**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, and facility document review, it was determined the facility staff failed to implement the comprehensive care plan for one of 28 residents in the survey sample, Resident #34. The findings include: The facility staff failed to implement the comprehensive care plan for oxygen as ordered for Resident #34. Resident #34 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/5/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 2/21/24, which revealed, FOCUS: Respiratory Status-altered respiratory status. Status post respiratory failure with risks for complications increased by CHF. INTERVENTIONS: Administer oxygen as ordered to keep sats above 90% as directed by physician. A review of the physician's orders dated 1/30/24, revealed, Oxygen 1-2 liters per minute to keep stats at 90% or greater. On 3/11/24 at 1:40 PM, during initial observation of Resident #34, oxygen was observed to be in use at 3 liters per minute via nasal cannula, and again on 3/12/24 at 8:21 AM. An interview was conducted on 3/11/24 at 1:40 PM with Resident #34, when asked what oxygen settings she was on, Resident #34 stated, it is on two liters. On 3/12/24 at 1:20 PM an interview was conducted with LPN (licensed practical nurse) #1. When asked to observe Resident #34's oxygen setting, LPN #1 came to room and stated it is on 3 liters. LPN #1 obtained oxygen saturation during this period which was 97%. LPN #1 then went back to EMR (electronic medical record) and reviewed Resident #34's order and stated, it should only be 1-2 liters per nasal cannula to keep sats 90% or greater. When asked the purpose of the care plan, LPN #1 stated, it is to provide the guide for the care of the resident. When asked if the care plan had been implemented, LPN #1 stated, no, it is not. On 3/12/24 at 4:15 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the AIT (administrator in training) was informed of the finding. A review of the facility's Comprehensive Care Planning policy revealed, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. No further information was provided prior to exit.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed to meet professional standards of quality for one of 28 residents in the survey sample, Resident #259. The findings include: For Resident #259 (R259), the facility staff changed an indwelling urinary Foley catheter size from 16 fr (French) to 24 fr without a physician order. (Note: a catheter French size of 24 is larger than the physician ordered 16 French size. According to Urinary catheters: history, current status, adverse events and research agenda - PMC (nih.gov), Catheter size is usually expressed in French gauge. The normal practice is to use the smallest catheter compatible with good drainage: 12-16 Fr is usually adequate and only rarely is a catheter larger than 18 Fr necessary.) Review of the clinical record revealed the following nurse's notes: A nurses note dated, 9/11/2023, revealed, Resident had urologist appointment new order to change foley cath, collect urine for UA/CS and increase Eliquis [an anticoagulant medication] to 5 mg BID, RP made aware. A nurse's note dated 9/11/23 documented, Resident foley changed out this shift, 24 fr, resident requested smaller size due to irritation. Resident is not in any pain or distress from this. The nurse who changed the Foley catheter no longer worked at the facility and therefore could not be interviewed. A nurse's note dated 9/13/23 documented, Resident c/o (complains of) pain, urinary discomfort, and a burning sensation since foley was placed 9/11/23. Resident informed writer that he had no urine output since morning time on day shift. Informed resident that I would reach out to the Dr. (doctor) and inform him of complaints and concerns pertaining to his foley cath. Per Dr. orders; to change foley. Removed a 24 fr size foley. Resident had 800 ml (milliliters) of urine residual. Noted some blood on the foley and blood in the tubing. Foley was changed during shift. 16 french 10cc (cubic centimeters) . Reassess resident, resident stated that he feels better, and he feels big relief since foley was changed. Reassess pain, discomfort, and burning sensation and all complaints subsides. Rechecked, and flushed 100 cc (cubic centimeters) per orders, 250 ml with amber color urine. On 3/13/24 at 9:31 a.m., an interview was conducted with RN (Registered Nurse) #1. She stated notifying the physician is required to change the size of a Foley catheter. She stated the staff should have reached out to the doctor if there was a need to change the catheter size. On 3/13/24 at 11:41 a.m., an interview was conducted with ASM (Administrative Staff Member) #2, the Director of Nursing. She stated that the resident faced a negative outcome due to the nurse using the wrong catheter size and the resident developed burning and other complications. She stated that they called the doctor to remove it. She also stated that the nurse should have looked in the supply room or contacted her instead of taking it upon herself to change the size without a physician's notification and order. The facility policy, Change in Condition was reviewed. The policy documented, (Name of facility) will immediately inform the resident and consult with the resident's physician, if appropriate, when changes occur .Notification of changes shall include: .3. A need to alter treatment significantly. On 3/13/24 at 1:51 p.m., ASM #1 (Administrative Staff Member) the Administrator, and ASM # 2 the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interviews, clinical record review, and facility document review, it was determined that the facility staff failed to provide urinary catheter care and services in accordance with the physician's order for one of 28 residents in the survey sample, Resident #259. The findings include: For Resident #259 (R259), the facility staff failed to utilize the correct catheter size when changing the Foley catheter on 9/11/23. The physician ordered the catheter size to be 16 fr (French size), however the facility used 24 fr. (Note: a catheter French size of 24 is larger than the physician ordered 16 French size. According to Urinary catheters: history, current status, adverse events and research agenda - PMC (nih.gov), Catheter size is usually expressed in French gauge. The normal practice is to use the smallest catheter compatible with good drainage: 12-16 Fr is usually adequate and only rarely is a catheter larger than 18 Fr necessary.) A review of the clinical record revealed a physician's order dated 7/28/23 for the use of an Indwelling Catheter 16 fr. Further review of the clinical record revealed the following nurse's notes: A nurses note dated, 9/11/2023, revealed, Resident had urologist appointment new order to change foley cath, collect urine for UA/CS and increase Eliquis to 5 mg (1) BID, RP made aware. A nurse's note dated 9/11/23 that documented, Resident foley changed out this shift, 24 fr, resident requested smaller size due to irritation. Resident is not in any pain or distress from this. A nurse's note dated 9/13/23 documented, Resident c/o (complains of) pain, urinary discomfort, and a burning sensation since foley was placed 9/11/23. Resident informed writer that he had no urine output since morning time on day shift. Informed resident that I would reach out to the Dr. (doctor) and inform him of complaints and concerns pertaining to his foley cath. Per Dr. orders; to change foley. Removed a 24 fr size foley. Resident had 800 ml (milliliters) of urine residual. Noted some blood on the foley and blood in the tubing. Foley was changed during shift. 