entered the room, placed the meal tray on the resident's overbed table, repositioned the resident's wheelchair and locked the wheels. Without performing hand hygiene, CNA1 left the room, called the kitchen to place an order, and then pushed the tray cart down the hall. At 1:10 PM, without performing hand hygiene, CNA1 retrieved a tray for R70, placed the tray on the resident's table in the hallway, and helped the resident prepare her food. CNA1 put butter on the potatoes and then entered room [ROOM NUMBER] and left with the same gloves. After removing her gloves, CNA1 was observed putting on gloves without performing hand hygiene and continued to help R70 with her food. At 1:14 PM, CNA1 removed her gloves, and without performing hand hygiene, entered R23's room, placed a clothing protector on the resident, and adjusted the resident's position in bed. At 1:16 PM, CNA1 retrieved a meal tray from the cart, entered R35's, placed the tray on the resident's overbed table, and adjusted the table. At 1:17 P M, CNA1 left the room and called the kitchen to place an order. At 1:19 PM, without performing hand hygiene, CNA1 re-entered R23's room, put on gloves, wet a washcloth, and washed the resident's face. CNA1 then removed her gloves, went back to R23, and handed the resident her spoon to eat with, without performing hand hygiene. At 1:22 PM, CNA1 approached R36 in the unit's dining area, sat down, and without performing hand hygiene, began to feed the resident. During an interview on 04/29/25 at 2:41 PM, CNA1 was asked if she performed hand hygiene while delivering the meal trays. CNA1 stated, No. CNA1 stated that she only needed to perform hand hygiene if she was touching the residents' food. CNA1 was asked if she should perform hand hygiene if she had touched items in the residents' rooms, such as wheelchairs and overbed tables. CNA1 stated that she did not think so. During an interview on 04/30/25 at 2:40 PM, RN4 stated staff should wash their hands before beginning to pass meal trays and perform hand hygiene after each tray that was delivered, especially if items in the residents' rooms were moved. During an interview on 04/30/25 at 3:17 PM, the DON stated her expectation was for staff to perform hand hygiene before passing meal trays and between each meal tray that was passed. Review of the facility's undated policy titled, Hand Hygiene revealed, . The facility promotes hand hygiene as a simple and effective method for preventing the spread of infections. Glove use is not a substitute for hand hygiene. All staff are to perform hand hygiene during all care activities and while working in all locations within the facility . 'Hand hygiene' means to clean one's hands with either a sanitizer product or with soap and water . All staff are responsible for following hand hygiene procedures . After contact with . body fluids or excretions . After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident . When hands move from a contaminated-body site to a clean body site during resident care . Before and after wearing gloves No additional information was provided prior to survey exit.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to notify the POA (power of attorney) of a change in condition for one resident (Resident #11) in a survey sample of 11 Residents. The findings included: On 1/4/24 and 1/5/24, a clinical record review was conducted of Resident #11's chart. The progress notes on 8/16/22 read, Patient found unresponsive and nurse practitioner notified and order received to send Resident #11 out to the hospital. On 8/16/22 at 3:42 p.m., a progress note documented that the POA was notified at 10:30 a.m. of Resident #11 being sent out to the hospital due to a blood sugar of 43. On 1/4/24 at 1:30 p.m., the DON [Director of Nursing] was interviewed and stated, the expectation of notifying NP [Nurse Practitioner] and family is during the transfer or shortly after unless unable to reach, then it may be a delay. On 1/5/24 at 10:55 a.m., Surveyor C interviewed Resident #11's POA. The POA stated, I was notified by facility staff after calling to the facility and not being able to reach [Resident #11], wanting the facility staff to check on [Resident #11]. That is when the facility staff informed me of the change in condition and that [Resident #11] had been sent out to the ER for evaluation. The facility policy titled Change in Resident's Condition, included the following excerpts: The facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) .3. Unless otherwise instructed by the resident, a nurse will notify the resident's representative .e. it is necessary to transfer the resident to a hospital/treatment center. On 1/4/24 the DON and Administrator was made aware of the above findings. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice for 7 Residents (Resident #1, #2, #3, #6, #7, #9, and #10) in a survey sample of 11 Residents. For Resident #1, #2, #3, #6, #7, #9, and #10, the facility staff failed to administer medications in accordance with physician orders and failed to notify the physician that the ordered medications were not administered. The findings included: On 1/4/24 and 1/5/24, clinical record reviews were performed, which revealed the following: 1. According to Resident #1's clinical record, the facility staff documented on 05/12/2022 at 10:13 AM, Administration Note: Hydrocodone-Acetaminophen [also known as Lortab and Norco] Tablet 7.5-325 MG, give 1 tablet by mouth two times a day for pain. Have not received from pharmacy. Review of the Medication Administration Record (MAR) revealed that the Norco was not administered on 05/12/22 and 5/20/22, but there was no documentation that the physician was notified that the order was not carried out. Review of the Omnicell (in-house emergency medication supply) contents listing revealed that the Norco was available, but had not been pulled and administered as ordered by the physician. There was no documentation that indicated the physician was notified that the order was not carried out. Review of the MAR also revealed that Resident #1 was not administered Mirtazapine on 5/14/22, as ordered. The physician order read, Mirtazapine Tablet Disintegrating 15 MG, Give 1 tablet by mouth at bedtime for depression. Review of the progress notes revealed no indication as to why the medication was not administered and there was no documentation that the physician was notified that the order was not carried out. On 5/18/22, the medical provider ordered Saccharomyces boulardii Capsule [a probiotic] 250 MG. Give 1 capsule by mouth two times a day for probiotic for 7 Days. Review of the MAR revealed that Resident #1 did not receive 5 of the 14 doses as ordered. Nursing notes documented that it was not available from the pharmacy. During interviews conducted on 1/5/24 with the director of nursing (DON) and LPN B, both stated that this probiotic is an over-the-counter medication and that a supply is always maintained in-house. There was no documentation that indicated the physician was notified that the order was not carried out. 2. According to the clinical record, Resident #2 was a resident of the facility from 6/23/22-6/28/22. Review of medication administration record, physician orders, and progress notes revealed that on 6/23/22 and 6/24/22, the following medications were not administered as ordered: atorvastatin calcium, cholecalciferol, dexamethasone, folic acid, furosemide, levothyroxine sodium, multivitamin, polyethylene glycol powder, potassium, rivaroxaban, famotidine, guaifenesin, and metoprolol tartrate. Resident #2's progress note entries for these dates indicated that the medications were on order. Review of the Omnicell contents listing revealed that atorvastatin calcium, furosemide, levothyroxine, and metoprolol were available for administration and that facility staff could have accessed the medications to give. The following medications were listed among the facility's over-the-counter supply and thereby were available for administration: cholecalciferol, folic acid, multivitamin, polyethylene glycol powder, potassium, famotidine, and guaifenesin. No documentation was found that the provider had been made aware that any of these medications were not administered as ordered. 3. According to the clinical record, Resident #3 was admitted to the facility on [DATE] related to a fractured pelvis. Review of the MAR revealed that on the morning of 6/24/22, Resident #3 was not administered the following morning medications (8am/9am): cholecalciferol, lidoderm topical pain patch, lisinopril, pantaprazole, zoloft, calcium 600 + D, Tylenol, and flomax. No reason was documented and there was no indication that the physician was made aware that the medications were not administered as ordered. 4. According to the clinical record, Resident #6 was admitted to the facility on [DATE]. Review of the MAR revealed that Resident #3 did not receive Carvedilol 25mg until the evening of 6/24, which was ordered twice daily, therefore missing 2 doses. Review of the Omnicell content listing revealed that the medication was available in half strength, which would require a call to the provider to get an order to give two of the 12.5 mg tabs to equal the 25 mg dose ordered for administration. The same was the case for the missed dose of Atorvastatin 80 mg that was ordered for bedtime on 6/23. Review of the Omnicell content listing revealed that the medication was available in 40 mg tablets, which would require a call to the provider to get an order to give two of the 40 mg tabs to equal the 80 mg dose ordered for administration. Further review of the MAR revealed that Resident #6 also missed her evening dose of Lisinopril 10 mg on 6/23/22. Although the dose was available for administration from the Omnicell, the medication was documented as not available pharmacy aware. No documentation was found that the physician had been notified that any of these medications were not administered as ordered. 5. According to the clinical record, Resident #7 was ordered bacillus Coagulans as a probiotic to be administered daily. Review of the MAR revealed that from 6/2/22-6/20/22, Resident #7 only received 8 doses of the 18 doses ordered. According to Resident #7's progress notes, either not on hand or not available was documented as the reason the medication was not available. There was no indication that the doctor was made aware that the order for this medication was not carried out. On 1/5/24, an interview was conducted with the director of nursing, who indicated that the probiotic was an over-the-counter medication that is stocked and maintained in house. On 1/5/24, surveyors B and C, accompanied by LPN B, were shown the medication storage room, noting that this probiotic was among the supply. When questioned specifically, LPN B confirmed that the probiotic is an item that the facility maintains in their stock of over-the-counter medications. No documentation was found that the physician had been notified that this medication was not administered as ordered. 6. According to the clinical record, Resident #9 was not administered medications in accordance with physician orders. Review of the MAR revealed that on 6/7/22, Resident #9 was not given Atorvastatin 20 mg at bedtime as ordered. The 6/7/22 progress note read, meds have not arrived from pharmacy. Review of the Omnicell content listing revealed that this medication was available for administration. Review of the MAR revealed that Resident #9 awas not administered the ordered dose of vitamin D3 on 6/8/22. Vitamin D3 was listed among the facility's over-the-counter supply and thereby was available for administration. Review of the MAR also revealed that Resident #9 was also ordered Hydroxyzine HCl 25 mg four times a day for anxiety. Resident #9's MAR documented that 3 doses of this medication was not given on 6/8/22. The 6/8/22 nursing note read in part, unavailable/on order. Review of the Omnicell content listing revealed that this medication was available for administration. No documentation was found that the physician had been notified that any of these medications were not administered as ordered. 7. According to the clinical record, Resident #10 had an order dated 6/19/22, for Venlafaxine HCL ER, 150 mg, two tablets were to be given daily for major depressive disorder. Review of the MAR revealed that Resident #10 did not receive this medication until 6/22/22. A review of Resident #10's progress notes revealed a 6/19/22 nursing note that documented the medication has not arrived from pharmacy, then on 6/20/22, a nursing note documented on order, and a 6/21/22 nursing note documented awaiting arrival from pharmacy. No documentation was found that the physician had been notified that this medication was not administered as ordered. On 1/5/24 at 10 AM, an interview was conducted with the Director of Nursing. When asked to describe what nurses are to do when a medication is not available, the DON stated that her expectation is that the nurses check the Omnicell and if not available, reach out to the pharmacy. When questioned further, the DON stated that if it is a delayed delivery, the nurses can reach out to a local pharmacy. The DON added that the facility has back-up pharmacies locally and these pharmacies can deliver orders for medications that are needed urgently. On 1/5/24 at 10:44 AM, an interview was conducted with LPN B. LPN B was asked to explain the process used if a medication is not available. LPN B stated that checking the entire cart to ensure the needed medications hadn't been placed in a different drawer, checking the Omnicell to see if the medication is available, but if not, then calling the pharmacy to see if it was in the next delivery. When questioned further, LPN B said, I would call the provider and let them know. When asked why is it important to notify the provider, LPN B said, In case they need to give them something else that we do have in-house. On 1/5/24 at 11:15 AM, an interview was conducted with the nurse practitioner (NP). When asked what time frame were orders expected to be carried out, the NP stated, within that shift. A review was conducted of the facility policy titled, General Guidelines for Medication Administration, with an effective date of 9-2018. The policy read in part, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer . IV. Documentation . 6. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the MAR [medication administration record] for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses, or in accordance with facility policy, of a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response. On 1/5/24, the Director of Nursing (DON) stated that the facility followed [NAME] and [NAME] standards of nursing practice. According to the [NAME] and [NAME], Fundamentals of Nursing, Eighth Edition, Chapter 4 Professional Standards in Nursing Care: Box 23-2 Common Negligent Acts were listed on page 302. The list included, but was not limited to, failure to follow orders . and failure to follow policies and procedures . On 1/4/24 and 1/5/24, during the end of day meetings and pre-exit conference, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide pharmaceutical services to meet the needs of 4 Residents (Resident #1, #2, #4, and #6) in a survey sample of 11 residents. The findings included: On 1/4/24 and 1/5/24, clinical record reviews were conducted, which included a review of progress notes, physician orders, medication administration records and care plans. The following was noted: 1. Resident #1 was ordered protonix to be given twice a day for gastro-esophageal reflux disease (GERD). The medication was not administered as ordered by the physician. A progress note dated 05/12/2022 at 10:13 AM, read, do not have from pharmacy. 2. Resident #2 was admitted to the facility on [DATE]. Review of the medication administration record (MAR) revealed that the resident missed multiple medication administrations due to medications not being available/ pharmacy had not delivered. They included, dexamethasone, Alfuzosin HCL ER, and rivaroxaban. Review of the pharmacy delivery information provided by the facility administration revealed that Resident #2's medications were not delivered to the facility until 6/24/22 at 3:23 PM. 3. Resident #4 was ordered to have a fentanyl 12.5 mcg/hr. patch applied every 72 hours for chronic pain. On 6/20/22, the Resident did not receive the patch as ordered. The nursing notes read, awaiting new patches from pharmacy. 4. Resident #6 was admitted to the facility on [DATE]. Following her admission, she went without medications on 6/24/22, to include Plavix and Trelegy. She missed evening dose on 6/23/22, and the morning dose of Cholestyramine, and Torsemide on 6/24/22 due to medications not being available. According to nursing notes the medications were not available. On the evening of 6/23/22, Resident #6 went without her dose of Escitalopram, due to the medication not being available. On 1/5/24 at 10 AM, an interview was conducted with the Director of Nursing. When asked to describe what nurses are to do when a medication is not available, the DON stated that her expectation is that the nurses check the Omnicell and if not available, reach out to the pharmacy. When questioned further, the DON stated that if it is a delayed delivery, the nurses can reach out to a local pharmacy. The DON added that the facility has back-up pharmacies locally and these pharmacies can deliver orders for medications that are needed urgently. On 1/5/24 at 10:44 AM, an interview was conducted with LPN B. LPN B was asked to explain the process used if a medication is not available. LPN B stated that checking the entire cart to ensure the needed medications hadn't been placed in a different drawer, checking the Omnicell to see if the medication is available, but if not, then calling the pharmacy to see if it was in the next delivery. When questioned further, LPN B said, I would call the provider and let them know. When asked why is it important to notify the provider, LPN B said, In case they need to give them something else that we do have in-house. On 1/5/24 at 11:15 AM, an interview was conducted with the nurse practitioner (NP). When asked what time frame were orders expected to be carried out, the NP stated, within that shift. A review was conducted of the facility policy titled, General Guidelines for Medication Administration, with an effective date of 9-2018. The policy read, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer . IV. Documentation . 6. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the MAR [medication administration record] for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. If 3 consecutive doses, or in accordance with facility policy, of a vital medication are withheld, refused, or not available, the physician is notified. Nursing documents the notification and physician response. Review of the Pharmaceutical services contract between the facilitiy and their contracted pharmacy was conducted. An excerpt from this contract read, 1.2 Methods of providing services . i. the pharmacy shall establish an emergency system for backup and/or interim order dispensing. Any emergency drug supply provided under this section shall be the property of the pharmacy as prescribed by applicable laws . On 1/4/24 and 1/5/24, during an end of day meeting, the administrator and director of nursing were made aware of the above findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents were free from significant medication errors, affecting 5 residents (Resident #1, #5, #6, #9, and #11), in a survey sample of 11. The findings included: On 1/4/24 and 1/5/24, comprehensive record reviews were conducted that revealed the following omissions in the medication administration records (MARs), physician orders. 1. Staff failed to administer sliding scale insulin to Resident #5 for the treatment of diabetes mellitus. Resident #5 had orders for Humulin R insulin to be administered on a sliding scale dependent upon the blood sugar level. On 6/4/22, Resident #5's blood sugar at 11 AM was 209, for which 2 units of insulin should have been administered, according to the sliding scale order. Then at 4 PM the blood sugar level was 164, for which 1 unit of insulin should have been administered. On 6/12/22, Resident #5's blood sugar at 9 PM was 349, for which 4 units of insulin should have been administered. On 6/14/22 at 11 AM, Resident #5's blood sugar was 157, which according to the sliding scale order, 1 unit of insulin should have been administered. On 6/17/22 at 9 PM, Resident #5's blood sugar was 295, for which 3 units of insulin should have been administered. On 6/19/22 at 9 PM, Resident #5's blood sugar reading was 243, for which 2 units of insulin should have been administered. On 7/15/22 at 4 PM, Resident 3#5's blood sugar was 220 and at 9 PM it was 292, for which insulin coverage was ordered, but was not administered. Review of the progress notes for any of these dates revealed no entry to indicate why the insulin was not administered as ordered. On 1/5/24, the Director of nursing (DON) was asked to review Resident #5's medication administration record (MAR). The DON confirmed the above findings that in each of the medication errors noted above, insulin was warranted and ordered by the provider in accordance with the sliding scale insulin orders, but had not been administered. When questioned further, the DON was not able to state why the insulin was not administered as ordered. When asked about the consequences of insulin not being administered, the DON said, You can have elevated blood sugar which could progress all the way to hospitalization or DKA [diabetic ketoacidosis]. Over a long period of time it can lead to other dysfunctions in the body. 2. Staff failed to administer anti-cancer medication to Resident #1. admitted to the facility on [DATE], Resident #1's diagnoses included, but were not limited to, gastrointestinal stromal tumor of stomach. On admission, Resident #1 was ordered Imatinib Mesylate tablet 400 mg, to be given daily in the morning for GI tumor. Imatinib is a medication used to manage and treat chronic myelogenous leukemia, gastrointestinal stromal tumors, and other malignancies. A nursing note entered on 05/12/2022 at 08:57 AM, read, Report received from [nurse name redacted] that pharmacy cannot get the Imatinab here until Friday [5/13/22]. Spoke with [name of nurse practitioner redacted] and made aware. There are no substitutes so we will wait for pharmacy to bring the medication. According to the MAR, Resident #1 was also not administered either dose on 6/18/22 or 6/19/22, but there was no indication of that in the progress notes. 3. Staff failed to administer Resident #6 an antibiotic medication which requires careful dosing for effective treatment without toxicity. Starting on 6/24/22, Resident #6 had a physician's order for Vancomycin 125 mg to be given four times a day for c-diff (Clostridioides difficile - a bacterial infection that causes diarrhea and colitis). According to the MAR, Resident #6 only received one dose on 6/24/22, then was not given 1 of 4 doses on 6/25/22, 2 of 4 doses on 6/6/29/22, 4 of 4 doses on 6/30/22, and 4 of 4 doses on 7/1/22. Until rehospitalized on [DATE], Resident #6's progress notes documented the following: 6/29/22 - med on order; 6/30/22 - medication is on order; 7/1/22 - not avail pharmacy aware. According to the nurse practitioner note written 6/24/22, prior to admission to this facility, Resident #6 was hospitalized from [DATE] to 06/23/2022 with enterocolitis due to Clostridium difficile and sepsis, diagnosed pancolitis, acute hypoxemic respiratory failure, acute-on-chronic heart failure, has anemia of chronic kidney disease, coronary artery disease, heart failure with reduced ejection fraction, bilateral pleural effusion, hypokalemia, hyponatremia, hyperlipidemia, hypertension, stenosis of the abdominal aorta, pressure injury left buttock stage 2 . The need for the antibiotic was significant in treating the c-diff infection, but the MAR revealed that the following medications were not administered on 6/24/22: plavix, trelegy ellipta, cholestyramine, nystatin, toresmide, carvediol, and ferrous sulfate. 4. Staff failed to administer a medication to decrease risk of post-operative complications. Resident #9 was admitted to the facility following a fracture of the patella and status post-surgical stabilization, with diagoses that included, but was not limited to, atrial fibrillation, diabetes mellitus, healing knee fracture, difficulty walking, and essential hypertension. Resident #9 was ordered to receive Dabigatran Etexilate Mesylate Capsule 150 mg twice daily to prevent a blood clot. According to the MAR, Resident #9 was not administered this medication on 6/10/22, 6/11/22, 6/18/22, & 6/19/22. According to the progress notes dated 6/10 & 6/11/22, documentation indicated the medication was on order from pharmacy. No progress notes were found to address the omissions on 6/18/22 & 6/19/22. 5. Staff failed to administer multiple medications, including an antiestrogen and antibiotics. admitted on [DATE] with diagnoses that included but were not limited to right hip replacement, breast cancer, diabetes, urinary tract infection, cystitis, Resident #11 was ordered Tamoxifen Citrate Tablet 20 MG, Give 1 tablet by mouth one time a day for breast cancer, which was scheduled to start 8/9/22 at 8am. According to the MAR, not only was this medication not administered, nor was the majority of the ordered medications. Among these omissions were the following doses of antibiotics: Trimethoprim Tablet 100 MG - two doses on 8/9/22 & 1 dose on 8/10/22; Nitrofurantoin Macrocrystal Capsule - two doses on 8/9/22 & 1 dose on 8/10/22; and Cefadroxil Capsule - two doses on 8/9/22 & 1 dose on 8/10/22. However, progress note dated 8/10/22 10:18pm documented that these antibiotics were still on order from the pharmacy. On 1/5/24 at 10 AM, an interview was conducted with the Director of Nursing. When asked to describe what nurses are to do when a medication is not available, the DON stated that her expectation is that the nurses check the Omnicell and if not available, reach out to the pharmacy. When questioned further, the DON stated that if it is a delayed delivery, the nurses can reach out to a local pharmacy. The DON added that the facility has back-up pharmacies locally and these pharmacies can deliver orders for medications that are needed urgently. On 1/5/24 at 10:44 AM, an interview was conducted with LPN B. LPN B was asked to explain the process used if a medication is not available. LPN B stated that checking the entire cart to ensure the needed medications hadn't been placed in a different drawer, checking the Omnicell to see if the medication is available, but if not, then calling the pharmacy to see if it was in the next delivery. When questioned further, LPN B said, I would call the provider and let them know. When asked why is it important to notify the provider, LPN B said, In case they need to give them something else that we do have in-house. On 1/5/24 at 11:15 AM, an interview was conducted with the nurse practitioner (NP). When asked what time frame were orders expected to be carried out, the NP stated, within that shift. A review was conducted of the facility policy titled, General Guidelines for Medication Administration, with an effective date of 9-2018. The policy read, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer . IV. Documentation . 6. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the MAR [medication administration record] for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record . Nursing documents the notification and physician response. On 1/4/24 and 1/5/24, during an end of day meeting, the administrator and director of nursing were made aware of the above findings. No further information was provided.

