**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review the facility staff failed to provide medication administration that meets professional standards of care for 5 residents (Resident #11, #102, #99, #36, #34) in a survey sample of 17 residents. The findings included: 1. For Resident #11 the facility staff failed to administer medications per physician orders. On 3/21/24 during clinical record review it was noted that Resident #11 had orders that included: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes - start date 08/30/2022. Tramadol HCl Oral Tablet 50 MG- Give 1 tablet by mouth every 8 hours for pain -start date 02/19/2024. A review of the MAR (Medication Administration Record) for February and March of 2024 revealed the following: Refresh Tears -2/27/24 - 8:00 a.m. dose was not administered and on 2/28/24 and 2/29/24 the 8:00 a.m. and 8:00 p.m. doses were not administered. On 3/4/24 and 3/7/24 the 8:00 a.m. doses were not administered. A review of the clinical record revealed the following progress notes: 2/27/2024 8:48 am Orders - Administration Note Text: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes drug unavailable. 2/28/2024 9:36 Orders - Administration Note Text: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes drug unavailable. 2/28/2024 8:40 pm Orders - Administration Note Text: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes drug unavailable. 2/29/2024 10:14 pm- Orders - Administration Note Text: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes med unavailable. 3/4/2024 07:58 Orders - Administration Note Text: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes eye drops not on cart- shown in system as already ordered and received. Tramadol 50 mg-2/19/24 6 a.m. and 2 p.m. dose not given and on 3/7/24 the 2 p.m. dose was not given. A review of the clinical record revealed the following progress notes: 2/19/2024 16:28 Orders - Administration Note Text: Tramadol HCl Oral Tablet 50 MG Give 1 tablet by mouth every 8 hours for pain Order entered after time window, medication not given. 3/7/2024 16:31 Orders - Administration Note Text: Tramadol HCl Oral Tablet 50 MG Give 1 tablet by mouth every 8 hours for pain patient stated no pain. On 3/20/24 at 1:00 PM an interview was conducted with LPN D (Licensed Practical Nurse-D) who was asked about the process for administering pain medication. LPN D stated that when administering pain medication, the nurse will ask the resident to rate their pain on a 1-10 scale. If the resident cannot verbalize this to the nurse, then the nurse will decide based on guarding, grimacing, wincing, and other non-verbal expression of pain. When asked if this also applies to scheduled pain medications, LPN D stated that it did apply to scheduled pain medications. When asked if a scheduled pain med will be administered if the pain scale documented was 0/10. LPN D stated the scheduled medication would be given and the chart noted that there was no pain. LPN D stated documenting the pain scale is for us to know if the pain medications are effectively managing pain. On 3/21/24 at 11:00 AM an interview was conducted with the Director of Nursing (DON) who stated that if a medication is not in the cart the nurses are expected to look in the Med Bank (stat box) and notify the pharmacy, if it is not available in the Med Bank, the nurse should notify the physician to get an alternative therapy or notify supervisor to get it from the backup pharmacy. When asked about the time window referred to in the nursing note on 2/19/24 the DON explained that There is a window of time in which we have to order medications to be delivered, if you miss the window of time they will not be delivered until the next day or possibly later. Nursing2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania Rights of Medication Administration 1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right documentation 7. Right reason 8. Right response On 3/22/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided. 2. For Resident #102 the facility staff failed to administer medications per physician orders. On 3/21/24 during the clinical record review, it was found that Resident #102 had orders that included: Cholecalciferol Oral Tablet 50 MCG (2000 UT) (Cholecalciferol) Give 0.5 tablet by mouth one time a day for Supplement -Start Date 03/07/2024 800. Fish Oil Oral Capsule 500 MG (Omega-3 Fatty Acids) Give 1 capsule by mouth at bedtime for Supplement -Start Date 03/06/2024 800pm. Latanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill 1 drop in both eyes at bedtime for Glaucoma -Start Date 3/06/2024. Multiple Vitamins Minerals Capsule Give 1 capsule by mouth one time a day for Supplement -Start Date 03/07/2024 800 am. Oyster Shell Calcium/Vitamin D Tablet 500-200 MG UNIT (Calcium Carb Cholecalciferol) Give 1 tablet by mouth one time a day for Supplement -Start Date 03/07/2024. Super B-Complex Oral Tablet (B Complex w/Biotin & Folic Acid) Give 1 tablet by mouth one time a day for Supplement. Norco Oral