16 french 10cc (cubic centimeters) . Reassess resident, resident stated that he feels better, and he feels big relief since foley was changed. Reassess pain, discomfort, and burning sensation and all complaints subsides. Rechecked, and flushed 100 cc per orders, 250 ml with amber color urine. On 3/13/24 at 9:31 a.m., an interview was conducted with RN (Registered Nurse) #1. She stated that a physician's order is required to change the size of a foley catheter. She stated the staff should have reached out to the doctor if there was a need to change the order for the size. She also stated, if the wrong size catheter is applied it could cause issues like splitting the penis. On 3/13/24 at 11:41 a.m., an interview was conducted with ASM (Administrative Staff Member) #2, the Director of Nursing. She stated that the resident faced a negative outcome due to the nurse using the wrong catheter size and the resident developed burning and other complications. She stated that they called the doctor to remove it. She also stated that the nurse should have looked in the supply room or contacted her instead of taking it upon herself to change the size without a physician's notification and order. The facility policy Foley Catheter Insertion, Male Resident was reviewed. This policy documented, Verify that there is a physician's order for this procedure The following equipment and supplies will be necessary when performing the procedure. 1. Foley catheter tray (size specified in the order) . On 3/13/24 at 1:51 p.m., ASM#1 (Administrative Staff Member) the Administrator, and ASM# 2 the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. Reference: (1) Apixaban (brand name Eliquis) is used to help prevent strokes or blood clots in people who have atrial fibrillation (a condition in which the heart beats irregularly, increasing the chance of clots forming in the body and possibly causing strokes) that is not caused by heart valve disease. Apixaban is also used to prevent deep vein thrombosis (DVT; a blood clot, usually in the leg) and pulmonary embolism (PE; a blood clot in the lung) in people who are having hip replacement or knee replacement surgery. Apixaban is also used to treat DVT and PE and may be continued to prevent DVT and PE from happening again after the initial treatment is completed. Apixaban is in a class of medications called factor Xa inhibitors. It works by blocking the action of a certain natural substance that helps blood clots to form. https://medlineplus.gov/druginfo/meds/a613032.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide respiratory care per physician orders for one of 28 residents in the survey sample, Resident #34. The findings include: The facility staff failed to provide oxygen as ordered for Resident #34. The physician's order was for 1-2 liters per minute, however the oxygen was set to 3 liters per minute. Resident #34 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 2/5/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the comprehensive care plan dated 2/21/24, which revealed, FOCUS: Respiratory Status-altered respiratory status. Status post respiratory failure with risks for complications increased by CHF. INTERVENTIONS: Administer oxygen as ordered to keep sats above 90% as directed by physician. A review of the physician's orders dated 1/30/24, revealed, Oxygen 1-2 liters per minute to keep stats at 90% or greater. On 3/11/24 at 1:40 PM, during initial observation of Resident #34, oxygen was observed to be in use at 3 liters per nasal cannula, and again on 3/12/24 at 8:21 AM. An interview was conducted on 3/11/24 at 1:40 PM with Resident #34, and when asked what oxygen settings she was on, Resident #34 stated, it is on two liters. On 3/12/24 at 1:20 PM an interview was conducted with LPN (licensed practical nurse) #1. When asked to observe Resident #34's oxygen setting, LPN #1 came to room and stated it is on 3 liters. LPN #1 obtained oxygen saturation during this period which was 97%. LPN #1 then went back to EMR (electronic medical record) and reviewed Resident #34's order and stated, it should only be 1-2 liters per nasal cannula to keep sats 90% or greater, and that they will correct it. On 3/12/24 at 4:15 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the AIT (administrator in training) was informed of the finding. A review of the facility's Oxygen Administration policy revealed, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to implement bed rail requirements for two of 28 residents in the survey sample, Residents #36 and #212. The findings include: 1. For Resident #36, the facility staff failed to assess the risks/benefits and obtain informed consent for the use of side rails. Resident #36 was observed in bed with quarter bed rails on 3/11/24 at 1:20 PM, 3/12/24 at 10:53 AM, and 3/13/24 at 9:40 AM. Resident #36 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: hemiplegia following cerebral vascular accident and dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/19/24, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring maximal assistance for bathing, bed mobility, transfer, dressing and hygiene. A review of the comprehensive care plan dated 12/21/23 revealed, FOCUS: Self care deficit-extensive assistance required for bathing, hygiene, dressing and grooming. INTERVENTIONS: .Siderails for turning/positioning. There was no evidence of assessment of risks/benefits or consent obtained for bed rail use for Resident #36. An interview was conducted on 3/11/24 at 1:20 PM with Resident #36. When asked if he used the side rails, Resident #36 stated, yes, to turn in bed. On 3/13/24 at 9:25 AM, ASM (administrative staff member) #1, the administrator, stated they do not have evidence of assessments of the risks/benefits or consents for this resident. On 3/13/24 at 1:30 PM, ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the AIT (administrator in training) was made aware of the concerns. A review of the facility's Bed Rail/Side Rail Entrapment and Consent policy, revealed, Answer the questions below using the Yes / No column. The answers to questions 1-21 will provide information regarding the resident's functional and medical needs, request for side rails, as well as associated risks related to injury against or over the rails. No responses to any question requires further assessment of the resident's, risk of side rail use and evaluation of bed and side rail gaps; if rails are to be used, the resident requires care planning and monitoring by staff to reduce risk of entrapment and injury. The resident has the right to be free from use of side rails when imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms / need. The consent is to be fully executed prior to the installation of any siderail. No further information was provided prior to exit. 2. For Resident #212, the facility staff failed to assess the risks/benefits and obtain informed consent for the use of side rails. Resident #212 was observed in bed with quarter bed rails on 3/11/24 at 2:10 PM, 3/12/24 at 8:35 AM, and 3/13/24 at 9:15 AM. Resident #212 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: right hip replacement and osteoarthritis. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 3/13/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the baseline care plan dated 3/6/24 revealed, FOCUS: Activities of Daily Living. INTERVENTIONS: Assist with turning, positioning, transfers, bed rails. A review of the physician orders revealed Siderail quarter length to assist resident in turning/positioning while in bed. There was no evidence of assessment of risks/benefits or consent obtained for bed rail use for Resident #212. An interview was conducted on 3/11/24 at 2:10 PM with Resident #212. When asked if she used the side rails, Resident #212 stated, yes, I use them to reposition myself in bed. On 3/13/24 at 9:25 AM, ASM (administrative staff member) #1, the administrator, stated they do not have evidence of assessments of the risks/benefits or consents for this resident. On 3/13/24 at 1:30 PM, ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the AIT (administrator in training) was made aware of the concerns. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to assess the risks and benefits of side rails for one of 20 residents in the survey sample, Resident #52. The findings include The facility staff failed to evidence that Resident #52 had the risks / benefits reviewed for her use of side rails. Resident #52 was observed in bed with bilateral half side rails on 4/19/22 at 1:10 PM, 2:48 PM, 4:15 PM and on 4/20/22 at 8:30 AM. Resident #52 was admitted to the facility on [DATE]. Resident #52's diagnoses included but were not limited to: acute respiratory failure, chronic obstructive pulmonary disease 'COPD', atrial fibrillation and arthritis. Resident #52's most recent MDS (minimum data set) assessment, a Medicare 5 day assessment, with an assessment reference date of 4/8/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G- Functional Status: coded the resident as requiring extensive assistance for bed mobility, transfers, walking/locomotion, and dressing; personal hygiene/bathing Resident #52 is totally dependent and the resident is independent for eating. A review of Resident #52's comprehensive care plan dated 4/8/22, documents in part, PROBLEMS-Turning/positioning in bed requires extensive assistance. INTERVENTIONS-Half side rails when in bed for repositioning and independence. A review of the physician orders dated 4/4/22, which revealed, One-half side rails up when in bed to assist with repositioning and independence. An interview was conducted on 4/19/21 at 2:48 PM with Resident #52. When asked if she used the side rails, Resident #52 stated, yes, I use them to turn and move around in the bed. A request was made on 4/20/22 at approximately 10:00 AM for the bed rail assessment and consent for Resident #52. On 4/20/22 at 3:45 PM, an interview was conducted with OSM (other staff member) #1, the social worker stated, we do not have any assessment, consent of bed inspection for the rails for Resident #52. On 4/20/22 at 4:25 PM, an interview was conducted with LPN (licensed practical nurse) #2. When asked who assesses the resident and obtains consent for use of bed rails, LPN #2 stated, nursing does the initial assessment and obtains consent. I believe that therapy comes after that and does another assessment. When asked who and when the bed with the rails is inspected, LPN #2 stated, we have a computerized system for work orders for maintenance to come and do the rail checks. On 4/21/22 at 8:00 AM, ASM (administrative staff member) #2, the director of nursing brought in the requested information for Resident #52 and stated, we grabbed a screen shot of the work order for the bed rails for Resident #52 and here is the assessment and consent we obtained yesterday (4/20/22) for the resident. The facility's Restraints (Including Side Rails) policy dated 4/22, which reveals, A pre-restraining assessment will be done: If the resident has a physician order for two full side rails or devices that prevent the resident from getting out of bed, a side rails assessment form will be completed in addition to the pre-restraint assessment. On 4/20/22 at 5:00 PM, ASM #1, the administrator and ASM #2, the director of nursing were informed of the above concern. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care in a manner to maintain and promote resident dignity for one of 20 residents in the survey sample, Resident #1. The facility staff failed to ensure Resident #1 was covered during the residents bath on 2/24/21, to promote and maintain Resident #1's, dignity. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to Parkinson's disease (1), disorientation, dementia (2), and lack of coordination. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/19/20, Resident #1 was coded as moderately cognitively impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of staff for bed mobility, transfers between surfaces, eating, toileting, and personal hygiene. She was coded as totally dependent on staff for bathing. On 2/23/21 at 3:05 p.m., Resident #1 was observed lying on her back in bed. Her bed was in the lowest position, approximately six inches above the floor. Fall mats were visible on both sides of her bed. An attempt was made to interview Resident #1, however Resident #1's voice was very soft and hoarse, and her words were unintelligible. On 2/24/21 10:04 a.m., Resident #1 was observed in her private bathroom. She was seated in a shower chair, and the back of the chair was reclined. The resident was elevated to waist-height of CNA (certified nursing assistant) #2 in the shower chair. CNA #2 was observed bathing the resident. Observation revealed Resident #1 was leaning to the right in the chair, and was completely uncovered. At 10:06 a.m., CNA #2 left Resident #1's room and closed the door behind her. Observation revealed CNA #2 returned to Resident #1's room in approximately 60-90 seconds. As she was entering the room, CNA #2 was asked if anyone was with Resident #1 while the CNA had been gone. CNA #2 stated, No. CNA #2 stated no one was assisting her to bathe Resident #1, and that no one was supervising Resident #1 while she was alone in the bathroom in the shower chair. CNA #2 stated, I'm getting ready to brush her teeth. I needed to get a cup for water. CNA #2 was accompanied back into Resident #1's private bathroom. Resident #1 was still in the elevated shower chair, leaning over to the right, with her back reclined. Resident #1 was totally uncovered. On 2/24/21 at 10:29 a.m., CNA #2 was interviewed. When asked why she had left Resident #1 alone in the shower chair, CNA #2stated, She was having a bowel movement so she asked me to step out for a minute. When asked if she had considered covering