Based on observation, staff interview, and clinical record review, the facility failed to evaluate for self administration of medications for one of 21 residents, Resident #8. The Findings Include: Diagnoses for Resident #8 included; Pneumonia, sepsis, chronic kidney disease, and major depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/29/22. Resident #8 was assessed with a cognitive score of 11 indicating moderately cognitively intact. On 4/19/22 at 10:56 a.m., while interviewing Resident #8 medications were observed on the bedside table in a dispense cup. Resident #8 verbalized not wanting to take the medications until after breakfast so had asked the nurse to leave them on the table. On 4/19/22 at 11: 06 a.m., licensed practical nurse (LPN #4) was interviewed and stated she had brought the medications in to Resident #8 earlier and Resident #8 said to leave them and would take them after breakfast. When asked about concerns of leaving medications at the bedside, LPN #4 stated understanding that medications should not be left at bedside. LPN #4 also was uncertain if Resident #8 was evaluated to self administer medications. On 4/20/22 Resident #8's medical records were reviewed and did not evidence that an assessment or a care plan for self administration had been completed. On 04/20/22 at 5:32 p.m., the above information was presented to the administrator and director of nursing (DON) and they were asked to present any additional information. On 4/20/22 the DON presented a policy titled Self Administration of Medication and Treatments and read in part: 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities and choice to determine whether self-administering medications and/or treatments is clinically appropriate for the resident. No other information was presented prior to exit conference on 4/21/22.

Based on staff interview, and clinical record review, the facility failed to document a discharge to the hospital in the clinical record for one of 21 residents, Resident #12. The Findings Include: Resident #12 was admitted with diagnosis that included: Dementia, Hypotension, dysphagia, peripheral vascular disease, and depression. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 2/25/22. Resident #12 was assessed with a cognitive score of 10 indicating moderately cognitively intact. On 4/19/22 Resident #12's medical record was reviewed. The MDS list indicated Resident #12 had been discharged to the hospital on 3/15/22. Review of the progress notes dated 3/15/22 indicated Resident #12 was found in bed with . medium amount of coffee ground emesis A nursing note dated 3/16/22 documented, Resident returned from the hospital There were no other progress notes or discharge notes indicating why Resident #12 had gone to the hospital. On 04/20/22 at 10:19 a.m. registered nurse (RN #2) reviewed Resident #12's medical record and could not find any documentation regarding the discharge to the hospital. RN #2 stated there should be a progress note or a transfer assessment when a resident goes out to the hospital. On 04/20/22 at 5:32 p.m. the above information was presented to the DON (director of nursing) and administrator. No other information was presented prior to exit conference on 4/21/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure admission orders for the immediate care and services of a central line catheter for one of 21 residents in the survey sample, Resident #230. Findings include: Resident #230 was admitted with diagnoses that included, but were not limited to: BPH (benign prostatic hypertrophy) with urinary retention, indwelling Foley catheter, urinary tract infection, entercolitis, C-Diff (clostridium difficile) infection, PVD (peripheral vascular disease), dementia, high blood pressure and bacteremia (infection in the blood). The resident's admission MDS (minimum data set) was still in progress. Resident #230's nursing admission assessment dated [DATE] documented, that the resident had dementia with cognitive deficits (unable to answer to place, time and situation). This admission assessment did not include the presence of a central line for Resident #230. Resident #230's hospital Discharge summary dated [DATE] documented the resident grew bacteria in the blood and urine and would receive IV Vancomycin for a total of 14 days (7 days remaining when admitted to the long term care facility), a [NAME] (central line access) catheter device was placed at the hospital for the use long term antibiotic administration. On 04/20/22 at 11:36 AM, Resident #230 was observed in his room. An IV (intravenous) pole with machine was observed in the corner of the room. Resident #230 was asked if he had any type of IV access. Resident #230 started feeling around on his body and under the blankets. The resident was asked again if he had IV access and was asked if there was something in/on his chest area. Resident #230 then started pulling at his shirt. The resident was asked to pull the collar of his shirt down in order to observe. The resident pulled down from his neck, exposing a central line catheter in the right chest wall. The central line catheter had a clear, dry dressing intact dated 04/15/22. The physician's orders were then reviewed. There were no care orders for the central line access device (dressing changes, IV flush, etc.). The MARs/TARs (medication/treatment administration records) were reviewed. There were no care orders listed for the central line catheter. The current care plan documented, .resident will not have complications related to infection .meds/treatments as ordered .IV medications related to C-diff, UTI . On 04/20/22 at 4:45 PM, LPN (Licensed Practical Nurse) #1 was interviewed regarding Resident #230's central line access. LPN #1 was asked about what to do for Resident #230's central line. LPN #1 stated, Nothing. LPN #1 was asked why and the LPN stated, We have no orders. LPN #1 was then asked why there were no orders for the resident's central line access device. LPN #1 stated, That's a good question. At 4:50 PM, the unit manager, registered nurse (RN) #1, was interviewed regarding Resident #230's orders for the care of the central line. RN #1 stated that she had not personally done any dressing changes or care for the resident's central line access. RN #1 stated that the central line access is supposed to be flushed and have dressing changes. RN #1 was asked where that information comes from. RN #1 stated, Physician's orders. RN #1 was made aware that there were no physician orders for the care of the central access line and was asked why there weren't any orders. RN #1 stated, I did not put them in. RN #1 began to look in the computer system and stated, No orders for flushes, or dressing changes .Nope, there aren't any in there. RN #1 was asked how nursing would know how to flush or when to change the dressing. RN #1 stated, From our provider. RN #1 was asked if they have standing orders for central line access device care and maintenance. RN #1 stated, No ma'am, no standing orders. On 04/20/22 at 5:15 PM, the DON (director of nursing), ADON (assistant director of nursing) and the administrator were made aware of concerns regarding Resident #230 not having any care orders for central line access device. A policy was requested on admission orders, specifically central line access device care on admission. A policy was presented titled, Medication Orders. The policy documented, .Each resident must be under the care of a Licensed Physician .a current list of orders must be maintained in the clinical record of each resident .All orders must clearly identify the resident for whom the order is intended . A policy was presented titled, Central Venous Catheter documented, .To provide a general procedure regarding central venous catheters .Obtain physician's order . No further information and/or documentation was presented prior to the exit conference on 04/21/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review the facility staff failed to ensure a baseline care plan for a central venous access catheter was completed for one of 21 residents in the survey sample, Resident #230. Findings include: Resident #230 was admitted with diagnoses that included, but were not limited to: BPH (benign prostatic hypertrophy) with urinary retention, indwelling Foley catheter, urinary tract infection, entercolitis, C-Diff (clostridium difficile) infection, PVD (peripheral vascular disease), dementia, high blood pressure and bacteremia (infection in the blood). The resident's admission MDS (minimum data set) was still in progress. Resident #230's nursing admission assessment dated [DATE] documented, that the resident had dementia with cognitive deficits (unable to answer to place, time and situation). This admission assessment did not include the presence of a central line for Resident #230. Resident #230's hospital Discharge summary dated [DATE] documented the resident grew bacteria in the blood and urine and would receive IV Vancomycin for a total of 14 days (7 days remaining when admitted to the long term care facility), a [NAME] (central line access) catheter device was placed at the hospital for the use long term antibiotic administration. On 04/20/22 at 11:36 AM, Resident #230 was observed in his room. An IV (intravenous) pole with machine was observed in the corner of the room. Resident #230 was asked if he had any type of IV access. Resident #230 started feeling around on his body and under the blankets. The resident was asked again if he had IV access and was asked if there was something in/on his chest area. Resident #230 then started pulling at his shirt. The resident was asked to pull the collar of his shirt down in order to observe. The resident pulled down from his neck, exposing a central line catheter in the right chest wall. The central line catheter had a clear, dry dressing intact dated 04/15/22. The physician's orders were then reviewed. There were no care orders for the central line access device (dressing changes, IV flush, etc.). The MARs/TARs (medication/treatment administration records) were reviewed. There were no care orders listed for the central line catheter. The current care plan documented, .resident will not have complications related to infection .meds/treatments as ordered .IV medications related to C-diff, UTI .If the catheter appears to be lodged in the tissues, an attempt to aspirate any fluid remaining in the catheter can be made in order to lessen the amount of drug at the site. After removing the cannula, elevate the affected arm, notify the physician .and apply a cool compress . On 04/20/22 at 5:15 PM, the DON (director of nursing), ADON (assistant director of nursing) and the administrator were made aware that Resident #230's baseline care plan did not include the care of the resident's central venous access device, but instead had listed peripheral IV care. On 04/21/22 at approximately 11:00 AM, the administrator stated, You are right, there is no care plan for central line. No further information and/or documentation was presented prior to the exit conference on 04/21/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide pain management for 1 of 21 residents in the survey sample, Resident #14. Resident #14 was not administered scheduled Lidocaine 4% patches for 4 consecutive days. The findings include: Resident #14 was admitted to the facility with diagnoses including chronic pain syndrome, gastro-esophageal reflux disease (GERD), glaucoma, hypo-osmoliaty, hyponatremia, major depressive disorder, anxiety disorder, hypertension, and joint pain (knees and hands). The most recent MDS dated [DATE] was a quarterly assessment and assessed Resident #14 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #14 was interviewed on 04/19/2020 at 12:11 p.m. Resident #14 stated there had been 3 to 4 days when the scheduled Lidocaine pain patches were not available for administration. Resident #14 stated, I get 3 of the same patches a day on my knees and shoulder because I have joint pain. From my understanding the medications come from a pharmacy in North Carolina and there was a mix-up in getting them delivered here. Resident #14 was asked about his pain level, Resident #14 stated, It was bearable even at my age. But, it just didn't make sense to me that I missed that many days. I get other pain medications so I'm sure that took some of the edge off. Resident #14's clinical record incuded the following orders: Aspercreme Lidocaine 4% Patch. apply to left knee topically in the morning remove at bed time. Start Date: 12/15/2021. Aspercreme Lidocaine 4% Patch. Apply to left shoulder topically in the morning for pain remove at bedtime. Start Date: 12/09/2021. Aspercreme Lidocaine 4% Patch. Apply to right knee topically in the morning for pain remove at bedtime. Start Date: 12/09/2021. Resident #14's medication administration record (MAR) was reviewed and documented on 04/10/2022, 04/11/2022, 04/12/2022, and 04/13/2022, the morning administration of each of the scheduled Aspercreme Lidocaine 4% patch was not administered for the left knee, right knee, and left shoulder. The missed doses were marked as 9, other/see progress notes. Nursing notes dated 04/10/2022 at 8:28 a.m. documented concerning the medication patches not administered, patch on order. Nursing notes dated 04/11/2022 at 12:16 p.m. documented, Notified NP. Nursing notes dated 04/12/2022 at 8:56 a.m., documented, on order. Nursing notes dated 04/13/2022 at 9:34 a.m. documented, on order. There was no documentation about use of a back-up pharmacy to acquire the medication patches. Resident #14's care plan documented the following focus area, The resident has pain r/t (related to) neuropathy, DDD (degenerative disc disease), osteoarthritis, and GERD (Rev. 12/12/2021). Goal: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieve pain through review date (Rev. 03/14/2022.). Interventions: . Administer pain medications as ordered and monitor for effectiveness On 04/20/2022 at 9:39 a.m. the licensed practical nurse (LPN) #3 who routinely provided care for Resident #14 and documented the nursing notes on 04/10/2022, 04/12/2022, and 04/13/2022 was interviewed about the missed doses. LPN #3 stated, There was some recent confusion about pharmacy changes with the patches switching from the pharmacy order to becoming house stock. We were ordering them from the pharmacy and waiting for them delivery and then we found they were switched to a house stock item. You can speak with the unit manager or DON (director of nursing) for more information because there was a meeting to discuss the new house stock items. On 04/20/2022 at 9:42 a.m., the DON and assistant director of nursing (ADON/RN #3) were interviewed. The DON stated the facility switched to a new pharmacy on January 1, 2022 and the facility had identified a problem with receiving medications. The DON stated the facility recently met with the pharmacy on Monday, 04/18/2022 and identified the house stock list had changed and the facility was not aware of the change. The DON stated, The pharmacy told us to pull from our house stock and we weren't aware the list had grown. Corporate grew the list and they didn't tell us. The DON was asked if the Lidocaine 4% patches were part of the house stock list. The ADON/RN #3 stated, Yes if it's on the house stock list we provided you all. Then it's house stock, but previously they were ordered through the pharmacy. On 04/20/2022 at 10:11 a.m. the central supply clerk (OS #1) who was responsible for ordering house stock items was interviewed. OS #1 stated, At first I was given a very short list of house stock items. I order weekly for supplies and over the counter (OTC) and house stock medications. We did just get an updated list and I'm told this is probably not all of the OTC/house stock meds. It will probably change again. OS #1 was asked when the Lidocaine 4% patches ordered. OS #1 stated, I spoke with (LPN #3) about the situation and they were ordered about 2 weeks ago. We use the Aspercreme or Salonpas 4% generic brands as house stock. I made sure to give her a large bag of them for the med cart. A review of the (Hill Valley Corporate - Do Not Supply List, Rev. 04/20/2022) documented the Lidocaine 4% as a house stock item. The above findings were reviewed with the administrator, DON, and ADON during a meeting on 04/20/2022 at 4:55 p.m. On 04/21/2022 at 8:55 a.m., the nurse practitioner (OS #4) who routinely provided care for Resident #14 was interviewed. OS #4 stated she honestly did not remember being notified about the patches not being available and it was possible the on-call provider was notified instead. OS #4 continued and stated she had recently started providing care for Resident #14 and knew the resident received a lot of pain medications. However, she was not fully familiar with the resident's history and planned to review the record prior to discussing some possible medication changes. OS #4 was asked how would the missed doses of the Lidocaine patches affect Resident #14. OS #4 stated, (Resident #14) could potentially have pain, but he does receive other pain related medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to develop a dementia care plan for 1 of 21 in the survey sample, Resident #13. Resident #13 who was diagnosed with dementia without behavioral disturbance did not have a dementia specific care plan including person centered interventions. The findings include: Resident #13 was admitted to the facility with diagnoses that included major depressive disorder, hypertension, type 2 diabetes, atrial fibrillation, dementia without behavioral disturbance, hypothyroidism, hyperlipidemia, dysphasia, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #13 as severely cognitively impaired with a score of 3 out of 15, having fluctuating periods of inattention and disorganized thinking; and wandering. The MDS documented in Section V- Care Area Assessments (CAA) that Resident #13 should be care planned for Dementia. Resident #13's clinical record was reviewed on 04/20/2022 and included the following: Quetiapine Fumarate Tablet 50 MG (Seroquel). Give 1 tablet by mouth two times a day for dementia. Order Date: 03/10/2022. Start Date: 03/10/2022. The medication administration record (MAR) for the period March 2022 through April 2022 documented Resident #13 received the Seroquel as ordered/scheduled. Observed within the nurse practitioner progress notes was the following: 04/19/2022 .The patient has recently been having behavioral disturbances associated with her dementia and was started on Seroquel. At first the Seroquel was too strong and was being titrated back to a reasonable dose. The patient was given a prescription for p.r.n. (as needed) Ativan to help cover for any breakthrough anxiety or behavioral issues while getting the Seroquel to the correct dose. The plan was to continue the Ativan order for 14 days and then stop it, as the Seroquel does appears to have been reached a therapeutic level and the patient's behaviors have resolved. The patient has not needed the Ativan since 4/2/22. Will discontinue the ativan On 04/20/2022 at 11:30 a.m., the licensed practical nurse (LPN) #3 who routinely provided care for Resident #13 was interviewed regarding Resident #13's behaviors. LPN #3 stated the resident was readmitted to the unit a couple months ago after a brief hospital stay due to having a stroke. LPN #3 stated after returning to the facility Resident #13 tested positive for COVID and was placed on the facility's COVID unit for a couple of weeks and then returned back to their normal room on the second floor. LPN #3 was asked what behaviors Resident #13 displayed. LPN #3 stated Resident #13 had behaviors of agitation, wandering and refusing care. LPN #3 stated, (Resident #13) has dementia. LPN #3 was asked what interventions were in place for Resident #13. LPN #3 stated, She likes to ambulate with her walker and sit at the end of the hall and look at the window. When she gets agitated we try to figure out why and letting her call her children and/or visit her husband across the hall helps to calm her. LPN #3 was asked who was responsible for the care plans. LPN #3 stated the unit manager. On 04/20/2022 at 12:30 p.m., the unit manager, registered nurse (RN) #2 was interviewed regarding Resident #13's care plans. RN #2 reviewed the care plans and stated the resident did have a diagnosis of dementia and a dementia specific care plan should have been developed. RN #2 was asked what specific interventions were in place for the resident. RN #2 stated, When (Resident #13) was readmitted after the hospital stay and then transferred to the facility's COVID unit and finally back to her regular room this appeared to bring on more confusion. She now seems back at her baseline. She enjoys walking the unit, likes sitting at the end of the hall, and visiting with her husband. The above information was shared with the administrator director of nursing (DON) and assistant director of nursing (ADON) during a meeting on 04/20/2022 at 4:55 p.m.