Tablet 5- 325 MG (Hydrocodone Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain -Start Date 03/06/2024. Hydrocodone Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours for Pain for 10 Days -Start Date 03/06/2024. A review of the MAR (Medication Administration Record) revealed that the following medications were not administered as ordered: Latanoprost Ophthalmic solution - Not administered on 3/6/24 at 8 PM Fish Oil Capsule 500 mg - Not administered on 3/6/24 at 8 PM Super B Complex - Not administered on 3/7/24 at 8 AM Oyster Shell Calcium - not administered on 3/7/24 at 8 AM Multiple-Vitamin -Mineral - Not administered on 3/7/24 at 8 AM Cholecalciferol Oral Tablet 50 MCG - Not administered on 3/7/24 at 8 AM A review of the clinical record revealed the following progress notes: 3/6/2024 21:24 Orders - Administration Note Text: Latanoprost Ophthalmic Solution 0.005 Instill 1 drop in both eyes at bedtime for Glaucoma medication unavailable. 3/6/2024 21:24 Orders - Administration Note Text: Fish Oil Oral Capsule 500 MG Give 1 capsule by mouth at bedtime for Supplement medication unavailable. 3/7/2024 11:09 Orders - Administration Note Text: Super B-Complex Oral Tablet Give 1 tablet by mouth one time a day for Supplement Needs to be ordered. 3/7/2024 11:10 Orders - Administration Note Text: Oyster Shell Calcium/Vitamin D Tablet 500-200 MG-UNIT Give 1 tablet by mouth one time a day for Supplement Needs to be ordered. 3/7/2024 11:10 Orders - Administration Note Text: Cholecalciferol Oral Tablet 50 MCG (2000 UT) Give 0.5 tablet by mouth one time a day for Supplement Needs to be ordered. 3/7/2024 11:10 Orders - Administration Note Text: Multiple Vitamins-Minerals Capsule Give 1 capsule by mouth one time a day for Supplement Needs to be ordered. A review of the med bank list revealed that Calcium + D 600/400 was available, and Calcium 600 mg was available, however, progress notes did not indicate that the physician was made aware of the available alternatives. On 3/20/24 at 1:00 PM an interview was conducted with LPN D (Licensed Practical Nurse-D) who was asked about the process for administering pain medication. LPN D stated that when administering pain medication, the nurse will ask the resident to rate their pain on a 1-10 scale. If the resident cannot verbalize this to the nurse, then the nurse will decide based on guarding, grimacing, wincing, and other non-verbal expression of pain. When asked if this also applies to scheduled pain medications, LPN D stated that it did apply to scheduled pain medications. When asked if a scheduled pain med will be administered if the pain scale documented was 0/10. LPN D stated the scheduled medication would be given and the chart noted that there was no pain. LPN D stated documenting the pain scale is for us to know if the pain medications are effectively managing pain. On 3/21/24 at 11:00 AM an interview was conducted with the DON who stated that if a medication is not in the cart the nurses are expected to look in the Med Bank (stat box) and notify the pharmacy, if it is not available in the Med Bank, the nurse should notify the physician to get an alternative therapy or notify supervisor to get it from the backup pharmacy. When asked if the nurses are expected to document when notifying a physician, she stated that they are supposed to document physician communications. Nursing2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania Rights of Medication Administration 1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right documentation 7. Right reason 8. Right response On 3/22/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided. 3. For Resident # 99, the facility staff failed to administer the medication, Prednisone, as ordered by the physician. The staff failed to notify the physician that the medication was not started timely and not administered for 5 days as ordered. Review of the Progress Notes revealed documentation regarding Prednisone 10 milligrams being unavailable for scheduled administration on 3/16/2024 at 8:00 a.m. Review of the MAR revealed Prednisone 10 milligrams for 5 days was ordered on 3/15/2024 and scheduled to be administered on 3/16/2024 at 8:00 a.m. It was not administered on 3/16/2024 and documented as unavailable from the Pharmacy. Prednisone Oral Tablet 10 MG (milligrams) (Prednisone) Give 1 tablet by mouth in the morning for Rash for 5 Days -Start Date 03/16/2024 0800 (8:00 a.m.) Review of the March 2024 Medical Administration Record (MAR) revealed the medication, Prednisone was documented as not available for administration on 3/16/2024 at 8:00 a.m. Review of the Progress Notes revealed that an order was written on 3/15/2024 at 8 p.m. for Resident # 99. The medication was to be started on the next morning (3/16/2024) at 8:00 a.m. and continued daily until 3/20/2024. Review of the MAR revealed the medication was not started on 3/16/2024 and the 5th day of administration was not adjusted to end on 3/21/2024. Further review revealed that the Prednisone was not started