Resident #1 up during her bath or when she left the room, she stated she did not. CNA #2 stated, She [Resident #1] has a private bathroom. CNA #2 stated she did not see a need for Resident #1 to be covered. When asked if being left completely exposed for any length of time added to Resident #1's experience of being treated with dignity, CNA #2 stated she could not speak for the resident. On 2/24/21 at 2:13 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated she had already been informed of the questions the surveyor had asked CNA #2. LPN #2 stated, From my understanding, [Resident #1] wanted to have privacy to have a bowel movement. When asked if Resident #1 should have been covered either during the bath, or while CNA #2 left her completely alone in the room, LPN #2 stated she could not say for sure. LPN #2 was asked if Resident #1 had been treated in a dignified manner when CNA #2 left the room and left Resident #1 completely uncovered. LPN #2 stated she could not say for sure because different people want different things. On 2/24/21 at 2:46 p.m., RN (registered nurse) #1, the unit manager, was interviewed. When asked if Resident #1 should have been covered either during her bath or when CNA #2 left her completely alone in the bathroom, RN #1 stated, Yes. She [Resident #1] should have been covered. She stated basic nursing practice is to cover the part of the body not being bathed. RN #1 stated, That is [nursing] 101. That is a basic thing to do. She should have been covered up. There is nothing else I can say. RN #1 stated Resident #1's dignity was not preserved when she was left totally uncovered by CNA #2. A review of Resident #1's care plan dated 4/11/19 revealed no information related to treating the resident with dignity. On 2/24/21 at 4:00 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Preservation of Resident Dignity, revealed, in part: [Name of Facility] ensures that each resident is treated with dignity and respect, and that each resident is assisted in maintaining and enhancing his or her well-being and self-esteem. No further information was provided prior to exit. (1) Parkinson's disease (PD) is a type of movement disorder. It happens when nerve cells in the brain don't produce enough of a brain chemical called dopamine. Sometimes it is genetic, but most cases do not seem to run in families. This information is taken from the website https://medlineplus.gov/parkinsonsdisease.html. (2) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/000746.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility failed to provide care in a safe manner for one of 20 residents in the survey sample, Resident #1. The facility staff failed to ensure Resident #1 was provide supervision during bathing on 2/24/21. Resident #1, who was assessed as at risk for falls, was left in the bathroom unattended, while seated and reclined in an elevated shower chair. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses including, but not limited to Parkinson's disease (1), disorientation, dementia (2), and lack of coordination. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/19/20, Resident #1 was coded as being moderately cognitively impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). She was coded as requiring the extensive assistance of staff for bed mobility, transfers between surfaces, eating, toileting, and personal hygiene. She was coded as being totally dependent on staff for bathing. On 2/23/21 at 3:05 p.m., Resident #1 was observed lying on her back in bed. Her bed was in the lowest position, just approximately six inches above the floor. On either side of her bed, fall mats were visible. An attempt was made to interview Resident #1. However, Resident #1's voice was very soft and hoarse, and her words were unintelligible. On 2/24/21 10:04 a.m., Resident #1 was observed in her private bathroom. She was seated in a shower chair, and the back of the chair was reclined. The resident was elevated to waist-height of CNA (certified nursing assistant) #2 in the shower chair. CNA #2 was observed bathing the resident. The resident was leaning to the right in the chair, and was completely uncovered. The surveyor exited the room. At 10:06 a.m., CNA #2 left Resident #1's room and closed the door behind her. In approximately 60-90 seconds, CNA #2 returned to Resident #1's room. As she was entering the room, CNA #2 was asked if anyone was with Resident #1 while the CNA had been gone. CNA #2 stated: No. CNA #2 stated no one was assisting her to bathe Resident #1, and that no one was supervising Resident #1 while she was alone in the bathroom in the shower chair. She stated: I'm getting ready to brush her teeth. I needed to get a cup for water. The surveyor accompanied CNA #2 back into Resident #1's private bathroom. Resident #1 was still in the elevated shower chair, leaning over to the right, with her back reclined. Resident #1 was totally uncovered. A review of Resident #1's clinical record revealed a physician's order dated 12/20/20. The order documented: Floor mats .check three times daily. A review of Resident #1's care plan dated 4/11/19, and updated 12/16 20, revealed: At risk for falls R/T (related to) Parkinson's. Fall mats beside bed when in bed. On 2/24/21 at 10:29 a.m., CNA #2 was interviewed. When asked why she had left Resident #1 alone in the shower chair, CNA #2 stated, She was having a bowel movement so she asked me to step out for a minute. When asked if Resident #1 was able to support herself in the chair, CNA #2 stated, No. She can't support herself. That's why it's good the chair leans back. When asked if Resident #1 was safe to be left alone in an elevated shower chair without a staff member within sight or sound range, CNA # 2 stated she thought so. On 2/24/21 at 2:13 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated she had already been informed of the questions the surveyor had asked CNA #2. LPN #2 stated, From my understanding, [Resident #1] wanted to have privacy to have a bowel movement. When asked if it was a safe practice to leave Resident #1 completely alone while she was in an elevated shower chair, LPN #2 stated, I probably would have stayed by the bathroom door. I feel like that chair is safe enough for her. That chair has arms. It is safe enough for her to be left alone. When asked why Resident #1's bed is kept at the lowest position and why the resident's floor has fall mats on both sides of the bed, LPN #2 stated, In case she [Resident #1] falls. On 2/24/21 at 2:46 p.m., RN (registered nurse) #1, the unit manager, was interviewed. When asked if Resident #1 was safe to be left alone in an elevated shower chair, she stated the resident was not safe. RN #1 stated, That was a safety issue. She should have been within eyesight. It was not safe. On 2/24/21 at 4:00 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Safety and Supervision of Residents, revealed, in part: Our resident-oriented approach to safety addresses safety and accident hazards for individual residents .