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure medications and biologicals were dated when opened on two of 4 units, Town Square and The Gardens. On the Peaks unit, facility staff failed to ensure an expired medication was not available for administration. A bottle of oral vancomycin (an antibiotic) was dated as do not use beyond 4/18/22 was still in the medication refrigerator. Findings include: On 4/20/22 beginning 8:00 a.m. the medication storage inspection was conducted in the facility. On the Town Square unit, the medication refrigerator was inspected with RN (registered nurse) # 4. An vial of tuberculin skin test solution was open with no date recorded on the box or the vial. RN # 4 stated I'm pretty sure that was opened last Wednesday when we sent a patient out .do you want me to date it now? RN # 4 was advised to do whatever the facility policy or procedure was. The medication refrigerator on Peaks unit was inspected with RN # 5. A bottle of vancomycin was observed in the refrigerator with a red label dated 4/18/22 and directed Do not use past this date. RN # 5 was asked about the expired medication, and she stated I will remove that right now. The Gardens unit medication cart was then inspected with LPN (licensed practical nurse) # 1. An opened vial of Lispro insulin was located in the cart, and was not dated when opened. LPN # 1 stated That belongs to a new admission .I can look to see when that came in since that's when it was probably opened .do you want me to date it now? Again, staff were told to follow the facility policy. On 4/20/22/at 9:30 a.m. the DON (director of nursing) was asked for the facility policy for storing and labeling medications and biologicals. The policy Medication Storage documented 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 5 a. The nurse shall place a 'date opened' sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating. 7. No expired medication will be administered to a resident. 8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. The package insert for the PPD solution was provided by the facility and directed A vial of Tubersol which has been entered and in use for 30 days should be discarded. The insulin storage guide directed that once insulin (including Lispro) is removed from the refrigerator it should be dated when removed and is good for 28 days. The administrator, DON, and ADON (assistant director of nursing) were informed of the above findings during an end of the day meeting 4/20/22 beginning at 4:55 p.m. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to have an physician's order for a therapeutic diet for Resident #13. Resident #13's clinical record did not document a nutrition/diet order upon readmission from the hospital. The findings include: Resident #13 was admitted to the facility with diagnoses that included major depressive disorder, hypertension, type 2 diabetes, atrial fibrillation, dementia without behavioral disturbance, hypothyroidism, hyperlipidemia, dysphasia, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #13 as severely cognitively impaired with a score of 3 out of 15, having fluctuating periods of inattention and disorganized thinking; and wandering. The MDS documented in Section V - Care Area Assessments (CAA) that Resident #13 should be care planned for nutritional needs. Resident #13's electronic health record (EHR) was reviewed on 04/20/2022. A review of EHR and order summary report did not document Resident #13 had an order for nutritional/dietary needs including a therapeutic diet. On 04/20/2022 at 12:08 p.m. the unit manager, registered nurse (RN) #2, who routinely provided care for Resident #13 was interviewed regarding the resident's EHR and order summary not having a nutritional/dietary orders. RN #2 reviewed Resident 13's EHR and stated she was not aware the order was missing. RN #2 then reviewed Resident #13's paper chart that included the most recent hospital Discharge summary dated [DATE]. RN #2 stated, The hospital discharge summary did not include diet orders for readmission. RN #2 was asked about the process to obtain/verify orders when a resident was admitted or readmitted . RN #2 stated nursing would verify the orders with the physician and if the resident required a speech consult than speech would make recommendations. RN #2 stated Resident #13 was not seen by speech upon readmission to the facility. RN #2 stated Resident #13 was a readmission and a diabetic and it was likely the kitchen used the previous diet orders. On 04/20/2022 at 3:45 p.m. the dietary manager (OS #2) was interviewed regarding Resident #13's diet orders. OS #2 reviewed the dietary records and stated the resident was receiving a no concentrated sweets diet. OS #2 was asked when this ordered was received. OS #2 stated on 03/03/2022. OS #2 was asked how did he receive the information. OS #2 stated nursing normally faxes or emails the admission/readmission diet orders to the kitchen. OS #2 was advised Resident #13 was readmitted on [DATE]. OS #2 reviewed the orders that were received by the kitchen for February 2022 and March 2022 and stated he could not locate the fax or email communication. OS #2 was asked why the dietary orders were not documented in the EHR. OS #2 stated nursing entered those orders in the (name of EHR system). OS #2 stated he only entered the dietary orders in the kitchen's (menu system) which generated the resident's meal tickets and/or preferences and this was not connected with the EHR. The above findings were reviewed with the administrator, DON and ADON during a meeting on 04/20/2022 at 4:55 pm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure professional standards of practice by a hospice provider for 1 of 21 residents in the survey sample, Resident #35. Records of weekly hospice visits for Resident #35 were not provided to the facility as required in the hospice services agreement. The findings include: Resident #35 was admitted to the facility with diagnoses that included anxiety disorder, cirrhosis of the liver, hepatic failure, congestive heart failure, stage 3 kidney disease, type 2 diabetes, hyperlipidemia, and encounter for palliative care (hospice). The most recent minimum data set (MDS) dated [DATE] was a quarterly and assessed Resident #35 as moderately impaired for daily decision making with a score of 11 out of 15. Under Section O - Special Programs and Treatments, the MDS documented Resident #35 was receiving hospice care. Resident #35 was interviewed on 04/19/2022 at 11:30 a.m. regarding the quality of care and quality of life since being at the facility. Resident #35 stated, I've been here for almost six years and this is home for me. Everyone treats me nice, they answer the call bells and we have so many activities. My only issue is the food. Resident #35 was asked if staff assisted with activities of daily living (ADLs). Resident #35 stated, I can do certain things for myself, but now that I am on hospice I have a hospice aide and nurse who come to visit at least twice a week. The aide will help me with my bathing and dressing. Resident #35's clinical record was reviewed and observed on the order summary report was a hospice order dated 01/17/2022. A review of Resident #35's care plans documented a focus area including goals and interventions for hospice care. Resident #35's paper chart was reviewed for the hospice notes. Observed were the hospice assessment, plan of care, medication list, hospice nursing visit notes and certified nursing assistant (CNA) visits sign-off form. The most recent hospice nursing visit note was dated 04/01/2022. On 04/20/2022 at 10:30 a.m., the unit manager, registered nurse (RN) #2 was interviewed regarding the missing hospice nursing visit notes. RN #2 was asked how often did hospice staff visit and provide/coordinate care for Resident #35. RN #2 stated, Someone usually comes a couple times per week. Usually the CNA will come one day and a nurse will come another day. RN #2 was asked how hospice visit notes were received by the facility once visits were completed. RN #2 stated, The hospice nurse is able to print the notes onsite after the visit. The CNA signs off a separate form that they have visited and provided care to the resident. RN #2 was asked about the most recent hospice nurse visit. RN #2 stated, I honestly can't say because I'm not always here when they visit, but I know someone visits twice weekly. If not we're notified. RN #2 was advised the most recent hospice nursing note was 04/01/2022. RN #2 stated, Someone has definitely visited (Resident #35) weekly, if not we would have been notified. I can't say why the notes weren't printed and filed. A review of the Nursing Home Agreement For Provision Of Hospice Services signed on 10/29/2021 between the facility and hospice provider documented on 8 the following: . 4. Records: 4/1 Compilation of Records: 4/1/1: Preparation: The Nursing Facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each Residential Hospice Patient receiving Nursing Facility Services and Hospice Services under this Agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state law and regulations and application Medicare and Medicaid program guidelines. Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each Residential Hospice Patient (including evaluations, treatments, progress notes, authorizations to admissions to Hospice and/or the Nursing Facility and physician orders, entered pursuant to the Agreement). The Nursing Facility and Hospice shall cause each entry made for services provided hereunder to be signed by the person providing the services The above findings were reviewed with the administrator, director of nursing (DON), and assistant director of nursing (ADON) during a meeting on 04/20/2022 at 4:55 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to notify the physician of medications not available for administration for three of 21 residents in the survey sample, Resident #230, Resident #59 and Resident #15. Findings include: 1. Resident #230 was admitted with diagnoses that included, but were not limited to: BPH (benign prostatic hypertrophy) with urinary retention, indwelling Foley catheter, urinary tract infection, entercolitis, C-Diff (clostridium difficile) infection, PVD (peripheral vascular disease), dementia, high blood pressure and bacteremia (infection in the blood). The resident's admission MDS (minimum data set) was still in progress. Resident #230's nursing admission assessment dated [DATE] documented, that the resident had dementia with cognitive deficits (unable to answer to place, time and situation). On 04/20/22 at 11:36 AM, Resident #230 was observed in his room. An IV (intravenous) pole with machine was observed in the corner of the room. The physician's orders were then reviewed and included the following: .Aricept tablet 23 mg (milligrams) give one tablet daily in the morning for dementia (order date: 04/15/22) (start date: 04/16/22) Vancomycin capsule 125 mg give one capsule by mouth four times a day for 8 days for C-diff (order date: 04/15/22) (start date: 04/15/22) Vancomycin .use 1.75 gram intravenously every 24 hours for C-diff for 7 administrations (order date: 04/15/22) (start date: 04/16/22) . The MARs/TARs (medication/treatment administration records) were reviewed for the month of April 2022. The MAR documented that Resident #230 did not receive Aricept 23 mg on April 16th, 17th, 18th, or 19th. The resident's progress notes documented that the medication was unavailable, on order, or awaiting from the pharmacy on these days. The MARs also documented that Resident #230 did not receive oral Vancomycin 125 mg capsules on April 16th (3 doses), April 17th (two doses) and April 19th (one dose). The resident's progress notes documented that the oral Vancomycin was on order from the pharmacy and not available for administration on these days. The MARs documented that Resident #230 did not receive the IV Vancomycin 1.75 grams IV on April 16th, 17th, 18th, or 19th. The resident's progress notes documented that the IV medication was on order from the pharmacy (04/16/22). A nursing progress note dated 04/18/22 documented that clarification was needed from the MD (Medical Doctor) regarding this medication. There was no clarification found in the resident's records regarding this medication. A nursing progress note dated 04/19/22 documented that the IV Vancomycin was on hold related to issues with pharmacy. There was no clarification regarding this, nor were there any physician's orders to hold this medication and no information regarding issues with pharmacy. Resident #230's current care plan documented, .keep physician informed of any problems . On 04/20/22 at 9:45 AM, the DON (director of nursing) and the ADON (assistant director of nursing) were interviewed. They were asked what happens if a medication is not available for the nurses to administer. The DON stated, We notify the physician that meds are not available. They were asked if they had been having issues with medications being unavailable for administration. The ADON stated, In the past, yes. The DON stated, Our nurses are still telling us we have problems getting meds that's why we've been having frequent meetings with pharmacy. The DON and ADON stated that they last met with pharmacy in January and the problem was still current. The DON stated, They (pharmacy) say they will call (if meds aren't available), out of stock or on back order .we really don't know either. On 04/20/22 at 4:45 PM, LPN (Licensed Practical Nurse) #1 was interviewed regarding Resident #230 not being administered the ordered medications. LPN #1 stated that the facility had been having ongoing trouble getting medications from the pharmacy. LPN #1 was asked if she had notified the physician of medications not being available for administration for Resident #230. LPN #1 stated that she had written one of the medications down in the physician's book (did not notify via phone) and that it was initialed as being seen, but there were new orders. LPN #1 stated that she did not notify physician of any other medications not being available to administer or that they were not administered as ordered. At 4:50 PM, the unit manager, Registered Nurse (RN) #1 was interviewed regarding Resident #230 not getting medications as ordered by the physician. RN #1 stated that the facility has had trouble getting medications for residents and that the facility has switched pharmacies. RN #1 was asked if she had notified the physician of Resident #230 not having medications available for administration and/or that the resident had not received the above medications as ordered. RN #1 stated that she had not notified the physician. On 04/20/22 at 5:15 PM, the DON (director of nursing), ADON (assistant director of nursing) and the administrator were made aware of concerns regarding Resident #230 not getting medications as ordered by the physician and the physician not being notified. The DON was asked for a policy on physician notification. A policy titled, Change in a resident's condition documented, .facility will promptly notify the resident, his or her physician/practitioner, and representative of changes in the resident's medical/mental condition and/or status .A need to alter treatment .change in the resident's condition .nurse will notify the resident's attending physician/practitioner .need to alter the resident's medical treatment .refusal of treatment or medications two or more consecutive times . No further information and/or documentation was presented prior to the exit conference on 04/21/22. 2. Resident #59's was admitted with diagnoses that included: Atrial fibrillation, high blood pressure, depression, polyneuropathy, spinal stenosis, chronic back pain, abdominal pain, abdominal pain, hyponatremia, and constipation. The most current MDS was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 14, indicating the resident was intact for daily decision making skills. Resident #59's clinical records documented in the progress notes that several, physician ordered medications for Resident #59 were not available for administration. The resident's physician orders included the following: Dulcolax 5 mg tablet every night at bedtime for laxative (order date: 04/09/22/start date: 0409/22) Bio-Freeze gel 4% topical for left hip pain apply twice daily (order date: 04/13/22/start date: 04/13/22) Naproxen tablet 220 mg give one tablet twice daily for inflammation (order date: 04/09/22/start date: 04/09/22) Magnesium Citrate solution 1.745 grams/30 ml (milliliters) Give 30 ml by mouth in the morning for laxative (order date: 04/09/22/start date: 04/10/22) Sodium Chloride tablet give one tablet by mouth one time a day for hyponatremia (order date: 04/15/22/start date: 04/16/22). The MARs/TARs (medication/treatment administration records) for the month of April 2022 indicated Resident #59 did not receive the following medications as ordered by the physician: Dulcolax 5 mg tablet each night for 9 days. Eleven of 14 doses of Bio-Freeze gel 4%. Twenty of 22 ordered doses of the twice daily Naproxen 220 mg. Magnesium Citrate solution for 5 of 11 days. Sodium Chloride tablet daily for 6 days. The progress notes documented that all of the above medications were on order, not available and/or awaiting pharmacy on the days the medication was not administered. On 04/20/22 at 9:45 AM, the DON (director of nursing) and the ADON (assistant director of nursing) were interviewed. They were asked what happens if a medication is not available for the nurses to administer. The DON stated, We notify the physician that meds are not available. They were asked if they had been having issues with medications being unavailable for administration. The ADON stated, In the past, yes. The DON stated, Our nurses are still telling us we have problems getting meds that's why we've been having frequent meetings with pharmacy. The DON and ADON stated that they last met with pharmacy in January and the problem was still current. The DON stated, They (pharmacy) say they will call (if meds aren't available), out of stock or on back order .we really don't know either. On 04/20/22 at 11:45 AM, the pharmacy director of quality was interviewed regarding medications being unavailable for Resident #59. The pharmacy director of quality stated that the medications Dulcolax, Magnesium Citrate, Naproxen, Bio-Freeze and Sodium Chloride tablets are all house stock medications and are supplied by the facility, not from the pharmacy. On 04/20/22 at approximately 12:45 PM, the administrator, DON and ADON were made aware of the above information and concern over medications not available for administration. The DON stated that their house stock medications just recently got updated and they were not made aware. On 04/21/22 at approximately 11:00 AM, the administrator, DON, and ADON were made aware of the concerns with medications not being available for administration or being administered as ordered by the physician and that the physician was not notified. No further information and or documentation was provided prior to the exit conference on 04/21/22.3. Resident #15 was admitted to the facility with diagnoses that included bladder-neck obstruction, diabetes, anemia, acute kidney failure, atrial fibrillation, hyperlipidemia, hematuria and hypertension. The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact. On 4/19/22 at 2:40 p.m., Resident #15 was interviewed about quality of care in the facility. Resident #15 stated his right ear had been stopped up with wax for over a week. The resident stated staff told him they were going to order drops and then irrigate the ear to remove the wax. The resident stated he had received no drops as of today (4/19/22). Resident #15 stated he had pressure and was not able to hear well out of the right ear due to the impacted wax. The resident described the condition as aggravating. A nurse practitioner (NP) progress note documented the resident was assessed on 4/12/22 for complaints of right ear wax. This progress note documented, .is complaining of right ear feeling plugged and thinks it is wax build up .On otoscopic exam, right TM (tympanic membrane) obscured by cerumen .Impacted cerumen .debox (Debrox), then flush ear in 5 days . Resident #15's clinical record documented a physician's order dated 4/13/22 for Debrox solution 6.5% with instructions to instill 4 drops in the right ear two times per day for 5 days for treatment of impacted cerumen. Nursing notes documented a physician's order dated 4/18/22 to flush ear after 5 days of Debrox drops with use of tepid water due to impacted cerumen in the right ear. Resident #15's medication administration record (MAR) from 4/13/22 through 4/20/22 documented the Debrox solution was not administered because the drops were not available. MAR notes from 4/12/22 through 4/20/22 documented the Debrox was on order from the pharmacy and Not delivered . There was no entry on the MAR regarding the ear irrigation. The physician and/or nurse practitioner were not promptly notified about the unavailable Debrox drops or inability to irrigate the resident's ear due to lack of Debrox. On 4/20/22 at 10:44 a.m., the licensed practical nurse (LPN) #1 caring for Resident #15 was interviewed about the Debrox. LPN #1 stated the Debrox never arrived from pharmacy. LPN #1 stated messages had been sent to the pharmacy about the Debrox with no response. LPN #1 was not aware of any other interventions for the impacted cerumen. On 4/20/22 at 10:46 a.m., the registered nurse (RN #1) unit manager was interviewed about Resident #15's Debrox. RN #1 stated she was told the Debrox had not been sent from pharmacy. RN #1 stated no other interventions had been initiated about Resident #15's impacted ear wax. RN #1 stated the provider was aware the Debrox was unavailable. On 4/21/22 at 8:53 a.m., the nurse practitioner (NP - other staff #4) caring for Resident #15 was interviewed about the Debrox. The NP stated she was not notified by nursing about the unavailable drops and incomplete order for ear irrigation. The NP stated, I thought he already had the drops. The NP stated the resident told her about not getting the drops on Monday (4/18/22). The NP stated the drops were needed prior to irrigation of the ear to loosen the impacted wax. This finding was reviewed with the administrator and director of nursing during a meeting on 4/20/22 at 5:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan (CCP) for 3 of 21 residents in the survey sample, Resident #28, Resident #13, and Resident #15. Resident #28's CCP did not include a focus area with goals and interventions for the use of antidepressants. Resident #13's CCP did not include a focus area with goals and interventions for nutrition. Resident #15's CCP did not include a focus area with goals and interventions for having an impacted ear related to wax build-up. The findings include: 1. Resident #28 was admitted to the facility with cerebral infarction, major depressive disorder, anemia, hypertension, dysphasia, adult failure to thrive, hemiplegia and hemiparesis, and heart disease. The most recent minimum data set (MDS) dated [DATE] was a 5-day significant change and assessed Resident #28 as having long and short term memory problems, severely impaired for daily decision-making, having hallucinations and delusions; and fluctuating periods of inattention and disorganized thinking. Resident #28's clinical record was reviewed on 04/20/2022. Observed on the order summary report were the following orders: Escitalopram Oxalate (Lexapro) Tablet 20 MG (milligrams). Give 1 tablet by mouth in the morning for depression. Order Date: 04/04/2022. Start Date: 04/05/2022 .Remeron Tablet (Mirtazapine) Give 7.5 mg by mouth at bedtime for Depression. Order Date: 02/09/2022. Start Date: 02/09/2022. Resident #28's medication administration record (MAR) was reviewed for the period of months of February through April 2022 and documented Resident #28 received both antidepressants as ordered. Resident #28's CCP was reviewed and did not include a focus area with goals and interventions for the use of the antidepressants, Escitalopram Oxalate (Lexapro) and Remeron. On 04/20/2022 at 12:13 p.m., the unit manager (RN #2) who routinely provided care for Resident #28 was interviewed regarding Resident #28's care plans. RN #2 reviewed Resident #28's electronic clinical record and stated the care plans should have been developed for the antidepressant medication use. The above findings were reviewed with the administrator, director of nursing (DON) and assistant director of nursing (ADON) during a meeting on 04/20/2022 at 4:55 p.m. 2. Resident #13 was admitted to the facility with diagnoses that included major depressive disorder, hypertension, type 2 diabetes, atrial fibrillation, dementia without behavioral disturbance, hypothyroidism, hyperlipidemia, dysphasia, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #13 as severely cognitively impaired with a score of 3 out of 15, having fluctuating periods of inattention and disorganized thinking; and wandering. The MDS documented in Section V - Care Area Assessments (CAA) that Resident #13 should be care planned for nutritional needs. Resident #13's clinical record was reviewed on 04/20/2022. A review of clinical record did not document Resident #13 had a comprehensive care plan (CCP) for nutritional needs including a therapeutic diet. On 04/20/2022 at 12:08 p.m. the unit manager (RN #2) who routinely provided care for Resident #13 was interviewed regarding the resident's clinical record not having a nutritional care plans. RN #2 reviewed Resident #13's paper (hard) copy of the clinical record and stated the discharge summary from the most recent hospital stay dated 02/19/2022 did not include dietary orders. RN #2 was asked what was the process to determine the resident's nutritional/diet orders. RN #2 stated Resident #13 was a readmission and a diabetic and it was likely the kitchen used the previous diet order since the resident had a short hospital stay and was readmitted to the facility. On 04/20/2022 at 4:00 p.m., RN #2 was interviewed a second time. RN #2 stated she reviewed the record with the MDS coordinator and they both believed the staff used the previous diet orders which was a no concentrated sweet because the resident is a diabetic. On 04/20/2022 at 4:40 p.m., the MDS coordinator (LPN # 2) was interviewed regarding Resident #13's nutritional care plans. LPN #2 reviewed the clinical record and stated the nutritional risk assessment dated [DATE] should have triggered for a nutritional care plan to be completed. The above findings were reviewed with the administrator, DON & ADON during a meeting on 04/20/2022 at 4:55 pm. 3. Resident #15 was admitted to the facility with diagnoses that included bladder-neck obstruction, diabetes, anemia, acute kidney failure, atrial fibrillation, hyperlipidemia, hematuria and hypertension. The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact. On 4/19/22 at 2:40 p.m., Resident #15 was interviewed about quality of care in the facility. Resident #15 stated his right ear had been stopped up with wax for over a week. The resident stated staff told him they were going to order drops and then irrigate the ear to remove the wax. The resident stated he had received no drops as of today (4/19/22). Resident #15 stated he had pressure and was not able to hear well out of the right ear due to the impacted wax. The resident described the condition as aggravating. Resident #15 stated he had reported to nurses and the nurse practitioner that he had not received drops and nothing had been done to relieve the ear wax. A nurse practitioner (NP) progress note documented the resident was assessed on 4/12/22 for complaints of right ear wax. This progress note documented, .is complaining of right ear feeling plugged and thinks it is wax build up .On otoscopic exam, right TM (tympanic membrane) obscured by cerumen .Impacted cerumen .debox (Debrox), then flush ear in 5 days . Resident #15's clinical record documented a physician's order dated 4/13/22 for Debrox solution 6.5% with instructions to instill 4 drops in the right ear two times per day for 5 days for treatment of impacted cerumen. Nursing notes documented a physician's order dated 4/18/22 to flush ear after 5 days of Debrox drops with use of tepid water due to impacted cerumen in the right ear. Resident #15's medication administration record (MAR) from 4/13/22 through 4/20/22 documented the Debrox solution was not administered because the drops were not available. MAR notes from 4/12/22 through 4/20/22 documented the Debrox was on order from the pharmacy and Not delivered . There was no entry on the MAR regarding the ear irrigation. Resident #15's plan of care (revised 3/8/22) included no problems, goals and/or interventions regarding the impacted ear wax and the ear discomfort described by the resident as aggravating. On 4/20/22 at 3:04 p.m., the unit manager (RN #1) was interviewed about a care plan for impacted wax. RN #1 stated no care plan had been developed regarding the ear wax and/or ear discomfort. RN #1 stated unit managers were responsible for entering and updating care plans. This finding was reviewed with the administrator and director of nursing during a meeting on 4/20/22 at 5:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #23 was admitted to the facility with diagnoses to include, but not limited to: COVID-19, osteoarthritis, and vitamin D deficiency. The most recent MDS (minimum data set) was a significant change assessment dated [DATE] and had the resident scored as cognitively intact with a score of 14 out of 15. The clinical record was reviewed 4/20/22 at approximately 2:00 p.m. An order on the current POS (physician order summary) with a start date of 3/30/22 directed CefTRIAXone (sic) Sodium Solution Reconstituted 1 gram Inject 1 gram intramuscularly every 24 hours for infection for 5 days mix in 2.1 ml (milliliters) lidocaine (a numbing agent) 1%. Review of the MAR (medication administration record) revealed the injections were completed, but one staff on 4/2/22 documented the injection was given in the arm. The package insert was reviewed for information about the injection, and documented in bold print, capitol letters, DO NOT GIVE IN THE DELTOID. (The deltoid is in the upper arm). The pharmacist, other staff (OS) # 5, was interviewed and asked about the IM injection given in the arm. OS # 5 stated If you can give me the resident name, I can see which formula she was given. OS # 5 then stated Yes, it says here on the medical information sheet it is not to be given in the deltoid, but given deep IM in the gluteal (buttock) area. On 4/20/22 the DON (director of nursing) and the ADON (assistant director of nursing) were interviewed. The ADON stated Well, the order says to inject intramuscularly, but doesn't say where . The DON was then asked for a policy on injections as related to what medication was to be given, and what her expectation was for staff to be knowledgeable about what was given. The DON stated I expect them to look up the medication if there is any question about giving it . The DON was then asked, seeing the medication was mixed with Lidocaine, and the resident being thin, was that correct giving a deep IM injection in the arm. She stated No. The policy presented Adverse Consequences and Medication Errors directed under #5. Examples of medication errors include:h. Failure to follow manufacturer instructions and /or accepted professional standards . 7. a. The dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. The administrator, DON, and ADON (assistant director of nursing) were informed of the above findings during an end of the day meeting 4/20/22 beginning at 4:55 p.m. No further information was provided prior to the exit conference.3. Resident #230 was admitted with diagnoses that included, but were not limited to: BPH (benign prostatic hypertrophy) with urinary retention, indwelling Foley catheter, urinary tract infection, entercolitis, C-Diff (clostridium difficile) infection, PVD (peripheral vascular disease), dementia, high blood pressure and bacteremia (infection in the blood). The resident's admission MDS (minimum data set) was still in progress. Resident #230's nursing admission assessment dated [DATE] documented, that the resident had dementia with cognitive deficits (unable to answer to place, time and situation). On 04/20/22 at 11:36 AM, Resident #230 was observed in his room. An IV (intravenous) pole with machine was observed in the corner of the room. Resident #230 was asked if he had any type of IV access. Resident #230 started feeling around on his body and under the blankets. The resident was asked again if he had IV access and was asked if there was something in/on his chest area. Resident #230 then started pulling at his shirt. The resident was asked to pull the collar of his shirt down in order to observe. The resident pulled down from his neck, exposing a central line catheter in the right chest wall. The central line catheter had a clear, dry dressing intact dated 04/15/22. The physician's orders were reviewed and included the following: Vancomycin capsule 125 mg give one capsule by mouth four times a day for 8 days for C-diff (order date: 04/15/22) (start date: 04/15/22) Vancomycin .use 1.75 gram intravenously every 24 hours for C-diff for 7 administrations (order date: 04/15/22) (start date: 04/16/22) . The MARs/TARs (medication/treatment administration records) documented that Resident #230 did not receive the IV Vancomycin 1.75 grams IV on April 16th, 17th, 18th, or 19th. A nursing progress note documented that the IV medication was on order from the pharmacy (04/16/22). A nursing progress note dated 04/18/22 documented that clarification was needed from the MD (Medical Doctor) regarding this medication. There was no clarification found in the resident's records regarding this medication. A nursing progress note dated 04/19/22 documented that the IV Vancomycin was on hold related to issues with pharmacy. There was no clarification regarding this, nor were there any physician's orders to hold this medication and no information regarding issues with pharmacy. On 04/20/22 at 9:45 AM, the DON (director of nursing) and the ADON (assistant director of nursing) were interviewed. They were asked what happens if a medication is not available for the nurses to administer. The DON stated, We notify the physician that meds are not available. They were asked if they had been having issues with medications being unavailable for administration. The ADON stated, In the past, yes. The DON stated, Our nurses are still telling us we have problems getting meds that's why we've been having frequent meetings with pharmacy. The DON and ADON stated that they last met with pharmacy in January and the problem was still current. The DON stated, They (pharmacy) say they will call (if meds aren't available), out of stock or on back order .we really don't know either. On 04/20/22 at 11:35 AM, the pharmacy director of quality was interviewed regarding the IV Vancomycin being unavailable for Resident #230, since being admitted to the facility (4 days). The pharmacy director stated that the IV Vancomycin request was sent to the pharmacy on 04/16/22 and the pharmacist had attached a note that documented that the medication was ordered for C-diff (not a blood infection per the resident's hospital discharge summary) and that the medication had been profiled for that reason. The pharmacy director stated that Resident #230 also had an order for oral Vancomycin for C-diff, and that antibiotics aren't ordered IV and by mouth for C-diff. The pharmacy director was made aware that Resident #230's hospital discharge summary listed the oral Vancomycin for C-diff and the IV Vancomycin for the blood infection. The pharmacy director stated that Resident #230 was on oral Vancomycin for C-diff and that IV Vancomycin isn't typically ordered for C-diff, but that is what the facility had put in when they submitted the order to the pharmacy. The pharmacy director stated that it appeared that the diagnoses was input incorrectly for the IV Vancomycin and that should have been clarified somewhere. The pharmacy director was made aware of progress notes documenting the need for clarification and issues with the pharmacy regarding the IV medication, but there was no evidence of any clarification or follow up, either by nursing or the pharmacy. On 04/20/22 at 5:15 PM, the DON (director of nursing), ADON (assistant director of nursing) and the administrator were made aware of concerns regarding Resident #230 not getting medications as ordered by the physician and that according to the pharmacy, the medication diagnosis was incorrect, which had stopped the medication from being filled and delivered as ordered. The ADON stated that she had input the orders in for Resident #230 and that the nurse giving her report from the hospital told her the IV medication was for C-diff. The ADON stated that she did not have access to the hospital discharge summary at that time to see what the medication was ordered for, and went by the information she was given in report. A policy was requested for new admissions/transfer orders and/or order transcription to ensure medication orders are entered correctly for new/re- admissions. A policy titled, Ordering and Receiving non-controlled Medications documented, .The facility maintains accurate records of medication order and receipt .written on a physician's order form, telephone order sheet, or reorder form .written in the chart by the physician, or entered into the facility's EHR (electronic health record) and transmitted to the pharmacy .date of order whether the order is new or a repeat order (refill) .include the prescription number .medication name, strength, when indicated, indication for use .directions for use .when phoning in, sending electronically, or faxing a medication order to the pharmacy, the following information must be given: resident's names and other identifying information, medication name, complete order if new, name of prescribers .indication for use, Name of person calling in order .calling/faxing/sending electronically medication orders for a newly admitted /readmitted resident, the pharmacy is also given all allergies, and diagnoses to facilitate generation of a patient profile and permit initial medication use assessment . No further information was presented prior to the exit conference on 04/21/22. Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for three of twenty-one residents in the survey sample, Resident #15, #23, and #230. A nurse administered the medication Depakote to Resident #15 in error. There was no report or investigation of the error by nursing administration. Resident #23 was administered a deep IM (intramuscular) injection of an antibiotic in the deltoid muscle which was against the manufacturer's recommendation. The facility failed to accurately transcribe a physician's order resulting in Resident #230 missing an IV (intravenous) antibiotic (Vancomycin) for four days. The findings include: 1. Resident #15 was admitted to the facility with diagnoses that included bladder-neck obstruction, diabetes, anemia, acute kidney failure, atrial fibrillation, hyperlipidemia, hematuria and hypertension. The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact. Resident #15's clinical record documented a nursing note on 2/27/22 stating, Patient was accidentally given a medication that was not on his chart. Depakote was administered around 2330 (11:30 p.m.). On-call (nurse practitioner) was notified as well as his family . A nurse practitioner progress note dated 2/28/22 documented, .The patient was seen today at the request of nursing following a med (medication) error .the patient was given a dose of Depakote meant for another patient by accident. Depakote will be fully processed through the body in 40 hours .Staff to monitor vital signs and watch for side effects for 40 hours .monitor for 40 hours following accidental ingestion of Depakote . Resident #15 had no physician's order for Depakote. The clinical record did not document the Depakote dosage that was administered in error. On 4/20/22 at 4:30 p.m., the licensed practical nurse (LPN #1) caring for Resident #15 was interviewed about the medication error. LPN #1 stated she was not aware of the medication error. LPN #1 reviewed the nursing notes and stated the med error was documented by a night shift nurse. On 4/20/22 at 4:41 p.m., the registered nurse unit manager (RN #1) was interviewed about the Depakote administered to Resident #15. RN #1 stated she was not aware of a medication error involving Resident #15. RN #1 stated, I don't recall knowing that. This finding was reviewed with the administrator and director of nursing (DON) during a meeting on 4/20/22 at 5:00 p.m. The DON stated at this time that she was not aware Depakote was administered to Resident #15 in error. The DON stated nurses were required to complete an incident form for any medication errors. On 4/21/22 at 10:47 a.m., the assistant director of nursing (RN #3) stated no incident form was entered regarding the 2/27/22 medication error and no investigation had been done. RN #3 stated she had no explanation of what happened and thought the nurse may be have distracted and busy. The facility's policy titled Adverse Consequences and Medication Errors (undated) documented, .Medication Error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders .Examples of mediations (medication) errors include .unauthorized drug - a drug is administered without a physician's order .The DON or designee will conduct a root cause analysis of medication administration errors to determine the source of errors, implement process improvement steps, and compare results over time to determine that system improvements are effective in reducing errors . The Nursing 2022 Drug Handbook on pages 1492 and 1493 describes Depakote as an anticonvulsant medication used for the treatment of seizures, mania and migraine headaches with possible adverse reactions such as dizziness, drowsiness, insomnia and rash. Page 17 of this reference documents concerning the eight rights of medication administration, .These are broadly stated goals and practices to help individual nurses administer drugs safely and correctly .2. The right patient: Confirm the patient's identify by checking two patient identifiers . (1) (1) Woods, [NAME] Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #14 was admitted to the facility with diagnoses including chronic pain syndrome, gastro-esophageal reflux disease (GERD), glaucoma, hypo-osmoliaty, hyponatremia, major depressive disorder, anxiety disorder, hypertension, and joint pain (knees and hands). The most recent MDS dated [DATE] was a quarterly assessment and assessed Resident #14 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #14 was interviewed on 04/19/2020 at 12:11 p.m. During the interview Resident #14 stated there had been 3-4 days when the scheduled Lidocaine pain patches were not available for administration. Resident #14 stated, I get 3 of the same patches a day on my knees and shoulder because I have joint pain. From my understanding the medications come from a pharmacy in North Carolina and there was a mix-up in getting them delivered here. Resident #14 was asked about his pain level, Resident #14 stated, it was bearable even at my age. But, it just didn't make sense to me that I missed that many days. I get other pain medications so I'm sure that took some of the edge off. Resident #14's clinical record was reviewed and observed on the order summary sheet was the following orders: Aspercreme Lidocaine 4% Patch. apply to left knee topically in the morning remove at bed time. Start Date: 12/15/2021. Aspercreme Lidocaine 4% Patch. Apply to left shoulder topically in the morning for pain remove at bedtime. Start Date: 12/09/2021. Aspercreme Lidocaine 4% Patch. Apply to right knee topically in the morning for pain remove at bedtime. Start Date: 12/09/2021. Resident #14's medication administration record (MAR) was reviewed and documented on 04/10/2022, 04/11/2022, 04/12/2022, and 04/13/2022, the morning administration of each of the scheduled Aspercreme Lidocaine 4% patch was not administered for the left knee, right knee, and left shoulder. The missed doses were marked as 9, other/see progress notes. Nursing notes dated 04/10/2022 at 8:28 a.m. documented concerning the medication patches not administered, patch on order. Nursing notes dated 04/11/2022 at 12:16 p.m. documented, Notified NP. Nursing notes dated 04/12/2022 at 8:56 a.m., documented, on order. Nursing notes dated 04/13/2022 at 9:34 a.m. documented, on order. There was no documentation about the use of a back-up pharmacy to acquire the medication patches. Resident #14's care plan documented the following focus area, The resident has pain r/t (related to) neuropathy, DDD (degenerative disc disease), osteoarthritis, and GERD (Rev. 12/12/2021). Goal: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieve pain through review date (Rev. 03/14/2022.). Interventions: . Administer pain medications as ordered and monitor for effectiveness On 04/20/2022 at 9:39 a.m. the licensed practical nurse (LPN) #3 who routinely provided care for Resident #14 and documented the nursing notes on 04/10/2022, 04/12/2022, and 04/13/2022 was interviewed about the missed doses. LPN #3 stated, There was some recent confusion about pharmacy changes with the patches switching from the pharmacy order to becoming house stock. We were ordering them from the pharmacy and waiting for delivery and then we found they were switched to a house stock item. You can speak with the unit manager or DON (director of nursing) for more information because there was a meeting to discuss the new house stock items. On 04/20/2022 at 9:42 a.m., the DON and assistant director of nursing (ADON/RN #3) were interviewed. The DON stated the facility switched to a new pharmacy on January 1, 2022 and the facility had identified a problem with receiving medications. The DON shared the facility recently met with the pharmacy on Monday, 04/18/2022 and identified the house stock list had changed and the facility was not aware of the change. The DON stated, The pharmacy told us to pull from our house stock and we weren't aware the list had grown. Corporate grew the list and they didn't tell us. The DON was asked if the Lidocaine 4% patches were part of the house stock list. The ADON/RN #3 stated, Yes if it's on the house stock list we provided you all. Then it's house stock, but previously they were ordered through the pharmacy. On 04/20/2022 at 10:11 a.m. the central supply clerk (OS #1) who was responsible for ordering house stock items was interviewed. OS #1 stated, At first I was given a very short list of house stock items. I order weekly for supplies and over the counter (OTC) and house stock medications. We did just get an updated list and I'm told this is probably not all of the OTC/house stock meds. It will probably change again. OS #1 was asked when the Lidocaine 4% patches ordered. OS #1 stated, I spoke with (LPN #3) about the situation and they were ordered about 2 weeks ago. We use the Aspercreme or Salonpas 4% generic brands as house stock. I made sure to give her a large bag of them for the med cart. On 04/20/2022 at 11:34 a.m. the pharmacy representative (OS #5) was interviewed and stated, .the facility is responsible for house items not the pharmacy A review of the (Hill Valley Corporate - Do Not Supply List - Rev. 4/20/2022) documented the Lidocaine 4% as a house stock item. The above findings were reviewed with the administrator, DON, and ADON during a meeting on 04/20/2022 at 4:55 p.m. On 04/21/2022 at 8:55 a.m., the nurse practitioner (OS #4) who routinely provided care for Resident #14 was interviewed. OS #4 stated she honestly did not remember being notified about the patches not being available and it was possible the on-call provider was notified instead. OS #4 continued and stated she had recently started providing care for Resident #14 and knew the resident received a lot of pain medications. However, she was not fully familiar with the resident's history and planned to review the record prior to discussing some possible medication changes. OS #4 was asked how would the missed doses of the Lidocaine patches affect Resident #14. OS #4 stated, (Resident #14) could potentially have pain, but he does receive other pain related medications. 