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. No further information was provided prior to exit. (1) Parkinson's disease (PD) is a type of movement disorder. It happens when nerve cells in the brain don't produce enough of a brain chemical called dopamine. Sometimes it is genetic, but most cases do not seem to run in families. This information is taken from the website https://medlineplus.gov/parkinsonsdisease.html. (2) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/000746.htm.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined, that the facility staff failed to provide care for respiratory equipment in a sanitary manner for one of 20 residents in the survey sample, Resident #30. The facility staff failed to store Resident #30's BIPAP facemask in a sanitary manner when not in use. Multiple observations revealed Resident #30's BIPAP facemask in a basket uncovered wrapped in the BIPAP tubing and head strap. The findings include: Resident #30 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (1), chronic respiratory failure (2) and pneumonia (3). Resident #30's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/27/2021, coded Resident #30 as scoring a 11 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 11- being moderately impaired for making daily decisions. Resident #30 was documented as receiving oxygen while a resident at the facility, in Section O of the assessment. On 2/23/21 at approximately 12:40 p.m. an interview was conducted with Resident #30 in their room. Observation of Resident #30's room revealed a rolling stand with attached basket housing a BIPAP (positive airway pressure) machine (4). Tubing was observed attached to the machine connecting a facemask with head strap in the basket. The facemask was observed uncovered in the basket wrapped in the tubing and head strap. When asked about the machine, Resident #30 stated that they used it at night when sleeping for their COPD. When asked how the mask was cared for, Resident #30 stated that the nursing staff applied the mask at night and took it off in the morning and placed it back in the basket. Resident #30 stated that they did not recall seeing staff clean the mask and or put it in a bag. Resident #30 stated that it was stored in the basket of the machine as observed. Additional observations made on 2/23/21 at 3:10 p.m., 2/24/21 at 8:35 a.m. and 2/25/21 at 9:15 a.m. revealed the same findings as above. The physician's orders for Resident #30 documented in part the following: - Home trilogy (brand of BIPAP machine) settings. Do not touch home trilogy machine. Settings are already in place. Home trilogy used at night only. Order Date: 2/17/2021. - Clean trilogy water tank. Refill water tank. Order Date: 2/17/2021. Frequency: Two Times Weekly . The comprehensive care plan for Resident #30 dated 11/22/2019 documented in part, [Name of Resident #30] has potential for difficulty in breathing related to: COPD, H/O (history of) pneumonia, COPD exacerbation, Status: Active (Current). Effective Date: 11/22/2019-Present. Under Interventions, it documented in part, .Trilogy machine at HS (hour of sleep) as ordered . On 2/25/21 at approximately 9:30 a.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that any respiratory equipment was stored in a plastic bag when not in use, and the bag was dated and changed weekly. When asked about the mask for Resident #30's trilogy machine, LPN #6 stated that the night shift cared for the mask but they thought that it was cleaned once a week and stored in a bag. LPN #6 stated that the night shift nurses normally handled the application and removal of Resident #30's trilogy machine because they only wore it during the night. LPN #6 stated that the purpose of storing the mask in the bag was to prevent dust from getting on it and to keep it clean. LPN #6 made an observation of Resident #30's trilogy machine with the mask uncovered in the basket at 9:35 a.m. and stated that the mask should have been stored in a bag when not in use. LPN #6 stated that they were going to clean the mask or replace it and place it in a bag with the date when not in use and report it to the unit manager. The facility policy Departmental (Respiratory Therapy) - Prevention of Infection, Level 1 (one), documented in part, Purpose, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff . The policy failed to evidence guidance on the storage of masks used for BIPAP ventilation, however it documented in part, .Keep oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use . On 2/25/21 at approximately 9:30 a.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. Chronic obstructive pulmonary disease (COPD) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2. Chronic respiratory failure When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. 3. Pneumonia An infection in one or both of the lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. This information was obtained from the website: https://medlineplus.gov/pneumonia.html. 4. BIPAP Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems. This information was obtained from the website: https://medlineplus.gov/ency/article/001916.htm

Based on staff interview, facility document review and clinical record review it was determined that the facility staff failed to act in a timely manner on the pharmacy medication regimen review for two of 20 residents in the survey sample, Residents #6 and #30. 1. Resident #6's medication regimen review was completed on 1/17/21 with recommendations for a gradual dose reduction of the antidepressant and hypnotic medications which were not discovered by the facility in their email or presented to the physician for action until 39 days later. 2. The facility staff failed to act in a timely manner on a medication regimen review for Resident #30. Resident #30's medication regimen review was completed on 9/17/2020 with recommendations to evaluate the as needed order for Klonopin (sedative medication) which was not reviewed by the physician until January of 2021. The findings include: 1. Resident #6's medication regimen review was completed on 1/17/21 with recommendations for a gradual dose reduction of the antidepressant and hypnotic medications which were not discovered by the facility in their email or presented to the physician for action until 39 days later. Resident #6 was admitted to the facility with diagnoses that included but were not limited to atrial fibrillation (1), insomnia (2) and major depressive disorder (3). Resident #6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/27/2020, coded Resident #6, as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section N documented Resident #6 as receiving antidepressant and hypnotic medications. The physician's orders for Resident #6 documented in part the following: - Order Date: 11/20/2020, Status: Active (Current), Description: Duloxetine (antidepressant) 60 mg (milligram) capsule, delayed release 1 (one) time daily. Start Date: 11/21/2020 . - Order Date: 11/22/2020, Status Active (Current), Description: Ambien (hypnotic) 10 mg tablet 1 time daily. Start Date: 11/22/2020 . - Order Date: 2/25/2021, Status: Active (Current), Description: Duloxetine 30 mg capsule, delayed release 1 time daily. Start Date: 2/25/2021 . - Order Date: 2/25/2021, Status Active (Current), Description: Ambien 5 mg tablet 1 time daily. Start Date: 2/25/2021 . The eMAR (electronic medication administration record) for Resident #6 dated January 2021 Medications documented Resident #6 received the Duloxetine 60mg daily and Ambien 10mg daily each day as ordered above. The eMAR (electronic medication administration record) for Resident #6 dated February 2021 Medications documented Resident #6 received the Duloxetine 60mg each day in February from 2/1/21 through 2/25/21 and the Ambien 10mg each day in February from 2/1/21 through 2/24/21. The eMAR further documented the new orders dated 2/25/2021 for the reduced dosages of the Duloxetine and Ambien. The progress notes for Resident #6 documented in part, 1/17/2021 15:51 (3:51 p.m.) Pharmacy. This patient's medical record/medication regimen has been reviewed. MD (medical doctor) notes- GDR (gradual dose reduction) requests . The comprehensive care plan for Resident #6 dated 11/20/20 documented, [Name of Resident #6] is at risk for side effects related to use of psychoactive medication: -sedatives/hypnotics -antidepressants. Psychoactive medications are being used to treat/manage following behaviors/symptoms: insomnia, depressed mood. Status: Active (Current) . Under Interventions, it documented in part, Conduct medication regiment review no less than monthly. Status: Active (Current) . On 2/24/21 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing for evidence of pharmacy medication regimen reviews and any recommendations for gradual dose reductions for Resident #6. On 2/25/21 at approximately 8:00 a.m., ASM #2 provided lists of residents having pharmacy medication regimen reviews completed in January and February containing Resident #6. ASM #2 also provided two documents titled Note to Attending Physician/Prescriber with a MRR (medication regimen review) date of 1/17/2021 for Resident #6. The documents requested the physician evaluate the duloxetine and Ambien for a potential gradual dose reduction. The documents were not signed and dated by the physician until 2/24/21, 39 days after the MRR date of 1/17/2021. The Physician/Prescriber Response for the document referencing the medication Duloxetine 60mg once daily documented a physician response of Agree and further documented, .1) Reduce dose to the following Duloxetine 30mg PO (by mouth) QD (every day) . The Physician/Prescriber Response for the document referencing the medication Ambien 10mg once daily documented a physician response of Agree and further documented, .1) Reduce dose to the following Ambien 5mg PO QD . On 2/25/21 at 9:40 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the pharmacist comes in monthly and sends the medication reviews to them by email. ASM #2 stated that they print out the reviews and place them in the doctor's book for them to review and sign. ASM #2 stated that after the physician reviews them the nurses fax the physician's response to the pharmacy and make any changes to medication orders as needed. When asked about the length of time between the date of the MRR and the date of the physician review, ASM #2 stated that the medication reviews sent from the pharmacy were normally reviewed the next day. When asked about the facility policy for review within thirty days, ASM #2 stated that they were having problems getting the emails and that their IT department was working to resolve the issue of the pharmacy emails going to their junk mail folder. ASM #2 stated that they had found these documents for Resident #6 in their junk folder yesterday after this surveyor had requested them and printed them out for review. ASM #2 stated that the pharmacist had observed that their reviews were not on the residents charts back in January and had resent them a bulk of pharmacy reviews in January of 2021. ASM #2 stated that was when they initially discovered the email problem, and they had received the reviews for September through December 2020 in January of 2021. The facility policy Drug Regimen Review/Medication Regime Review, Developed: 6/19 documented in part, .Specific Procedures/Requirement: .a) The consulting pharmacist will provide copy of recommendations to the attending physician, medical director, and director of nursing within five (5) working days of completion of the review .b) The director of nursing or designee will review the recommendations and the attending physicians will be contacted for review and response. c) If the attending physician does not respond within thirty (30) days, the medical director will be asked to review the recommendations and/or contact the attending physician . On 2/25/21 at approximately 11:10 a.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. Atrial fibrillation A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. 2. Insomnia A common sleep disorder. If you have it, you may have trouble falling asleep, staying asleep, or both. As a result, you may get too little sleep or have poor-quality sleep. You may not feel refreshed when you wake up. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/insomnia.html. 3. Major depressive disorder Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm. 2. The facility staff failed to act in a timely manner on a medication regimen review for Resident #30. Resident #30's medication regimen review was completed on 9/17/2020 with recommendations to evaluate the as needed order for Klonopin (sedative medication) which was not reviewed by the physician until January of 2021. Resident #30 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (1), dementia (2) and major depressive disorder (3). Resident #30's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/27/2021, coded Resident #30 as scoring a 11 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 11- being moderately impaired for making daily decisions. Section N documented Resident #30 receiving antipsychotic, antidepressant and antianxiety medications while a resident at the facility. The physician's orders for Resident #30 documented the following in part, - .Oder Date: 8/10/202. Discontinued 11/27/2020. Klonopin 0.5 mg (milligram) tablet PRN (as needed) .Give 0.25mg 1 (one) time daily as needed in addition to scheduled dose . - .Order Date: 11/27/2020. Discontinued 2/7/2021. Klonopin 0.5mg tablet PRN (Max (maximum) 1(one) doses), . Give 0.25 mg 1 time daily at (bedtime) as needed in addition to scheduled dose . - Clonazepam (generic name for Klonopin) 0.5 mg (milligram) tablet (0.25 mg) Tablet Oral. Give 0.25 mg nightly as needed for anxiety .Order Date: 2/7/2021 . The eMAR (electronic medication administration record) for Resident #30 dated January 2021 Medications and February 2021 Medications failed to evidence any as needed Clonazepam administrations 1/1/21 through 1/31/21. The progress notes for Resident #30 documented in part, - 8/20/2020 14:25 (2:25 p.m.) Pharmacy. Clarify duration for prn (as needed) clonazepam- rec (recommendation) to provider. Medications and chart reviewed. This DRR (drug regimen review) was conducted within the limitations imposed by the COVID-19 outbreak . - 9/17/2020 18:26 (6:26 p.m.) Pharmacy. Medication regimen has been reviewed. MD (medical doctor) note- PRN (as needed) order . - 10/21/2020 11:28 (11:28 a.m.) Pharmacy. This patient's medical record/medication regimen has been reviewed. NN (nursing notes) - clinical monitoring . - 11/17/2020 12:12 (12:12 p.m.) Pharmacy. This patient's medical record/medication regimen has been reviewed. NN- order clarification . The comprehensive care plan for Resident #30 dated 11/22/2019 documented in part, [Name of Resident #30] is at risk for side effects related to use of psychoactive mediation [sic]: -antipsychotics -antidepressants -antianxiety, Psychoactive medications are being used to treat/manage following behaviors/symptoms: Status: Active (Current), Effective: 11/22/2019 . Under Interventions it documented in part, .Conduct medication regimen review no less than monthly. Effective: 1/22/2019 . On 2/24/21 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing for evidence of pharmacy medication regimen reviews and any recommendations for gradual dose reductions for Resident #30. On 2/25/21 at approximately 8:00 a.m., ASM #2 provided lists of residents having pharmacy medication regimen reviews completed in January and February containing Resident #30. ASM #2 also provided a document titled Note to Attending Physician/Prescriber with a MRR (medication regimen review) date of 9/17/2020 for Resident #30. The Note to Attending Physician/Prescriber for Resident #30 dated 9/17/2020 documented in part, .Please evaluate the order for PRN: Klonopin and select one of the following: 1) Continue for 14 days, 2) Continue for 60 days due to the following:, 3) Continue for __ days due to the following: . The note further documented in the Physician/Prescriber response section, .Continue standing order, [Signature of Physician/Prescriber], 1/21 (January 2021) . On 2/25/21 at 9:40 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the pharmacist comes in monthly and sends the medication reviews to them by email. ASM #2 stated that they print out the reviews and place them in the doctor's book for them to review and sign. ASM #2 stated that after the physician reviews them the nurses fax the physician's response to the pharmacy and make any changes to medication orders as needed. When asked about the length of time between the date of the MRR and the date of the physician review, ASM #2 stated that the medication reviews sent from the pharmacy were normally reviewed the next day. When asked about the facility policy for review within thirty days, ASM #2 stated that they were having problems getting the emails and that their IT department was working to resolve the issue of the pharmacy emails going to their junk mail folder. ASM #2 stated that they had received the Note to Attending Physician/Prescriber dated 9/17/2020 from the pharmacy in January after the pharmacist had resent it to them. ASM #2 stated that the pharmacist had observed that their reviews were not on the residents charts back in January and had resent them a bulk of pharmacy reviews in January of 2021. ASM #2 stated that was when they initially discovered the email problem, and they had received the reviews for September through December 2020 in January of 2021. On 2/25/21 at approximately 11:10 a.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. References: 1. Chronic obstructive pulmonary disease (COPD) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. 2. Dementia A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. 3. Major depressive disorder Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm.

Based on staff interview, facility document review and clinical record review it was determined that the facility staff failed to ensure one of 20 sampled residents, (Resident #6), was free from unnecessary medications. The facility failed to act in a timely manner on the on 1/17/21 pharmacy medication regimen review, with recommendations for a gradual dose reduction of the antidepressant and hypnotic medications prescribed and administered to Resident #6. The 1/17/21, pharmacy gradual dose reduction recommendation was not discovered by the facility in their email or presented to the physician for action until 2/24/21, a period of 39 days. The findings include: Resident #6 was admitted to the facility with diagnoses that included but were not limited to atrial fibrillation (1), insomnia (2) and major depressive disorder (3). Resident #6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/27/2020, coded Resident #6, as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section N documented Resident #6 receiving antidepressant and hypnotic medications. The comprehensive care plan for Resident #6 dated 11/20/20 documented, [Name of Resident #6] is at risk for side effects related to use of psychoactive medication: -sedatives/hypnotics -antidepressants. Psychoactive medications are being used to treat/manage following behaviors/symptoms: insomnia, depressed mood. Status: Active (Current) . Under Interventions, it documented in part, Conduct medication regiment review no less than monthly. Status: Active (Current) . The physician's orders for Resident #6 documented the following in part, - Order Date: 11/20/2020, Status: Active (Current), Description: Duloxetine (antidepressant) 60 mg (milligram) capsule, delayed release 1 (one) time daily. Start Date: 11/21/2020 . - Order Date: 11/22/2020, Status Active (Current), Description: Ambien (hypnotic) 10 mg tablet 1 time daily. Start Date: 11/22/2020 . - Order Date: 2/25/2021, Status: Active (Current), Description: Duloxetine 30 mg capsule, delayed release 1 time daily. Start Date: 2/25/2021 . - Order Date: 2/25/2021, Status Active (Current), Description: Ambien 5 mg tablet 1 time daily. Start Date: 2/25/2021 . The eMAR (electronic medication administration record) for Resident #6 dated January 2021 Medications documented Resident #6 receiving the Duloxetine 60mg daily and Ambien 10mg daily each day as documented above. The eMAR (electronic medication administration record) for Resident #6 dated February 2021 Medications documented Resident #6 received the Duloxetine 60mg each day in February from 2/1/21 through 2/25/21 and the Ambien 10mg each day in February from 2/1/21 through 2/24/21. The eMAR further documented the new orders dated 2/25/2021 for the reduced dosages of the Duloxetine and Ambien. The progress notes for Resident #6 documented in part, 1/17/2021 15:51 (3:51 p.m.) Pharmacy. This patient's medical record/medication regimen has been reviewed. MD (medical doctor) notes- GDR (gradual dose reduction) requests . On 2/24/21 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing for evidence of pharmacy medication regimen reviews and any recommendations for gradual dose reductions for Resident #6. On 2/25/21 at approximately 8:00 a.m., ASM #2 provided lists of residents having pharmacy medication regimen reviews completed in January and February containing Resident #6. ASM #2 also provided two documents titled Note to Attending Physician/Prescriber with a MRR (medication regimen review) date of 1/17/2021 for Resident #6. The documents requested the physician evaluate the duloxetine and Ambien for a potential gradual dose