6. On 4/20/22 beginning at 8:00 a.m. the blood glucose monitoring quality control logs were reviewed on Town Square unit. The controls were not documented as done daily. Registered nurse (RN) # 4 was asked if the controls were to be done daily. RN # 4 stated The night shift nurse does the controls. I think they only have to be done every 2-3 days . On the Peaks unit, blood glucose monitoring logs were reviewed and the controls were not documented as done daily. RN # 5 stated the night shift performed the controls. On The Gardens unit, LPN (licensed practical nurse) # 1 was asked for the control logs for the unit. She began looking for them, then stated I can't find them. Let me go ask (name of RN # 1) if she knows where they are. RN # 1 then came to the nurses' station and began looking for the logs. She stated I don't know where they are. Let me call (name of night nurse) and see where those are kept. On 4/20/22/at 9:30 a.m. the DON (director of nursing) was asked for the facility policy for blood glucose monitoring quality control. The policy Blood Glucose Monitors- Quality Control Checks directed Documentation: 1. The facility staff will document blood glucose monitor control checks for each blood glucose monitor daily. The administrator, DON, and ADON (assistant director of nursing) were informed of the above findings during an end of the day meeting 4/20/22 beginning at 4:55 p.m. On 4/21/21 at approximately 10:00 a.m. the DON stated that a couple of quality control checks were written down, but not on the log. The logs for The Gardens unit was not located. No further information was provided prior to the exit conference. Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure six of 21 residents in the survey sample were administered medications as ordered by the physician, Resident #230, #59, #15, #46, and #14; and failed to ensure glucometer calibration monitoring was completed on three of 4 nursing units, The Gardens, [NAME] Square, and The Peaks. 1. Resident #230 was not administered IV (intravenous) Vancomycin, oral Vancomycin, or Aricept as ordered by the physician. 2. Resident #59 was not administered a sodium chloride supplement or medications for a bowel regimen as ordered by the physician. 3. Resident #15 had no prescribed medication/irrigation treatment for impacted ear wax for over a week, as ordered by the provider, was not administered the medication lisinopril as ordered by the physician, and was administered the medication Depakote in error. 4. Resident #46 was not administered the medications Aricept and Remeron as ordered by the physician. 5. Resident # 14 was not administered scheduled pain patches for 4 consecutive days. 6. The facility staff failed to document blood glucose monitor quality control checks on a daily basis. Two of 4 units (Town Square and Peaks) glucose monitor logs did not have daily documentation of the quality controls, and one unit (The Gardens) did not have quality control logs available for review. Findings include: 1. Resident #230 was admitted with diagnoses that included, but were not limited to: BPH (benign prostatic hypertrophy) with urinary retention, indwelling Foley catheter, urinary tract infection, entercolitis, C-Diff (clostridium difficile) infection, PVD (peripheral vascular disease), dementia, high blood pressure and bacteremia (infection in the blood). The resident's admission MDS (minimum data set) was still in progress. Resident #230's nursing admission assessment dated [DATE] documented, that the resident had dementia with cognitive deficits (unable to answer to place, time and situation). On 04/20/22 at 11:36 AM, Resident #230 was observed in his room. An IV (intravenous) pole with machine was observed in the corner of the room. Resident #230 was observed with a central line catheter that had a clear, dry dressing intact dated 04/15/22. The physician's orders were then reviewed and included the following: .Aricept tablet 23 mg (milligrams) give one tablet daily in the morning for dementia (order date: 04/15/22) (start date: 04/16/22) Vancomycin capsule 125 mg give one capsule by mouth four times a day for 8 days for C-diff (order date: 04/15/22) (start date: 04/15/22) Vancomycin .use 1.75 gram intravenously every 24 hours for C-diff for 7 administrations (order date: 04/15/22) (start date: 04/16/22) . The MARs/TARs (medication/treatment administration records) were reviewed for the month of April 2022. The MAR documented that Resident #230 did not receive Aricept 23 mg on April 16th, 17th, 18th, or 19th. The resident's progress notes documented that the medication was unavailable, on order, or awaiting from the pharmacy on these days. The MARs also documented that Resident #230 did not receive oral Vancomycin 125 mg capsules on April 16th (3 doses), April 17th (two doses) and April 19th (one dose). The resident's progress notes documented that the oral Vancomycin was on order from the pharmacy and not available for administration on these days. The MARs documented that Resident #230 did not receive the IV Vancomycin 1.75 grams IV on April 16th, 17th, 18th, or 19th. The resident's progress notes documented that the IV medication was on order from the pharmacy (04/16/22). A nursing progress note dated 04/18/22 documented that clarification was needed from the MD (Medical Doctor) regarding this medication. There was no clarification found in the resident's records regarding this medication. A nursing progress note dated 04/19/22 documented that the IV Vancomycin was on hold related to issues with pharmacy. There was no clarification regarding this, nor were there any physician's orders to hold this medication and no information regarding issues with pharmacy. On 04/20/22 at 9:45 AM, the DON (director of nursing) and the ADON (assistant director of nursing) were interviewed. They were asked what happens if a medication is not available for the nurses to administer. The DON stated, We notify the physician that meds are not available. They were asked if they had been having issues with medications being unavailable for administration. The ADON stated, In the past, yes. The DON stated, Our nurses are still telling us we have problems getting meds that's why we've been having frequent meetings with pharmacy. The DON and ADON stated that they last met with pharmacy in January and the problem was still current. The DON stated, They (pharmacy) say they will call (if meds aren't available), out of stock or on back order .we really don't know either. On 04/20/22 at 11:35 AM, the pharmacy director of quality was interviewed regarding the IV Vancomycin being unavailable for Resident #230, since being admitted to the facility (4 days). The pharmacy director stated that the IV Vancomycin request was sent to the pharmacy on 04/16/22 and the pharmacist had attached a note that the medication was ordered for C-diff (not a blood infection per the resident's hospital discharge summary) and that the medication had been profiled for that reason. The pharmacy director stated the oral Vancomycin 125 mg order was requested and processed on 04/16/22 and 32 capsules (a supply to administer 4 capsules per day for 8 days-as ordered) were delivered on 04/17/22. The pharmacy director was made aware that Resident #230's hospital discharge summary listed the oral Vancomycin for C-diff and the IV Vancomycin for the blood infection. The pharmacy director stated that IV Vancomycin is not well absorbed and isn't typically used to treat C-diff. The pharmacy director stated that it appeared the diagnoses was input incorrectly for the IV Vancomycin and the oral form of the medication was sent and available for administration according to the dispensing records. The pharmacy director was made aware of progress notes documenting the need for clarification and issues with the pharmacy regarding the IV medication, but there was no evidence of any clarification or follow up, order to hold, or any notification to the physician that the resident was not administered the IV Vancomycin as ordered. The pharmacy director stated that the Aricept was dispensed on 04/16/22, but not delivered to the facility until 04/19/22, and was unsure why there was a delay in delivery. On 04/20/22 at 4:45 PM, LPN (Licensed Practical Nurse) #1 was interviewed regarding Resident #230 not being administered the ordered medications. LPN #1 stated that the facility had been having ongoing trouble getting medications from the pharmacy. LPN #1 stated that they do carry some medications in they pyxis machine, but not everything that they may need, and that the facility does have house stock meds. At 4:50 PM, the unit manager, Registered Nurse (RN) #1 was interviewed regarding Resident #230 not getting medications as ordered by the physician. RN #1 stated that the facility has had trouble getting medications for residents and that the facility has switched pharmacies. On 04/20/22 at 5:15 PM, the DON (director of nursing), ADON (assistant director of nursing) and the administrator were made aware of concerns regarding Resident #230 not getting medications as ordered by the physician and that according to the pharmacy, some medications were here to be administered, while others required clarification. The DON was asked for a policy on unavailable medications. A policy titled, Unavailable Medications documented, .Medication used by residents in the nursing facility may be unavailable for dispensing from pharmacy on occasion .due to .out of stock .recall .manufacturer's shortage .medication no longer being produced. The facility must make every effort to ensure that medications are available to meet the needs of each resident .pharmacy staff shall .notify nursing staff that the order product is unavailable .when it is anticipated .will be become available .comparable drugs .dosage of drugs .are available .nursing staff shall .notify the attending physician .notify nursing supervisor .or contact facility director for orders and/or direction . No further information and/or documentation was presented prior to the exit conference on 04/21/22. 2. Resident #59's was admitted with diagnoses that included: Atrial fibrillation, high blood pressure, depression, polyneuropathy, spinal stenosis, chronic back pain, abdominal pain, abdominal pain, hyponatremia, and constipation. The most current MDS was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 14, indicating the resident was intact for daily decision making skills. Resident #59's clinical records documented in the progress notes that several, physician ordered medications for Resident #59 were not available for administration. The resident's physician orders included the following: Dulcolax 5 mg tablet every night at bedtime for laxative (order date: 04/09/22/start date: 0409/22) Bio-Freeze gel 4% topical for left hip pain apply twice daily (order date: 04/13/22/start date: 04/13/22) Naproxen tablet 220 mg give one tablet twice daily for inflammation (order date: 04/09/22/start date: 04/09/22) Magnesium Citrate solution 1.745 grams/30 ml (milliliters) Give 30 ml by mouth in the morning for laxative (order date: 04/09/22/start date: 04/10/22) Sodium Chloride tablet give one tablet by mouth one time a day for hyponatremia (order date: 04/15/22/start date: 04/16/22). The MARs/TARs (medication/treatment administration records) for the month of April 2022 indicated Resident #59 did not receive the following medications as ordered by the physician: Dulcolax 5 mg tablet each night for 9 days. Eleven of 14 doses of Bio-Freeze gel 4%. Twenty of 22 ordered doses of the twice daily Naproxen 220 mg. Magnesium Citrate solution for 5 of 11 days. Sodium Chloride tablet daily for 6 days. The progress notes documented that all of the above medications were on order, not available and/or awaiting pharmacy on the days the medication was not administered. On 04/20/22 at 9:45 AM, the DON (director of nursing) and the ADON (assistant director of nursing) were interviewed. They were asked what happens if a medication is not available for the nurses to administer. The DON stated, We notify the physician that meds are not available. They were asked if they had been having issues with medications being unavailable for administration. The ADON stated, In the past, yes. The DON stated, Our nurses are still telling us we have problems getting meds that's why we've been having frequent meetings with pharmacy. The DON and ADON stated that they last met with pharmacy in January and the problem was still current. The DON stated, They (pharmacy) say they will call (if meds aren't available), out of stock or on back order .we really don't know either. On 04/20/22 at 11:45 AM, the pharmacy director of quality was interviewed regarding medications being unavailable for Resident #59. The pharmacy director of quality stated that the medications Dulcolax, Magnesium Citrate, Naproxen, Bio-Freeze and Sodium Chloride tablets are all house stock medications and are supplied by the facility, not from the pharmacy. On 04/20/22 at approximately 12:45 PM, the administrator, DON and ADON were made aware of the above information and concern over medications not available for administration. The DON stated that their house stock medications just recently got updated and they were not made aware. A policy titled, House - Supplied (Floor Sock) Medications documented, .The floor stock medication list is posted in the medication rooms/carts .and provided to the dispensing pharmacy .floor stock medications are ordered from the contracted supplier . On 04/21/22 at approximately 11:00 AM, the administrator, DON, and ADON were made aware of the concerns with medications not being available or administered as ordered. The administrator stated that they are working on it. No further information and/or documentation was provided prior to the exit conference on 04/21/22.3. Resident #15 was admitted to the facility with diagnoses that included bladder-neck obstruction, diabetes, anemia, acute kidney failure, atrial fibrillation, hyperlipidemia, hematuria and hypertension. The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact. a) Resident #15's clinical record documented a nursing note on 2/27/22 stating, Patient was accidentally given a medication that was not on his chart. Depakote was administered around 2330 (11:30 p.m.). On-call (nurse practitioner) was notified as well as his family . A nurse practitioner progress note dated 2/28/22 documented, .The patient was seen today at the request of nursing following a med (medication) error .the patient was given a dose of Depakote meant for another patient by accident. Depakote will be fully processed through the body in 40 hours .Staff to monitor vital signs and watch for side effects for 40 hours .monitor for 40 hours following accidental ingestion of Depakote . Resident #15 had no physician's order for Depakote. The clinical record did not document the Depakote dosage that was administered in error. On 4/20/22 at 4:30 p.m., the licensed practical nurse (LPN #1) caring for Resident #15 was interviewed about the medication error. LPN #1 stated she was not aware of the medication error. LPN #1 reviewed the nursing notes and stated the med error was documented by a night shift nurse. On 4/20/22 at 4:41 p.m., the registered nurse unit manager (RN #1) was interviewed about the Depakote administered to Resident #15. RN #1 stated she was not aware of a medication error involving Resident #15. RN #1 stated, I don't recall knowing that. This finding was reviewed with the administrator and director of nursing (DON) during a meeting on 4/20/22 at 5:00 p.m. The DON stated at this time that she was not aware Depakote was administered to Resident #15 in error. The Nursing 2022 Drug Handbook on pages 1492 and 1493 describes Depakote as an anticonvulsant medication used for the treatment of seizures, mania and migraine headaches with possible adverse reactions such as dizziness, drowsiness, insomnia and rash. (1) b) On 4/19/22 at 2:40 p.m., Resident #15 was interviewed about quality of care in the facility. Resident #15 stated his right ear had been stopped up with wax for over a week. The resident stated staff told him they were going to order drops and then irrigate the ear to remove the wax. The resident stated he had received no drops as of today (4/19/22). Resident #15 stated he had pressure and was not able to hear well out of the right ear due to the impacted wax. The resident described the condition as aggravating. Resident #15 stated he had reported to nurses and the nurse practitioner that he had not received drops and nothing had been done to relieve the ear wax. A nurse practitioner (NP) progress note documented the resident was assessed on 4/12/22 for complaints of right ear wax. This progress note documented, .is complaining of right ear feeling plugged and thinks it is wax build up .On otoscopic exam, right TM (tympanic membrane) obscured by cerumen .Impacted cerumen .debox (Debrox), then flush ear in 5 days . Resident #15's clinical record documented a physician's order dated 4/13/22 for Debrox solution 6.5% with instructions to instill 4 drops in the right ear two times per day for five days for treatment of impacted cerumen. Nursing notes documented a physician's order dated 4/18/22 to flush ear after 5 days of Debrox drops with use of tepid water due to impacted cerumen in the right ear. Resident #15's medication administration record (MAR) from 4/13/22 through 4/20/22 documented the Debrox solution was not administered because the drops were not available. MAR notes from 4/12/22 through 4/20/22 documented the Debrox was on order from the pharmacy and Not delivered . There was no entry on the MAR regarding the ear irrigation. There was no notification to the provider about the unavailable Debrox. There were no other treatments and/or interventions implemented for Resident #15's ear wax other than the Debrox that was unavailable. The resident had no plan of care regarding the ear wax or the ear discomfort described by the resident as aggravating. On 4/20/22 at 10:44 a.m., the licensed practical nurse (LPN) #1 caring for Resident #15 was interviewed about the Debrox. LPN #1 stated the Debrox never arrived from pharmacy. LPN #1 stated messages had been sent to the pharmacy about the Debrox with no response. LPN #1 stated the pharmacy requested a form last evening (4/19/22) and that was sent as requested but she still did not have the drops. LPN #1 was not aware of any other interventions for the impacted ear wax. On 4/20/22 at 10:46 a.m., the registered nurse (RN #1) unit manager was interviewed about Resident #15's Debrox. RN #1 stated she was told the Debrox had not been sent from pharmacy. RN #1 stated no other interventions had been initiated about Resident #15's impacted ear wax. c) Resident #15's clinical record documented a physician's order dated 2/23/22 for the medication lisinopril 10 mg (milligrams) with instructions to give one dose each morning for the treatment of hypertension. Resident #15's MAR documented the lisinopril was not given on 4/12/22, 4/13/22, 4/16/22, 4/17/22 and 4/18/22 because the medication was not available. The MAR documented the medication was administered on 4/15/22 with nursing notes stating the medication was not available. MAR notes documented the following regarding the availability of the lisinopril. 4/12/22 - Lisinopril .ordered . 4/13/22 - .ordered .still on order . 4/14/22 - .on order .awaiting on arrival from pharmacy . 4/15/22 - .on order . 4/17/22 - .on order . 4/18/22 - .Not in stock and reordered . On 4/19/22 at 3:15 p.m., LPN #1 caring for Resident #15 was interviewed about the lisinopril availability. LPN #1 stated she did not know why the lisinopril had not been provided. LPN #1 stated there were ongoing issues with getting medications from the pharmacy. On 4/19/22 at 3:24 p.m., unit manager (RN #1) was interviewed about Resident #15's lisinopril. RN #1 stated medications were ordered from the pharmacy and they just don't show up. RN #1 stated the pharmacy did not communicate when medications were not available. RN #1 stated the pharmacy was supposed to provide a back-up service for needed medications but that protocol had not been effective in getting medications. On 4/20/22 at 9:42 a.m., the director of nursing (DON) was interviewed about the unavailable medications. The DON stated when medications were out, nurses were supposed to call the pharmacy and request the needed drugs. The DON stated there was an emergency supply of some medications onsite but it did not contain all medications. The DON stated the pharmacy was supposed to provide back-up service for needed medications. These findings were reviewed with the administrator and director of nursing during a meeting on 4/20/22 at 5:00 p.m. 4. Resident #46 was admitted to the facility with diagnoses that included Parkinson's disease, orthostatic hypotension, hyperlipidemia, seizures, gout, major depressive disorder and dementia with behavioral disturbance. The minimum data set (MDS) dated [DATE] assessed Resident #46 as cognitively intact. Resident #46's clinical record documented a physician's order dated 4/13/22 for Aricept 10 mg (milligrams) to be administered at each bedtime for dementia. The record documented a physician's order dated 4/13/22 for Remeron Soltab 15 mg to be administered at each bedtime for depression. Resident #46's medication administration record (MAR) documented the Aricept and Remeron were not administered on 4/18/22 as ordered. A nursing note dated 4/18/22 documented regarding the Aricept and Remeron, medication unavailable. On 4/20/22 at 9:42 a.m., the director of nursing (DON) was interviewed about unavailable medications. The DON stated when medications were out, nurses were supposed to call the pharmacy and request the needed drugs. The DON stated there was an emergency supply of some medications onsite but it did not contain all medications. The DON stated the pharmacy was supposed to provide back-up service for needed medications. On 4/20/22 at 3:47 p.m., the registered nurse unit manager (RN #5) was interviewed about the doses of Aricept and Remeron not administered to Resident #46. RN #5 stated the Aricept and Remeron were identified as on order from the pharmacy. RN #5 stated she did not know why these medications ran out and a supply was not maintained. This finding was reviewed with the administrator and director of nursing during a meeting on 4/20/22 at 5:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #14 was admitted to the facility with diagnoses including chronic pain syndrome, gastro-esophageal reflux disease (GERD), glaucoma, hypo-osmoliaty, hyponatremia, major depressive disorder, anxiety disorder, hypertension, and joint pain (knees and hands). The most recent MDS dated [DATE] was a quarterly assessment and assessed Resident #14 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #14 was interviewed on 04/19/2020 at 12:11 p.m. Resident #14 stated there had been 3 to 4 days when the scheduled Lidocaine pain patches were not available for administration. Resident #14 stated, I get 3 of the same patches a day on my knees and shoulder because I have joint pain. From my understanding the medications come from a pharmacy in North Carolina and there was a mix-up in getting them delivered here. When asked about his pain level, Resident #14 stated, It was bearable even at my age. But, it just didn't make sense to me that I missed that many days. I get other pain medications so I'm sure that took some of the edge off. Resident #14's clinical record included the following orders: Aspercreme Lidocaine 4% Patch. apply to left knee topically in the morning remove at bed time. Start Date: 12/15/2021. Aspercreme Lidocaine 4% Patch. Apply to left shoulder topically in the morning for pain remove at bedtime. Start Date: 12/09/2021. Aspercreme Lidocaine 4% Patch. Apply to right knee topically in the morning for pain remove at bedtime. Start Date: 12/09/2021. Resident #14's medication administration record (MAR) was reviewed and documented on 04/10/2022, 04/11/2022, 04/12/2022, and 04/13/2022, the morning administration of each of the scheduled Aspercreme Lidocaine 4% patch was not administered for the left knee, right knee, and left shoulder. The missed doses were marked as 9, other/see progress notes. Nursing notes dated 04/10/2022 at 8:28 a.m. documented concerning the medication patches not administered, patch on order. Nursing notes dated 04/11/2022 at 12:16 p.m. documented, Notified NP. Nursing notes dated 04/12/2022 at 8:56 a.m., documented, on order. Nursing notes dated 04/13/2022 at 9:34 a.m. documented, on order. There was no documentation about use of a back-up pharmacy to acquire the medication patches. On 04/20/2022 at 9:39 a.m. the licensed practical nurse (LPN) #3 who routinely provided care for Resident #14 and documented the nursing notes on 04/10/2022, 04/12/2022, and 04/13/2022 was interviewed about the missed doses. LPN #3 stated, There was some recent confusion about pharmacy changes with the patches switching from the pharmacy order to becoming house stock. We were ordering them from the pharmacy and waiting for them delivery and then we found they were switched to a house stock item. You can speak with the unit manager or DON for more information because there was a meeting to discuss the new house stock items. On 04/20/2022 at 9:42 a.m., the director of nursing (DON) and assistant director of nursing (ADON/RN #3) were interviewed. The DON stated the facility switched to a new pharmacy on January 1, 2022 and the facility had identified a problem with receiving medications. The DON shared the facility recently met with the pharmacy on Monday, 04/18/2022 and identified the house stock list had changed and the facility was not aware of the change. The DON stated, Told us to pull from our house stock and we weren't aware the list had grown. (Corporate) grew the list and they didn't tell us. The DON was asked if the Lidocaine 4% patches were part of the house stock list. The ADON/RN #3 stated, Yes if it's on the house stock list we provided you all. Then it's house stock, but previously they were ordered through the pharmacy. On 04/20/2022 at 10:11 a.m. the central supply clerk (OS #1) who was responsible for ordering house stock items was interviewed. OS #1 stated, At first I was given a very short list of house stock items. I order weekly for supplies and over the counter (OTC) and house stock medications. We did just get an updated list and I'm told this is probably not all of the OTC/house stock meds. It will probably change again. OS #1 was asked when were the Lidocaine 4% patches ordered. OS #1 stated, I spoke with (LPN #3) about the situation and they were ordered about 2 weeks ago. We use the Aspercreme or Salonpas 4% generic brands as house stock. I made sure to give her a large bag of them for the med cart. On 04/20/2022 at 11:34 a.m. the pharmacy representative (OS #5) was interviewed via phone with the survey team. During the phone interview, OS #5 stated, .the facility is responsible for house items not the pharmacy A review of the (Hill Valley Corporate - Do Not Supply List, Rev. 04/20/2022) documented the Lidocaine 4% as a house stock item. A review of the facility's policy titled, House-Supplied (Floor Stock) Medications (Rev. 08/2020) documented, When permitted by state regulations, the facility may maintain a supply of commonly used over-the-counter (OTC) medications considered floor stock or house medications (not resident-specific), to be administered only upon receipt of an order from an authorized prescriber The above findings were reviewed with the administrator, DON, and ADON during a meeting on 04/20/2022 at 4:55 p.m. Based on staff interview, clinical record review, and facility document review the facility staff failed to ensure medications were available for administration for 5 of 21 residents in the survey sample, Resident #230, Resident #59, Resident #15, Resident #46, and Resident #14. Findings include: 1. Resident #230 was admitted with diagnoses that included, but were not limited to: BPH (benign prostatic hypertrophy) with urinary retention, indwelling Foley catheter, urinary tract infection, entercolitis, C-Diff (clostridium difficile) infection, PVD (peripheral vascular disease), dementia, high blood pressure and bacteremia (infection in the blood). The resident's admission MDS (minimum data set) was still in progress. Resident #230's nursing admission assessment dated [DATE] documented, that the resident had dementia with cognitive deficits (unable to answer to place, time and situation). On 04/20/22 at 11:36 AM, Resident #230 was observed in his room. An IV (intravenous) pole with machine was observed in the corner of the room. Resident #230 was observed with a central line catheter that had a clear, dry dressing intact. The physician's orders were then reviewed and included the following: .Aricept tablet 23 mg (milligrams) give one tablet daily in the morning for dementia (order date: 04/15/22) (start date: 04/16/22) Vancomycin capsule 125 mg give one capsule by mouth four times a day for 8 days for C-diff (order date: 04/15/22) (start date: 04/15/22) Vancomycin .use 1.75 gram intravenously every 24 hours for C-diff for 7 administrations (order date: 04/15/22) (start date: 04/16/22) . The MARs/TARs (medication/treatment administration records) were reviewed for the month of April 2022. The MAR documented that Resident #230 did not receive Aricept 23 mg on April 16th, 17th, 18th, or 19th. The resident's progress notes documented that the medication was unavailable, on order, or awaiting from the pharmacy on these days. The MARs also documented that Resident #230 did not receive oral Vancomycin 125 mg capsules on April 16th (3 doses), April 17th (two doses) and April 19th (one dose). The resident's progress notes documented that the oral Vancomycin was on order from the pharmacy and not available for administration on these days. The MARs documented that Resident #230 did not receive the IV Vancomycin 1.75 grams IV on April 16th, 17th, 18th, or 19th. The resident's progress notes documented that the IV medication was on order from the pharmacy (04/16/22). A nursing progress note dated 04/18/22 documented that clarification was needed from the MD (Medical Doctor) regarding this medication. There was no clarification found in the resident's records regarding this medication. A nursing progress note dated 04/19/22 documented that the IV Vancomycin was on hold related to issues with pharmacy. There was no clarification regarding this, nor were there any physician's orders to hold this medication and no information regarding issues with pharmacy. On 04/20/22 at 9:45 AM, the DON (director of nursing) and the ADON (assistant director of nursing) were interviewed. They were asked what happens if a medication is not available for the nurses to administer. The DON stated, We notify the physician that meds are not available. They were asked if they had been having issues with medications being unavailable for administration. The ADON stated, In the past, yes. The DON stated, Our nurses are still telling us we have problems getting meds that's why we've been having frequent meetings with pharmacy. The DON and ADON stated that they last met with pharmacy in January and the problem was still current. The DON stated, They (pharmacy) say they will call (if meds aren't available), out of stock or on back order .we really don't know either. On 04/20/22 at 11:35 AM, the pharmacy director of quality was interviewed regarding the IV Vancomycin being unavailable for Resident #230, since being admitted to the facility. The pharmacy director stated that the IV Vancomycin request was sent to the pharmacy on 04/16/22 and the pharmacist had attached a note that the medication was ordered for C-diff (not a blood infection per the resident's hospital discharge summary) and that the medication had been profiled for that reason. The pharmacy director stated the oral Vancomycin 125 mg order was requested and processed on 04/16/22 and 32 capsules (a supply to administer 4 capsules per day for 8 days-as ordered) were delivered on 04/17/22. The pharmacy director stated that IV Vancomycin is not well absorbed and isn't typically used to treat C-diff. The pharmacy director stated that the Aricept was dispensed on 04/16/22, but not delivered to the facility until 04/19/22, and was unsure why there was a delay in delivery. On 04/20/22 at 4:45 PM, LPN (Licensed Practical Nurse) #1 was interviewed regarding Resident #230 not being administered the ordered medications. LPN #1 stated that the facility had been having ongoing trouble getting medications from the pharmacy. LPN #1 stated that they do carry some medications in they pyxis machine, but not everything that they may need, and that the facility does have house stock meds. At 4:50 PM, the unit manager, Registered Nurse (RN) #1 was interviewed regarding Resident #230 not getting medications as ordered by the physician. RN #1 stated that the facility has had trouble getting medications for residents and that the facility has switched pharmacies. On 04/20/22 at 5:15 PM, the DON (director of nursing), ADON (assistant director of nursing) and the administrator were made aware of concerns regarding Resident #230 not getting medications as ordered by the physician and that according to the pharmacy, some medications were here to be administered, while others required clarification. The DON was asked for a policy on unavailable medications and the pharmacy contract. A policy titled, Unavailable Medications documented, .Medication used by residents in the nursing facility may be unavailable for dispensing from pharmacy on occasion .due to .out of stock .recall .manufacturer's shortage .medication no longer being produced. The facility must make every effort to ensure that medications are available to meet the needs of each resident .The pharmacy staff shall .notify nursing staff that the order product is/are unavailable .Notify nursing staff of when it is anticipated that the drug(s) will be become available .Suggest alternative, comparable drug(s) and dosage of drug(s) that is/are available .The nursing staff shall .notify the attending physician or on call physician when applicable of the situation and explain the circumstances, expected availability, and alternative therapies available. If the facility nurse is unable to obtain a response from the attending physician or on call physician, the nurse should notify the nursing supervisor and contact the facility director for orders and/or direction .notify the pharmacy of replacement order . No further information and/or documentation was presented prior to the exit conference on 04/21/22. 2. Resident #59's was admitted with diagnoses that included: Atrial fibrillation, high blood pressure, depression, polyneuropathy, spinal stenosis, chronic back pain, abdominal pain, abdominal pain, hyponatremia, and constipation. The most current MDS was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 14, indicating the resident was intact for daily decision making skills. Resident #59's clinical records documented in the progress notes that several, physician ordered medications for Resident #59 were not available for administration. The resident's physician orders included the following: Dulcolax 5 mg tablet every night at bedtime for laxative (order date: 04/09/22/start date: 0409/22) Bio-Freeze gel 4% topical for left hip pain apply twice daily (order date: 04/13/22/start date: 04/13/22) Naproxen tablet 220 mg give one tablet twice daily for inflammation (order date: 04/09/22/start date: 04/09/22) Magnesium Citrate solution 1.745 grams/30 ml (milliliters) Give 30 ml by mouth in the morning for laxative (order date: 04/09/22/start date: 04/10/22) Sodium Chloride tablet give one tablet by mouth one time a day for hyponatremia (order date: 04/15/22/start date: 04/16/22). The MARs/TARs (medication/treatment administration records) for the month of April 2022 indicated Resident #59 did not receive the following medications as ordered by the physician: Dulcolax 5 mg tablet each night for 9 days. Eleven of 14 doses of Bio-Freeze gel 4%. Twenty of 22 ordered doses of the twice daily Naproxen 220 mg. Magnesium Citrate solution for 5 of 11 days. Sodium Chloride tablet daily for 6 days. The progress notes documented that all of the above medications were on order, not available and/or awaiting pharmacy on the days the medication was not administered. On 04/20/22 at 9:45 AM, the DON (director of nursing) and the ADON (assistant director of nursing) were interviewed. They were asked what happens if a medication is not available for the nurses to administer. The DON stated, We notify the physician that meds are not available. They were asked if they had been having issues with medications being unavailable for administration. The ADON stated, In the past, yes. The DON stated, Our nurses are still telling us we have problems getting meds that's why we've been having frequent meetings with pharmacy. The DON and ADON stated that they last met with pharmacy in January and the problem was still current. The DON stated, They (pharmacy) say they will call (if meds aren't available), out of stock or on back order .we really don't know either. On 04/20/22 at 11:45 AM, the pharmacy director of quality was interviewed regarding medications being unavailable for Resident #59. The pharmacy director of quality stated that the medications Dulcolax, Magnesium Citrate, Naproxen, Bio-Freeze and Sodium Chloride tablets are all house stock medications and are supplied by the facility, not from the pharmacy. On 04/20/22 at approximately 12:45 PM, the administrator, DON and ADON were made aware of the above information and concern over medications not available for administration. The DON stated that their house stock medications just recently got updated and they were not made aware, but they now have the updated list. A policy titled, House - Supplied (Floor Sock) Medications documented, .the facility may maintain a supply of commonly used over the counter medications considered floor stock or house medications to be administered only upon receipt of an order from an authorized prescriber .The floor stock medication list is posted in the medication rooms/carts with the facility policy, and provided to the dispensing pharmacy .floor stock medications are ordered from the contracted supplier . The pharmacy contract was reviewed and documented, .The pharmacy shall deliver medications and provide services to the facility 7 days a week, 365 days a year .The pharmacy shall establish an emergency system for backup and/or interim order dispensing. Any emergency drug supply provided under this section shall be the property of the pharmacy .The pharmacy shall provide the pharmaceutical services in compliance with all applicable laws .Non-Prescription Drugs: The facility may order OTC drugs from the pharmacy and such drugs shall be billed to the facility . On 04/21/22 at approximately 11:00 AM, the administrator, DON, and ADON were made aware of the concerns with medications not being available for administration. No further information and/or documentation was provided prior to the exit conference on 04/21/22.3. Resident #15 was admitted to the facility with diagnoses that included bladder-neck obstruction, diabetes, anemia, acute kidney failure, atrial fibrillation, hyperlipidemia, hematuria and hypertension. The minimum data set (MDS) dated [DATE] assessed Resident #15 as cognitively intact. a) On 4/19/22 at 2:40 p.m., Resident #15 was interviewed about quality of care in the facility. Resident #15 stated his right ear had been stopped up with wax for over a week. The resident stated staff told him they were going to order drops and then irrigate the ear to remove the wax. The resident stated he had received no drops as of today (4/19/22). Resident #15 stated he had pressure and was not able to hear well out of the right ear due to the impacted wax. The resident described the condition as aggravating. Resident #15 stated he had reported to nurses and the nurse practitioner that he had not received drops and nothing had been done to relieve the ear wax. A nurse practitioner (NP) progress note dated 4/12/22 documented the resident was assessed complaints of right ear wax. This progress note documented, .is complaining of right ear feeling plugged and thinks it is wax build up .On otoscopic exam, right TM (tympanic membrane) obscured by cerumen .Impacted cerumen .debox (Debrox), then flush ear in 5 days . Resident #15's clinical record documented a physician's order dated 4/13/22 for Debrox solution with instructions to instill 4 drops in the right ear two times per day for 5 days for treatment of impacted cerumen. Resident #15's medication administration record (MAR) from 4/13/22 through 4/20/22 documented the Debrox solution was not administered because the drops were not available. MAR notes about the unavailable Debrox were as follows. 4/12/22 - Debrox Solution .On order . 4/13/22 - .still on order . 4/14/22 - .on order .awaiting arrival from pharmacy . 4/15/22 - .on order . 4/16/22 - .Not delivered yet . 4/17/22 - .On order from pharmacy . 4/18/22 - .Not in stock on order .On order from pharmacy . 4/20/22 - .Pharmacy notified the debrox solution did not come last pm as expected . On 4/20/22 at 10:44 a.m., the licensed practical nurse (LPN) #1 caring for Resident #15 was interviewed about the Debrox. LPN #1 stated the Debrox never arrived from pharmacy. LPN #1 stated messages had been sent to the pharmacy about the Debrox with no response. LPN #1 stated the pharmacy requested a form last evening (4/19/22) and that was sent as requested but she still did not have the drops. On 4/20/22 at 10:46 a.m., the registered nurse (RN) #1, unit manager, was interviewed about Resident #15's Debrox. RN #1 stated she was told the Debrox was on the list and ordered. RN #1 stated the Debrox had not been sent from pharmacy. On 4/20/22 at 11:02 a.m., the facility's supply clerk (other staff #1) was interviewed about the Debrox. The supply clerk stated the list of house stock items was recently updated with about 100 meds (medications). The supply clerk stated no Debrox had been ordered for the facility. On 4/20/22 at 11:34 a.m., the registered pharmacist/director of quality (Rph - other staff #5) was interviewed by phone about Resident #15's unavailable Debrox. The Rph stated the Debrox was a house stock item and was supposed to be ordered by the facility and not supplied by the pharmacy. b) Resident #15's clinical record documented a physician's order dated 2/23/22 for the medication lisinopril 10 mg (milligrams) with instructions to give one each morning for the treatment of hypertension. Resident #15's MAR documented the lisinopril was not given on 4/12/22, 4/13/22, 4/16/22, 4/17/22 and 4/18/22 because the medication was not available. The MAR documented the medication was administered on 4/15/22 with nursing notes stating the medication was not available. MAR notes documented the following regarding the availability of the lisinopril. 4/12/22 - Lisinopril .ordered . 4/13/22 - .ordered .still on order . 4/14/22 - .on order .awaiting on arrival from pharmacy . 4/15/22 - .on order . 4/17/22 - .on order . 4/18/22 - .Not in stock and reordered . On 4/19/22 at 3:15 p.m., LPN #1 caring for Resident #15 was interviewed about the lisinopril availability. LPN #1 stated she did not know why the lisinopril had not been provided. LPN #1 stated there had been ongoing issues with getting medications from the pharmacy. On 4/19/22 at 3:24 p.m., the unit manager (RN #1) was interviewed about Resident #15's lisinopril. RN #1 stated medications were ordered from the pharmacy and they just don't show up. RN #1 stated the pharmacy did not communicate when medications were not available. RN #1 stated the pharmacy was supposed to provide a back-up service for needed medications but that protocol had not been effective in getting medications. On 4/20/22 at 9:42 a.m., the director of nursing (DON) was interviewed about the unavailable medications. The DON stated when medications were out, nurses were supposed to call the pharmacy and request the needed drugs. The DON stated there was an emergency supply of some medications onsite but it did not contain all medications. The DON stated the pharmacy was supposed to provide back-up service for needed medications. On 4/20/22 at 11:34 a.m., the Rph/director of quality (other staff #5) was interviewed about Resident #15's unavailable lisinopril. The Rph stated she would investigate and advise. There was no response from Rph prior to end of the survey on 4/21/22. These findings were reviewed with the administrator and director of nursing during a meeting on 4/20/22 at 5:00 p.m. 4. Resident #46 was admitted to the facility with diagnoses that included Parkinson's disease, orthostatic hypotension, hyperlipidemia, seizures, gout, major depressive disorder and dementia with behavioral disturbance. The minimum data set (MDS) dated [DATE] assessed Resident #46 as cognitively intact. Resident #46's clinical record documented a physician's order dated 4/13/22 for Aricept 10 mg (milligrams) to be administered at each bedtime for dementia. The record documented a physician's order dated 4/13/22 for Remeron Soltab 15 mg to be administered at each bedtime for depression. Resident #46's medication administration record (MAR) documented the Aricept and Remeron were not administered on 4/18/22 as ordered. A nursing note dated 4/18/22 documented regarding the Aricept and Remeron, medication unavailable. On 4/20/22 at 9:42 a.m., the director of nursing (DON) was interviewed about unavailable medications. The DON stated when medications were out, nurses were supposed to call the pharmacy and request the needed drugs. The DON stated there was an emergency supply of some medications onsite but it did not contain all medications. The DON stated the pharmacy was supposed to provide back-up service for needed medications. On 4/20/22 at 3:47 p.m., the registered nurse unit manager (RN #5) was interviewed about the unavailable medications. RN #5 stated the Aricept and Remeron were identified as on order from the pharmacy. RN #5 stated she did not know why these medications ran out and a supply was not maintained. This finding was reviewed with the administrator and director of nursing during a meeting on 4/20/22 at 5:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to ensure two of 21 residents in the survey sample were free of a significant medication error, Resident #230 and #59. Resident #230 was not administered IV (intravenous) antibiotics for a blood infection for four consecutive days; and Resident #59 was not administered sodium chloride for hyponatremia for 5 days and wasn't administered a bowel regimen, Dulcolax for 9 days. Findings include: 1. Resident #230 was admitted with diagnoses that included, but were not limited to: BPH (benign prostatic hypertrophy) with urinary retention, indwelling Foley catheter, urinary tract infection, entercolitis, C-Diff (clostridium difficile) infection, PVD (peripheral vascular disease), dementia, high blood pressure and bacteremia (infection in the blood). The resident's admission MDS (minimum data set) was still in progress. Resident #230's nursing admission assessment dated [DATE] documented, that the resident had dementia with cognitive deficits (unable to answer to place, time and situation). On 04/20/22 at 11:36 AM, Resident #230 was observed in his room. An IV (intravenous) pole with machine was observed in the corner of the room. Resident #230 was observed with a central line catheter that had a clear, dry dressing intact. The physician's orders were reviewed and included, Vancomycin .use 1.75 gram intravenously every 24 hours for C-diff for 7 administrations (order date: 04/15/22) (start date: 04/16/22) . The MARs/TARs (medication/treatment administration records) were reviewed for the month of April 2022. The MARs documented that Resident #230 did not receive the IV Vancomycin 1.75 grams IV on April 16th, 17th, 18th, or 19th. The resident's progress notes documented that the IV medication was on order from the pharmacy (04/16/22). A nursing progress note dated 04/19/22 documented that the IV Vancomycin was on hold related to issues with the pharmacy. There were no physician's orders to hold this medication and there was no further information regarding issues with pharmacy. There was no evidence that the resident's physician had been notified that the resident was not administered this medication for 4 days. On 04/20/22 at 9:45 AM, the DON (director of nursing) and the ADON (assistant director of nursing) were interviewed. They were asked what happens if a medication is not available for the nurses to administer. The DON stated, We notify the physician that meds are not available. They were asked if they had been having issues with medications being unavailable for administration. The ADON stated, In the past, yes. The DON stated, Our nurses are still telling us we have problems getting meds that's why we've been having frequent meetings with pharmacy. The DON and ADON stated that they last met with pharmacy in January and the problem was still current. The DON stated, They (pharmacy) say they will call (if meds aren't available), out of stock or on back order .we really don't know either. The DON and ADON were made aware that the resident missed this medication 4 days in a row. On 04/20/22 at 11:35 AM, the pharmacy director of quality was interviewed regarding the IV Vancomycin being unavailable for Resident #230, since being admitted to the facility (4 days). The pharmacy director stated that the IV Vancomycin request was sent to the pharmacy on 04/16/22 and the pharmacist had attached a note that the medication was ordered for C-diff and that the medication had been profiled for that reason. The pharmacy director stated that IV Vancomycin is not well absorbed and isn't typically used to treat C-diff. On 04/20/22 at 4:45 PM, LPN (Licensed Practical Nurse) #1 was interviewed regarding Resident #230 not being administered the ordered medications. LPN #1 stated that the facility had been having ongoing trouble getting medications from the pharmacy. LPN #1 was asked if she had notified the physician that Resident #230 was not getting the IV Vancomycin. LPN #1 stated that she had contacted the pharmacy, but had not contacted the physician. At 4:50 PM, the unit manager, Registered Nurse (RN) #1 was interviewed regarding Resident #230 not getting medications as ordered by the physician. RN #1 stated that the facility has had trouble getting medications for residents and that the facility has switched pharmacies. RN #1 was asked if she had notified the physician that the resident wasn't getting the ordered IV antibiotics. RN #1 stated that she had not notified the physician and also stated that she had contacted pharmacy. On 04/20/22 at 5:15 PM, the DON (director of nursing), ADON (assistant director of nursing) and the administrator were made aware of the significant concerns regarding Resident #230 not getting IV antibiotics for 4 days. On 04/21/22 at 8:25 AM, the NP (nurse practitioner) was interviewed regarding Resident #230 not getting the prescribed IV antibiotics for, 4 days straight. The NP stated that she was not aware that Resident #230 had not receive this medication until this morning (04/21/22). The NP stated that the potential negative outcomes from missing the 4 doses of IV antibiotics could result in the resident not going to get better, can be life threatening; the infection would progress, medication may not work as well and prolonged treatment. No further information and/or documentation was presented prior to the exit conference on 04/21/22. 