reduction. The documents were observed to be signed and dated by the physician 2/24/21, 39 days after the MRR date of 1/17/2021. The Physician/Prescriber Response for the document referencing the medication Duloxetine 60mg once daily documented a physician response of Agree and further documented, .1) Reduce dose to the following Duloxetine 30mg PO (by mouth) QD (every day) . The Physician/Prescriber Response for the document referencing the medication Ambien 10mg once daily documented a physician response of Agree and further documented, .1) Reduce dose to the following Ambien 5mg PO QD . On 2/25/21 at 9:40 a.m., an interview was conducted with ASM #2. ASM #2 stated that the pharmacist came in monthly and sent the medication reviews to them by email. ASM #2 stated that they print out the reviews and place them in the doctor's book for them to review and sign. ASM #2 stated that after the physician reviewed them the nurses would fax their response to the pharmacy and make any changes to medication orders as needed. When asked about the length of time between the date of the MRR and the date of the physician review, ASM #2 stated that the medication reviews sent from the pharmacy were normally reviewed the next day. When asked about the facility policy for review within thirty days, ASM #2 stated that they were having problems getting the emails and that their IT department was working to resolve the issue of the pharmacy emails going to their junk mail folder. ASM #2 stated that they had found these documents in their junk folder yesterday after this surveyor had requested them and printed them out for review. ASM #2 stated that the pharmacist had observed that their reviews were not on the residents charts back in January and had resent them a bulk of pharmacy reviews in January of 2021. ASM #2 stated that was when they initially discovered the email problem, and they had received the reviews for September through December 2020 in January of 2021. The facility policy Drug Regimen Review/Medication Regime Review, Developed: 6/19 documented in part, .Specific Procedures/Requirement: .a) The consulting pharmacist will provide copy of recommendations to the attending physician, medical director, and director of nursing within five (5) working days of completion of the review .b) The director of nursing or designee will review the recommendations and the attending physicians will be contacted for review and response. c) If the attending physician does not respond within thirty (30) days, the medical director will be asked to review the recommendations and/or contact the attending physician . On 2/25/21 at approximately 11:10 a.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: 1. Atrial fibrillation A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. 2. Insomnia A common sleep disorder. If you have it, you may have trouble falling asleep, staying asleep, or both. As a result, you may get too little sleep or have poor-quality sleep. You may not feel refreshed when you wake up. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/insomnia.html. 3. Major depressive disorder Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/000945.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the facility staff failed to label medications in one of three medication carts and dispose of biologicals upon expiration date in one of two medication rooms. The facility staff failed to label medications; two white pills were observed in a medication cup in second medication drawer on the Unit C Wing 1. The facility staff failed to dispose of biologicals upon expiration date. Eight bottles of expired tube feeding formula and three medication wound dressings were observed in the Unit C Wing 1medication storage room. The findings include: On 2/24/21 at 8:30 AM, an inspection of Unit C Wing 2 medication cart was conducted. The medication cart was unlocked and in the second medication drawer, two white round pills were observed in a 30-milliliter clear medication cup. There was no labeling of medication, dose, resident name or date on the cup. An interview was conducted on 2/24/21 at 8:30 AM, with LPN (licensed practical nurse) #1. When asked if the medications were stored properly, LPN #1 stated, No, they are not. I am not sure why they would be in the cup like that. They look like Tylenol (pain reliever) (1) pills. When asked what labeling the cup should have, LPN #1 stated, It should have the resident name, drug, dose at a minimum. On 2/24/21 at 10:07 AM, an inspection of Unit C Wing 2 medication cart and medication storage room was conducted. The medication storage room was unlocked and observation of the first cabinet revealed eight 1.1 quart bottles of Osmolite (tube feeding nutrition) (2) that expired on 2/1/21. Observation of the wound care cart, revealed in the second and fourth drawers, three expired dressings. One Dermaginate calcium alginate (3) dressing 4.25 x 4.25 inches that had expired on 9/2020 and two Mepitel One (4) 3x4 inch dressings that had expired on 1/28/21. An interview was conducted on 2/24/21 at 10:07 AM with LPN #2. When shown the expired Osmolite bottles, LPN #2 stated, We hardly ever use them. I don't know why we have so many. When asked who was responsible for checking the tube feeding dates, LPN #2 stated, It is nursing's responsibility to check the dates. When shown the expiration dates for the three dressings in the wound care cart, LPN #2 stated, Those should have been disposed of. When asked who was responsible for checking the expiration dates of the wound care dressings, LPN #2 stated, Nursing is responsible to check the dates and dispose of any expired dressings. An interview was conducted on 2/24/21 at 2:52 PM with RN (registered nurse) #1, the unit manager. When asked about the process staff follows for labeling medications and removing expired medications, RN #1 stated, It is the nursing responsibility to label medications with the drug name, dose, resident name and time to be administered. Pharmacy delivers the tube feedings and central supply delivers the dressings. Central supply checks their stock to make sure there is no expired supplies prior to delivery. Nursing is responsible for checking the wound care cart and the tube feedings to make sure they aren't expired. ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were informed of the unlabeled medications, expired wound dressings and expired tube feedings on 2/24/21 at 3:50 PM. According to the facility's policy, Storage of Medications revised 4/2007, which documents in part, The facility shall store all drugs and biologicals in a safe, secure and orderly manner. The nursing staff shall be responsible for maintaining medication storage in a clean, safe and sanitary manner. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. No further information was provided prior to exit. References: (1) 2019 [NAME] Pocket Drug Guide for Nurses, Wolters, Kluwer, page 4. (2) American College of Gastroenterologists GI.org: enteral and parental nutrition (3) 2019 [NAME] Pocket Drug Guide for Nurses, Wolters, Kluwer, page 438. (4) 2019 [NAME] Pocket Drug Guide for Nurses, Wolters, Kluwer, page 438.