2. Resident #59's was admitted with diagnoses that included: Atrial fibrillation, high blood pressure, depression, polyneuropathy, spinal stenosis, chronic back pain, abdominal pain, abdominal pain, hyponatremia, and constipation. The most current MDS was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 14, indicating the resident was intact for daily decision making skills. Resident #59's clinical records documented in the progress notes that several, physician ordered medications for Resident #59 were not available for administration. A hospital Discharge summary dated [DATE] was reviewed. The discharge summary documented that Resident #59 had a 6 day hospitalization from 04/03/22 to 04/09/22. The discharge summary documented that the resident had, nausea and vomiting, abdominal pain, constipation, hypo-osmolality and hyponatremia .resident's symptoms were felt to be related to colonic fecal impaction and was put on a clear liquid diet and aggressive bowel program .hyponatremic .monitor patient's sodium level .Orders: bisacodyl (Dulcolax) 5 mg one tab daily . The resident's physician orders included the following: Dulcolax 5 mg tablet every night at bedtime for laxative (order date: 04/09/22/start date: 0409/22) Sodium Chloride tablet give one tablet by mouth one time a day for hyponatremia (order date: 04/15/22/start date: 04/16/22). The MARs/TARs (medication/treatment administration records) for the month of April 2022 indicated Resident #59 did not receive the following medications as ordered by the physician: Dulcolax 5 mg tablet each night for 9 days, and Sodium Chloride tablet daily for 6 days. The progress notes documented that all of the above medications were on order, not available and/or awaiting pharmacy on the days the medication was not administered. The current care plan was reviewed and documented, diet as ordered .supplements as ordered .document consumption resident has constipation follow facility bowel protocol for bowel management .increase fiber and fluid intake .monitor medications for side effects of constipation .keep physician informed of any problems . On 04/20/22 at 9:45 AM, the DON (director of nursing) and the ADON (assistant director of nursing) were interviewed. They were asked what happens if a medication is not available for the nurses to administer. The DON stated, We notify the physician that meds are not available. They were asked if they had been having issues with medications being unavailable for administration. The ADON stated, In the past, yes. The DON stated, Our nurses are still telling us we have problems getting meds that's why we've been having frequent meetings with pharmacy. The DON and ADON stated that they last met with pharmacy in January and the problem was still current. The DON stated, They (pharmacy) say they will call (if meds aren't available), out of stock or on back order .we really don't know either. On 04/20/22 at approximately 12:45 PM, the administrator, DON and ADON were made aware of the above information and concern over medications not available for administration. On 04/20/22 at 4:45 PM, LPN (Licensed Practical Nurse) #1 was interviewed regarding Resident #59 not being administered the above medications. LPN #1 stated that the facility had been having ongoing trouble getting medications from the pharmacy. LPN #1 stated that they do carry some medications in they pyxis machine, but not everything that they may need and the facility does have house stock meds, but they don't always have all of those. LPN #1 stated that she had not reported to the physician that the resident's medications were not available to administer or that the resident had not received the medications. At 4:50 PM, the unit manager, Registered Nurse (RN) #1 was interviewed regarding Resident #230 not getting medications as ordered by the physician. RN #1 stated that the facility has had trouble getting medications for residents and that the facility has switched pharmacies. RN #1 stated that she had not reported to the physician that medication was not available to administer or that Resident #59 had not received the medications. RN #1 stated, I did tell the NP in passing about the Sodium Chloride. RN #1 stated that she did document that and did not get any new orders regarding that medication. On 04/21/22 at 8:25 AM, the NP (nurse practitioner) was interviewed regarding Resident #59 not receiving these medications for days and the significant concerns related to the resident's diagnoses. The NP stated, I didn't know the medications weren't available or that she didn't get them. The NP stated, I did know of a history of colonic impaction (forResident #59), but didn't know she didn't have or receive the bowel medications. The NP was asked about any negative outcomes related to Resident #59 not getting these medications. The NP stated, She could get a bowel obstruction, impaction, ileous and without sodium shloride, she (Resident #59) could have a really bad day, she could end up in the ICU (intensive care unit). On 04/21/22 at approximately 11:00 AM, the administrator, DON, and ADON were made aware of the concerns with medications not being available for administration and the significant medication error related to multiple missed doses of the above medications. On 04/21/22 at 11:30 AM, Resident #59 was interviewed. Resident #59stated that she doesn't have a bowel movement every day and it can be uncomfortable. Resident #59 stated that she had a smidge of a bowel movement the day before, but it had been several days or longer that she could say she had a good bowel movement. Resident #59 stated that she wasn't getting the Dulcolax tablets and that staff had been trying to give her Miralax, but that made her sick and nauseated. Resident #59 stated that she had told them that, but they keep trying to give that to her instead of something else. Resident #59 stated that she didn't understand why they would just give her salt to add to her food for the hyponatremia and give her milk of magnesia bowels, and that would be easier and has worked in the past. Resident #59 was asked if she felt constipated. Resident #59 stated that she didn't, but stated that she didn't feel constipated the last time either. No further information and/or documentation was provided prior to the exit conference on 04/21/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interviews, and facility document review, the facility staff failed to offer alternate menu entrée items that were prepared in advance and compatible to other menu items. No meal alternatives menu entrée items were listed on the main menus posted on each unit, or on the copy provided to the residents. The census was 79 residents. The findings include: On 04/19/2022 during the initial tour, three3 residents, Resident #8, Resident #35, and Resident #14 stated they were not offered alternate menu items. Resident #8 was admitted with diagnoses that included, pneumonia, sepsis, chronic kidney disease, and major depression. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #9 as moderately impaired for daily decision making with a cognitive score of 11 out of 15. On 04/19/22 at 11:00 a.m. when asked about food and choices Resident #8 stated the food was not very appealing and they did not get a choice or alternative. Resident #35 was admitted to the facility with diagnoses that included anxiety disorder, cirrhosis of the liver, hepatic failure, congestive heart failure, stage 3 kidney disease, type 2 diabetes, hyperlipidemia, and encounter for palliative care (hospice). The most recent minimum data set (MDS) dated [DATE] was a quarterly and assessed Resident #35 as moderately impaired for daily decision making with a cognitive score of 11 out of 15. Resident #35 was interviewed on 04/19/2022 at 11:30 a.m. regarding the quality of care and quality of life since being at the facility. Resident #35 stated, I've been here for almost six years and this is home for me. Everyone treats me nice, they answer the call bells and we have so many activities. My only issue is the food. Resident #35 stated, Since the ownership has changed so has the quality of food. We no longer are able to choose the main meal entrée. We have to eat what they serve us. My family brings me food, but I don't feel like that should be the answer. Resident #35 was asked if the facility provided alternate menu items. Resident #35 pulled out a document titled Always Offered Items which included items available for each meal (breakfast, lunch, dinner). Resident #35 stated, We're having fish today and I don't like fish. I've asked for soup which is listed as 'always available' but was told there is no soup. So then I asked for a grilled cheese. I will have to wait to eat with my roommate. We've talked with the dietary manager (OS #2) so many times and just seems like nothing is getting done. Resident #35 stated, Look at the menu they give us. Some of these food names I don't even know what they are. Then we have to match up the calendar dates at the top of with the menu week number to figure out what we're having for each meal. It's very confusing. We've asked them to change the menus so they are easily understood and to allow us to check what we want to eat. A review of Resident #35's lunch meal ticket documented low sodium, no concentrated sweet diet and the following items for lunch: herb and lemon fish (3 ounces), mashed garlic cauliflower (1/2 cup), squash medley (1/2 cup), assorted ice cream (1/2 cup), diet lemonade (8 fl oz). 2 sweet n low/ 1 pepper. Resident #14 was admitted to the facility with diagnoses including chronic pain syndrome, gastro-esophageal reflux disease (GERD), glaucoma, hypo-osmoliaty, hyponatremia, major depressive disorder, anxiety disorder, hypertension, and joint pain (knees and hands). The most recent MDS dated [DATE] was a quarterly assessment and assessed Resident #14 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #14 was interviewed on 04/19/2022 at 12:11 p.m. regarding the quality of care and quality of life since being admitted to the facility. Resident #14 stated, The food is horrible. You don't get to choose your own meal or select what you want to eat anymore since we have new owners. We had a meeting with the Ombudsman to discuss food concerns. Resident #14's lunch meal tray was observed on the tray table. Resident #14 pointed toward the meal tray and stated, Just look at this mess. Who wants this fish, it's not our usual fish. We used to have flounder or tilapia. I have no idea what this it. Then who in their right mind wants mashed cauliflower and these squash looked barely cooked. Resident #14 was asked if alternate menu items were provided. Resident #14 stated, No ma'am. Before we were sold out, we received a menu where we could check off what we wanted. Now if you don't like what is served, you either suck it up and eat it, go hungry or have someone to bring you something from home or a restaurant. I'm paying good money to be here and so is my insurance provider. We expect to have good care and good food. On 04/19/2022 at 12:12 pm., the facility's administrator stated Resident #14 had meet with the Ombudsman earlier this month to discuss food concerns. The administrator stated the residents had developed a dining committee to address their concerns with dietary and the dietary manager was addressing the concerns as he was notified of them. A review of the Resident Council Meeting minutes for the months of November 2021 through April 2022 documented the following dietary concerns: November 1, 2021 .(Dietary Manager and Clincial Dietitian) were in attendance to answer questions, complaints or concerns the resident's might have concerning meals, menus, etc .Residents were happy to be informed of a new dietary meal selections . December 7, 2021 .(Dietary Manager) addressed resident's concerns during the meeting. Residents should feel fee to have staff call the kitchen when something is not right with their meal. Dietary continues to work on all issues brought to their attention as they come in. Dietary meets with residents that have concerns on a day by day basis to change meal settings to what they prefer Residents shared their thoughts about the meals now being provided. The Thanksgiving meal was good. Some stated the meat was sometimes not done/too done and at time too tough. Preferred a different brand of sausage . January 4, 2022 .Residents had some concerns of dietary and dietary staff follow-up on those concerns. February 1, 2022 .residents had concerns about dietary and asked to have a separate meeting about the food selection .We have scheduled a food committee meeting on March 2, 2022 . The March 2022 group meeting was canceled due to COVID related concerns. A review of the Resident Dining Committee minutes from April 6, 2022 documented the facility started new menus on April 3. The new menus were reviewed and the dietary manager stated he continues to work on changing the names of some of the menu items to make them more identifiable. The minutes documented the residents' concerns with the process to request a meal/food substitution and how long the process took to receive their requested item. Per the minutes, the ombudsman suggested the residents were provided copies of the updated menu so they could review and send in what they want to substitute. On 04/19/2022 at 1:00 p.m. a group meeting was conducted with four cognitive intact residents, Resident #8, Resident #35, Resident #14, and Resident #11. Resident #14 stated, We don't have much to look for at our age and food is one of those things that makes most people happy and brings them together. We all understand the facility changed owners, but it has been since November and some things should have gotten better. The group was asked if they were provided with menus and the always offered list. Resident #8 stated, No, I don't know anything about that 'always offered list.' I have the menu list but that is very confusing to read and sometimes they don't serve us the main entrée listed. They tell us the menus may change because items are out of stock or supply change issues. Observed posted on the wall near the second floor nursing station was the current menu. There were no alternative menu entrées listed for lunch or dinner meals. On 04/20/2022 at 2:58 p.m. the dietary manager (OS #2) was interviewed regarding the facility offering alternate meal items. OS #2 provided a copy of the always offered item list and stated, We don't have an alternate. When we were with (previous owners) we had an alternate meal option, but when we changed over to the new company it was stopped. We have the one main entrée for lunch and dinner. OS #2 continued and stated, We offer an alternate item next door at AL (assisted living), but not here. OS #2 was asked if the resident's preferences were reviewed and documented. OS #2 stated, Yes when we switched owners I went around to the residents and updated their preferences in the dietary system. Also, we just changed to our new Spring/Summer menus and when I'm told resident's don't like certain foods I continue to update their meal tickets. It has been a process with all of the changes. We recently meet with the dining committee and the ombudsman to discuss more changes. I'm working on updates, but it does take time. OS #2 was asked if the residents were notified when the menu changed due to availability issues. OS #2 stated, I have to get creative sometimes if items are out of stock. I discussed with the residents that I plan to update the menus and if items aren't available I will let them know what the substitutes are. The above findings were reviewed with the administrator, director of nursing (DON), and assistant director of nursing (ADON) during a meeting on 04/20/2022 at 4:55 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control protocols for one of twenty-one residents in the survey sample, Resident #75; and failed to implement facility protocols for Legionella prevention. The findings include: 1. Resident #75 was admitted to the facility with diagnoses that included clostridium difficile (C-diff), sepsis, chronic respiratory failure, hypoxia, COPD (chronic obstructive pulmonary disease), epilepsy, chronic pain, history of venous thrombosis and major depressive disorder. The minimum data set (MDS) dated [DATE] assessed Resident #75 as cognitively intact. Resident #75's clinical record documented a physician's order dated 3/31/22 for contact precautions due to C-diff colitis. On 4/20/22 at 8:56 a.m., certified nurses' aide (CNA) #1 was observed entering Resident #75's room. CNA #1 had on a mask but no gown or gloves and performed no hand hygiene prior to entering the room. CNA #1 retrieved the resident's partially eaten meal tray from breakfast, picking up the banana still on the tray. CNA #1 took the tray from the resident's room and placed it on a cart in the hall near the nursing desk. CNA #1 performed no hand hygiene upon exit from the room. CNA #1 then went to a resident eating breakfast in the day area and assisted with her tray items, touching the resident's napkin. Without hand hygiene, CNA #1 went to the nursing desk and used the telephone to call the kitchen for requested food items. On 4/20/22 at 9:01 a.m., CNA #1 was interviewed about not donning PPE prior to entering Resident #75's room and no hand hygiene after handling her breakfast tray. CNA #1 stated the resident was on contact precautions. CNA #1 stated gloves and a gown were not required unless she was providing direct care for the resident. CNA #1 stated she was not required to put a gown and gloves on/off when picking up food trays from residents on contact precautions. On 4/20/22 at 2:48 p.m., the registered nurse unit manager (RN #5) was interviewed about required PPE for Resident #75. RN #5 stated gowns and gloves were required for all staff crossing the threshold of Resident #75's doorway. RN #5 stated the resident was on contact precautions due to infection with C-diff. RN #5 stated the gown and gloves were to be discarded prior to exiting the room and hands washed. RN #5 stated CNA #1 should have donned a gown and gloves prior to entering Resident #75's room. The facility's policy titled Transmission-Based Precautions (undated) documented, The facility will ensure systems and processes are in place for the prevention and spread of infectious diseases .Contact Precautions: may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment . This policy documented concerning protocol for contact precautions, .Staff and visitors will wear gloves when entering the room for all interactions that may involve contact with the resident and/or the resident's environment .Staff and visitors will remove gloves and perform hand hygiene prior to leaving the resident's room .Staff and visitors will wear a gown when entering the room for all interactions that may involve contact with the resident and/or the resident's environment .Staff and visitors will remove the gown and perform hand hygiene prior to leaving the resident's room . This finding was reviewed with the administrator and director of nursing during a meeting on 4/20/22 at 5:00 p.m.2. As part of the review of the facility's Legionella Protocol, documentation was requested regarding surveillance (testing) of those areas where Legionella and other opportunistic waterborne agents could grow. The Maintenance Director was identified as the person in charge of the Legionella program. At 8:40 a.m. on 4/21/2022, the Maintenance Director was interviewed regarding the Legionella and the facility's surveillance program. The Maintenance Director provided copies of water analysis performed on four showers and one whirlpool conducted on 5/7/2018. The analysis results noted No Legionella isolated. The Maintenance Director said testing was conducted in 2019, but he could not find the results of that testing. Asked about more recent testing, the Maintenance Director said no testing has been conducted since 2019 because of COVID. At 10:20 a.m. on 4/21/2022, during a meeting with the Administrator, Director of Nursing, Assistant Director of Nursing, Legionella surveillance was discussed. According to the Administrator, testing was put on hold due to COVID and not being able to let vendors in the facility. At 11:10 a.m. on 4/21/2022, the Director of Nursing, who serves as the Infection Preventionist, was interviewed. Asked if she was aware Legionella testing was not being conducted, she said, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, facility staff failed to obtain physician orders for the immediate care of a wound vac for one of 22 residents, Resident #89. Findings were: Resident #89 was admitted to the facility on [DATE] with the following diagnoses including but not limited to: Left hip fracture, malignant neoplasm of the bone, COPD (chronic obstructive pulmonary disease), dysphagia, and pain. He died at the facility on [DATE]. A five day MDS (minimum data set) assessment was completed with an ARD (assessment reference date) of [DATE]. Resident #89 was assessed as cognitively intact with a cognitive summary score of 15. The clinical record was reviewed on [DATE]. On [DATE] the following nursing note was written: Pt [patient] arrived by [name of transport company] via stretcher at 1420 [2:20 p.m.] Pt moved to bed .on 4 L NC [liters nasal cannula] .skilled for left hip fracture. Wound vac on and running . A physician's order dated [DATE] contained the following information: Wound vac. There were no orders for the wound vac settings, or for dressing changes to the wound vac. On [DATE] at approximately 1:45 p.m. RN (registered nurse) #1, the unit manager for the unit where Resident #89 resided, and the ADON [assistant director of nursing] were interviewed regarding the wound vac. RN #1 stated, It was discontinued on Monday so we didn't need to do any dressing changes, we do those on Monday, Wednesday, and Friday .the settings were in place from the hospital. RN #1 was asked how they knew the setting was correct or what to do if the seal on the dressing was lost and the wound vac stopped working. She stated, We would need to contact the physician. The DON (director of nursing) presented progress notes from Resident #89's hospital record. The first dated [DATE] contained the following: .wound vac replaced over intact staples to outer left thigh .Periwound windowpaned with drape, covered all staples using one piece versatel, covered all with one piece black foam, drape to seal. Settings 125 mmhg/low/cont [continuous] . The second dated [DATE] contained the following: Attempted to visit resident today to assess surgical wound with wound vac over a closed incision. Patient was discharged today to the [name of facility] and was discharged with the hospital wound vac in place. Inquired to the whereabouts of he vac with the charge nurse who though the patient was sent home with a home vac but was unsure who switched it out .patient was indeed transferred to [name of facility] with [name of hospital] wound vac in place. Requested vac be removed and sent back to [hospital] via security or transport and a vac from the [facility] be applied. The above information was discussed during an end of the day meeting on [DATE] with the DON and the administrator. The DON was asked about the progress notes presented. She stated that they had been part of the hospital record not part of the facility record. She was asked if the wound vac had been changed out as documented in the progress note from the hospital. She stated, No, the family didn't want us to change it since it was working so well. She was asked if that was documented in the clinical record. She stated, I will need to look. On [DATE] a discharge summary from the hospital was presented by the DON. The hospital discharge summary contained no orders/parameters for the wound vac. The DON was asked how the nursing staff knew what to do with the wound vac if no orders were in place at the time of admission and were not obtained from the physician. She did not answer. No further information was obtained prior to the exit conference on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility staff failed to develop a baseline care plan for two of 21 residents. Resident #89 was admitted to the facility with a wound vac and a port-a-cath, and Resident #85 was admitted with a wound vac. A baseline care plan for the devices was not developed for either resident. Findings were: 1. Resident #89 was admitted to the facility on [DATE] with the following diagnoses including but not limited to: Left hip fracture, malignant neoplasm of the bone, COPD (chronic obstructive pulmonary disease), dysphagia, and pain. He died at the facility on [DATE]. A five day MDS (minimum data set) assessment was completed with an ARD (assessment reference date) of [DATE]. Resident #89 was assessed as cognitively intact with a cognitive summary score of 15. The clinical record was reviewed on [DATE]. On [DATE] the following nursing note was written: Pt[patient] arrived by [name of transport company] via stretcher at 1420 [2:20 p.m.] Pt moved to bed .on 4 L NC [liters nasal cannula] .skilled for left hip fracture. Wound vac on and running . Another note also dated [DATE] contained the following: .implanted port noted to right chest wall. Patient states this was decannulated and flushed today. The care plan was reviewed. There were no interventions listed on the care plan for the care of the wound vac or the implanted device. On [DATE] at approximately 1:45 p.m. RN (registered nurse) #1, the unit manager for the unit where Resident #89 resided, and the ADON [assistant director of nursing] were interviewed regarding the care plan. RN #1 stated, We mentioned the wound vac under falls because of the tubing. The area on the care plan RN#1 referred to was: Problem: [Name] has a potential for falls and injury rt [related to] recent fall, hip fracture and multiple devices (wound vac). Goals: [Name] will not sustain serious injury rt fall thru next review. Interventions: Ensure call bell is within reach .PT [physical therapy] referral, Therapy interventions. There was no mention in the fall interventions regarding the wound vac tubing. RN#1 also stated, We have an intervention for dressing changes as ordered beside the problem surgical incision/wound .that would include the wound vac even if it isn't mentioned .we don't care plan specifics about wound care because the orders change frequently .The wound vac was discontinued on Monday so we didn't really do anything with it. RN #1 was asked what the nurse's should be doing with a wound vac. She stated, Monitoring the site, making sure the dressing is clean and dry, make sure the wound vac is running. She was asked if she thought that should be on the care plan. Neither she or the ADON answered. They were asked what the purpose of the care plan was. The ADON stated, To direct the patient's care. She was asked if that meant the nursing interventions such as assessing the wound vac, the site, etc, should be on the care plan. She stated, Yes. The implanted port was also discussed. RN #1 stated, We weren't doing anything with that so it wouldn't go on the care plan. She was asked if it should be added as a point of information for the nurses. She did not answer. The above information was discussed during an end of the day meeting on [DATE] with the DON (director of nursing) and the administrator. No further information was obtained prior to the exit conference on [DATE]. 2. Resident # 85 was admitted to the facility on [DATE] with diagnoses that included arteriosclerotic heart disease, diabetes mellitus, chronic kidney disease, hyperlipidemia, difficulty walking, malignant neoplasm of the prostate, chronic systolic (congestive) heart failure, and MRSA (Methicillin Resistant Staphylococcus Aureus) of a surgical wound. According to a comprehensive Minimum Data Set, with an Assessment Reference Date of [DATE], the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. At entry on [DATE], Resident # 85 had the following physician's order: Clean sternum incision with saline. Place Versatel in wound bed with two pieces of black foam. Apply suction at 150 mmHg (millimeters of Mercury), low continuous. Three times (a week) on Monday, Wednesday, Friday. During the orientation tour at 10:50 a.m. on [DATE], a small, clear plastic two drawer cabinet was observed outside the door to Resident # 85's room. A sign on the stand indicated the resident was on Contact Precautions and directed visitors to see a nurse before entering the room. At approximately 11:00 a.m. on [DATE], RN # 2 (Registered Nurse), the Assistant Director of Nursing and the Unit Manager of the unit where Resident # 85's room was located, were asked about the cabinet and Contact Precautions sign. RN # 2 indicated the resident was on contact precautions for MRSA in a chest surgical wound, and that he had a Wound Vac. (NOTE: A wound vac is a type of therapy that reduces air pressure on a wound in order to help the wound heal more quickly. Ref. hopkinsmediciane.org.) On at least two occasions, and during a resident interview, Resident # 85 was observed carrying the pump and canister portion of the wound vac, which was operating on battery power at the time. Resident # 85's baseline care plan, dated [DATE], included the following problem, (Name of resident) has the potential for pressure injury/skin care. The goal for the problem was, Prevent pressure injury and skin breakdown. The interventions for the stated problem included, Follow facility skin protocol; Preventative measures; and, Report to charge nurse any redness or skin breakdown immediately. A thorough review of Resident # 85's baseline care plan failed to reveal any problem, goal, or interventions related to the use of a Wound Vac to aid in the healing of his surgical incision. The findings were discussed at 4:00 p.m. on [DATE] during a meeting that included the Administrator, Director of Nursing, and the survey team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for two of 22 residents in the survey sample. Resident #62 had no plan of care regarding use of a mitten and Resident #85 had no care plan regarding wound vacuum treatment. The findings include: 1. Resident #62 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #62 included chronic kidney disease, cerebral infarction with right side hemiplegia, atrial fibrillation, high blood pressure, hyperlipidemia, constipation, depression and vascular dementia with behavioral disturbance. The minimum data set (MDS) dated [DATE] assessed Resident #62 with severely impaired cognitive skills and as requiring the extensive assistance of one person for dressing. On 10/23/19 at 9:00 a.m., Resident #62 was observed seated in the day area in a Broda chair. The resident had a purple mitten on her right hand with her right hand and forearm positioned on a pillow. Resident #62's clinical record documented a hospice note dated 7/22/19 stating, .A mitten is placed on her right hand to cover a very large cyst to her right wrist . A nursing note dated 7/23/19 documented, .skin assessment performed, raised area noted to right lower anterior arm dark in color, mitten on . Resident #62's plan of care (effective 3/22/19) made no mention of the resident's use of the mitten or any reference to the mitten's purpose. On 10/23/19 at 9:09 a.m., the certified nurses' aide (CNA #1) caring for Resident #62 was interviewed about the mitten. CNA #1 stated the resident wore the mitten on her right hand to keep her hand warm. CNA #1 stated the resident was not able to use her right arm/hand and that was why the hand was positioned on the pillow. CNA #1 stated the resident had a cyst on the back of her right wrist that was covered by the mitten. On 10/23/19 at 11:20 a.m., the licensed practical nurse (LPN #1) caring for Resident #62 was interviewed. LPN #1 stated the family provided the mitten to cover the large cyst on the back of the resident's wrist. LPN #1 stated the mitten, was a dignity thing and a preference of the resident's family. LPN #1 stated the resident had little use of the right hand/arm and was on hospice care with no plans for aggressive treatment of the cyst. LPN #1 stated the unit managers were responsible for creating and/or updating care plans as needed. LPN #1 stated, We could update it [care plan]. This finding was reviewed with the administrator and director of nursing during a meeting on 10/23/19 at 4:15 p.m.2. Resident # 85 was admitted to the facility on [DATE] with diagnoses that included arteriosclerotic heart disease, diabetes mellitus, chronic kidney disease, hyperlipidemia, difficulty walking, malignant neoplasm of the prostate, chronic systolic (congestive) heart failure, and MRSA (Methicillin Resistant Staphylococcus Aureus) of a surgical wound. According to a comprehensive Minimum Data Set, with an Assessment Reference Date of 9/30/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. At entry on 9/25/19, Resident # 85 had the following physician's order: Clean sternum incision with saline. Place Versatel in wound bed with two pieces of black foam. Apply suction at 150 mmHg (millimeters of Mercury), low continuous. Three times (a week) on Monday, Wednesday, Friday. During the orientation tour at 10:50 a.m. on 10/22/19, a small, clear plastic two drawer cabinet was observed outside the door to Resident # 85's room. A sign on the stand indicated the resident was on Contact Precautions and directed visitors to see a nurse before entering the room. At approximately 11:00 a.m. on 10/22/19, RN # 2 (Registered Nurse), the Assistant Director of Nursing and the Unit Manager of the unit where Resident # 85's room was located, was asked about the cabinet and Contact Precautions sign. RN # 2 indicated the resident was on contact precautions for MRSA in a chest surgical wound, and that he had a Wound Vac. (NOTE: A wound vac is a type of therapy that reduces air pressure on a wound in order to help the wound heal more quickly. Ref. hopkinsmediciane.org.) Resident # 85's comprehensive care plan, developed after the baseline care plan, included the following problem, (Name of resident) has the potential for pressure injury/skin care. Wound Vac. The goal for the problem was, Prevent pressure injury and skin breakdown. Interventions to the stated problem were, Follow facility skin care protocol; Preventative measures; and, Report to charge nurse any redness or skin breakdown immediately. A thorough review of the comprehensive care plan for Resident # 85 failed to identify any problem, goal, or interventions related to the care of the Wound Vac. The findings were discussed at 4:00 p.m. on 10/23/19 during a meeting that included the Administrator, Director of Nursing, and the survey team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan for one 22 residents, Resident #86. Interventions regarding the use of a PICC (Peripherally Inserted Central Catheter) line and the administration of IV (intravenous) antibiotics were not removed from the care plan when they were discontinued. Findings were: Resident #86 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Bacteremia, cellulitis of left lower limb, atrial fibrillation, hypertension, chronic ulcer of left lower limb, and type II diabetes mellitus. The admission MDS (minimum data set) with an ARD (assessment reference date) of 09/18/2019, assessed Resident #86 as cognitively intact with a summary score of 13. On 10/22/2019 at approximately 2:00 p.m., Resident #86 was interviewed. She stated that she came to the facility due to sepsis and cellulitis. She stated, I had it in my left leg and it was resolving when this area came up in my right leg .I went to the hospital and found out I had a staph infection and I got septic .I was on IV antibiotics and then oral antibiotics for a total of 36 days. I just finished the ones I was taking orally yesterday .I see a wound doctor and also infectious disease about it. She was asked is she had a special line when she was getting her IV antibiotics. She stated, Yes, I had a PICC line in my left arm it's out now. The clinical record was reviewed on 10/22/2019 and the following entry was observed in the progress notes section: 10/11/2019 Pt's [patient's] PICC line was removed by nurse. Nursing supervisor also present. Pt tolerated procedure well and had head turned away from site during removal. PICC line was inspected after removal and line was intact. Pressure held on site for 3 minutes. Gauze secured with tape. No pain, redness, or tenderness noted. Will continue to monitor. The care plan was reviewed and contained the following: Problems: [Name] is receiving IV antibiotic therapy for Bacteremia via left upper arm PICC line .Goals: [Name] will receive IV antibiotics as ordered without complications through the next review. Interventions: Medications as ordered; Maintain IV site per facility/IV therapy protocol; Change tubing every 72 hours; Observe site for signs of infection .; Observe for signs/symptoms of allergy to medication .; Contact physician with any changes as needed. The DON (director of nursing) was interviewed on 10/23/2019 at approximately 2:00 p.m. regarding Resident #86's care plan interventions for IV antibiotics and the use of a PICC Line. She was asked if the interventions should still be in place. She stated, No, the care plan should have been updated when the PICC line and the IV antibiotics were discontinued. No further information was obtained prior to the exit conference on 10/24/2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to accurately assess, obtain informed consents and attempt alternatives prior to the use of bed rails for two of 22 residents in the survey sample. Residents #11 and #62 had bed rails in use with conflicting safety assessments, no prior attempted alternatives and without informed consent from their responsible parties. The findings include: 1. Resident #62 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #62 included chronic kidney disease, cerebral infarction with right side hemiplegia, atrial fibrillation, high blood pressure, hyperlipidemia, constipation, depression and vascular dementia with behavioral disturbance. The minimum data set (MDS) dated [DATE] assessed Resident #62 with severely impaired cognitive skills and as requiring the extensive assistance of one person for bed mobility. On 10/22/19 at 3:00 p.m., Resident #62 was observed in bed with two half-length bed rails in the raised position near the head of the bed. Resident #62's clinical record included conflicting documentation regarding the resident's need and safety with use of bed rails. The record documented a physician's order dated 8/1/17 for 1/2 rail both sides. The resident's plan of care (effective 3/22/19) listed the resident was at risk of falls due to fall history, right sided weakness, poor safety awareness and impaired awareness of functional limitations. Included in interventions for fall/injury prevention was 2-1/2 side rails to assist with bed mobility. Resident #62's most recent side rail assessment dated [DATE] documented the resident was not a candidate for side rail use. This assessment listed the resident was non-ambulatory, had poor balance and trunk control and did not use the rails for positioning or support. The record and assessment listed no prior attempts at alternatives to the rails. The clinical record documented no informed consent from the resident's family regarding risks/benefits of the side rails. On 10/23/19 at 11:20 a.m., the licensed practical nurse (LPN #1) caring for Resident #62 was interviewed about the bed rails. LPN #1 stated Resident #62 was totally dependent upon staff for all of her care needs. LPN #1 stated Resident #62 did not independently use the rails to move about in bed. LPN #1 stated the resident was able to hold the rail during care with her left hand but the resident had little use of her right arm/hand due to a stroke. LPN #1 stated Resident #62 was combative at times and had attempted to get out of the bed. LPN #1 was not aware of any attempted alternatives to the rails. On 10/23/19 at 1:40 p.m., the director of nursing (DON) was interviewed about Resident #62's conflicting assessments and orders for bed rails. The DON stated the use of side rails listed on the care plan might have been about the resident holding the rails when staff provided care. The DON made no other comment regarding the bed rail assessment or any prior attempted alternatives to the rails. On 10/23/19 at 3:10 p.m., the DON stated she looked and found no informed consent from Resident #62's responsible party and/or family regarding bed rails. This finding was reviewed with the administrator and DON during a meeting on 10/23/19 at 4:15 p.m. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses that included heart failure, atrial fibrillation, urinary retention, benign prostatic hyperplasia, neuralgia, depression, dysphagia and cervical spinal cord injury. The minimum data set (MDS) dated [DATE] assessed Resident #11 with severely impaired cognitive skills and as requiring the total assistance of two people for bed mobility. On 10/23/19 at 9:14 a.m., Resident #11 was observed in bed with two half-length side rails in the raised position near the head of the bed. A blanket was hanging over each of the bed rails. Resident #11's clinical record documented a nursing note dated 10/1/19 stating the resident rubbed his forehead against the bed rail during care and obtained a 1-centimeter skin tear. Resident #11's clinical record included conflicting documentation regarding the resident's need and safety with use of bed rails. The record documented a physician's order dated 10/4/18 for, Bedside rails for mobility/independence. The resident's plan of care (effective 6/13/19) listed the resident was at risk of falls due to fall history and non-ambulatory status. Included in interventions to prevent falls/injury were 2-1/2 side rails to assist with bed mobility. Resident #11's most recent side rail assessment dated [DATE] documented the resident was not a candidate for side rail use. This assessment listed the resident was non-ambulatory, had poor mobility, difficulty moving and did not use the rails for positioning or support. The record and assessment listed no prior attempts at alternatives to bed rails. The clinical record documented no informed consent from the resident's family regarding risks/benefits of the side rails. On 10/23/19 at 11:40 a.m., the licensed practical nurse (LPN #1) caring of Resident #11 was interviewed about the bed rails. LPN #1 stated Resident #11 was totally dependent upon staff for turning and moving about in bed. LPN #1 stated the resident had declined recently and was on hospice. LPN #1 was not sure why the blankets were draped over Resident #11's side rails. LPN #1 was not aware of any prior attempts at alternatives to the bed rails. On 10/23/19 at 1:40 p.m., the director of nursing (DON) was interviewed about Resident #11's conflicting assessments and orders for bed rails. The DON made no other comment regarding the bed rail assessment or any prior attempts at alternatives to the rails. On 10/23/19 at 3:10 p.m., the DON stated she looked and found no informed consent from Resident #11's responsible party regarding bed rails. The facility's policy titled Bedside Rail Utilization (undated) documented, This organization will take measures to develop and implement a strategy to minimize the possibility of resident entrapment while using side rails. This will include assessment of resident who have a need for or desire to use side rails and that may have characteristics that place them at special risk for entrapment .The side rail assessment is completed .Quarterly .At any time there is a significant change in resident condition .If the resident's assessment identifies him or her as appropriate for the use of side rails .Educate the resident/resident representative on the risks/benefits and obtain consent for use . This finding was reviewed with the administrator and DON during a meeting on 10/23/19 at 4:15 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure one of 22 residents was free from unnecessary medication. Resident #62 had a prn (as needed) physician's order for the anti-anxiety medication Lorazepam in place for over 14 days without a documented rationale and specified duration. The findings include: Resident #62 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #62 included chronic kidney disease, cerebral infarction with right side hemiplegia, atrial fibrillation, high blood pressure, hyperlipidemia, constipation, depression and vascular dementia with behavioral disturbance. The minimum data set (MDS) dated [DATE] assessed Resident #62 with severely impaired cognitive skills. Resident #62's clinical record documented a physician's order dated 1/31/19 for Lorazepam 0.5 mg (milligrams) to be administered every four hours as needed for treatment of anxiety and restlessness. A pharmacy recommendation to the physician dated 2/25/19 documented, Patient has an order for prn ativan [Lorazepam] .CMS [Center for Medicare & Medicaid Services] guidelines mandate prn psychoactive medications be limited to 2 week duration. Please consider a d/c [discontinue] of this medication. The nurse practitioner responded on 2/8/19 documenting, Patient is followed by hospice - she continues to need ativan prn. She currently has f/u [follow-up]. There was no new order or specified duration written for Resident #62's Lorazepam. On 10/23/19 at 11:40 a.m., the licensed practical nurse (LPN #1) caring for Resident #62 was interviewed. LPN #1 stated the resident's prn Lorazepam order had been in place since January 2019. LPN #1 stated the resident was administered the Lorazepam occasionally due to agitation. LPN #1 stated the resident's orders were now provided by hospice services. On 10/23/19 at 1:40 p.m., the director of nursing (DON) was interviewed about the prn Lorazepam order in place since January 2019. The DON stated Resident #62 received hospice care and the hospice physician wrote orders for the prn medications. This finding was reviewed with the administrator and director of nursing during a meeting on 10/23/19 at 4:15 p.m.