until the scheduled dose on 3/17/2024 at 8:00 a.m. There was documentation that the last scheduled dose was not adjusted to reflect the 5th day as 3/21/2024. Review of the MAR and Progress Notes on 3/22/2024 revealed that the 5th dose of Prednisone was not administered as ordered by the Physician. There was no documentation of the Physician being informed that the medication was not started on 3/16/2024 as ordered, and there was no documentation of the Physician being notified that the 5th dose of Prednisone had been omitted. On 3/21/2024 at 3:05 p.m., an interview was conducted with the Director of Nursing who stated the Pharmacy was responsible for delivery of medications. The Director of Nursing stated the nurses had access to medications that were delivered to the facility, if a medication was not available at the time of scheduled administration, the nurses should go to the Pixus (on-site Stat box) to see if the medication was available in that stock. The Director of Nursing stated if the medication was not in the Pixus, the nurse was expected to inform the physician to see if there was another medication order or if the doctor would give the approval for the medication to be started later when available from the Pharmacy. Review of the Pixus Medbank STAT box contents revealed the medication, Prednisone 10 milligrams, was on hand. There was a quantity of 8 tablets in the box. The nurses could have retrieved the medication from the Pixus Pixus Medbank STAT box. Review of Physicians Orders revealed valid orders for the medication that was not available for administration. During the end of day debriefing on 3/21/2024, the Administrator, Corporate Director of Clinical Services, Director of Nursing, Staff Development Coordinator and Assistant Director of Nursing were informed of the findings. They stated medications should be available for administration and nurses should notify the physician. The Director of Nursing stated the facility used Elsevier for professional guidance. Elsevier was formerly known as Mosby's or [NAME]-[NAME]. Guidance for nursing standards for the administration of medication provided by Fundamentals of Nursing, 7th Edition, Mosby's/ [NAME]-[NAME], p. 705 stated Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (2004), apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. On 3/22/2024 at 9:15 a.m., the Director of Nursing was interviewed. The Director of Nursing stated medications should be given as ordered by the Physician. She also stated that if medications were not available at the scheduled time, the nurse should notify the physician after verifying that the medication was not available in the Pixus (Stat box) supply. The Director of Nursing stated she reviewed some of the documentation and noticed that several of the entries about medications being unavailable were written by one of the Agency nurses who worked in the facility as needed. The Director of Nursing stated some of those medications were available in the Pixus when that nurse documented they were not available. The Director of Nursing stated the nurses should have administered the Prednisone on 3/21/2024 to follow the order of administration for 5 days. No further information was provided. 4. For Resident # 36, the facility staff failed to ensure medications including (eye drops) for Glaucoma were available for administration as ordered by the physician. Review of the Progress Notes revealed the following documentation regarding medications: Effective Date: 02/26/2024 20:43 Type: Orders - Administration Note Note Text : Lumigan Ophthalmic Solution 0.01 % Instill 1 drop in both eyes at bedtime for wide angle glaucoma not available. Lumigan is a Prostaglandin to increase the outflow of the fluid in the eye, helping to reduce eye pressure. Effective Date: 02/15/2024 16:19 Type: Orders - Administration Note Note Text : Baclofen Oral Tablet Give 5 mg by mouth three times a day for muscle relaxant patient was in an activity. Effective Date: 02/15/2024 16:19 Type: Orders - Administration Note Note Text : Tylenol Oral Tablet 325 MG Give 650 mg by mouth three times a day for pain patient was in activity. Effective Date: 02/07/2024 11:06 Type: Orders - Administration Note Note Text : Istalol Ophthalmic Solution 0.5 % Instill 1 drop in both eyes two times a day for Wide angle glaucoma Clarification needed. Provider notified. Istalol is a Beta blocker used to reduce the production of fluid in the eye helping go lower eye pressure Effective Date: 02/06/2024 11:42 Type: Orders - Administration Note Note Text : Istalol Ophthalmic Solution 0.5 % Instill 1 drop in both eyes two times a day for Wide angle glaucoma Clarification needed. Provider made aware. Effective Date: 01/31/2024 08:10 Type: Orders - Administration Note Note Text : Istalol Ophthalmic Solution 0.5 % Instill 1 drop in both eyes two times a day for Wide angle glaucoma Medication on order. Effective Date: 01/30/2024 19:56 Type: Orders - Administration Note Note Text : Lumigan Ophthalmic Solution 0.01 % Instill 1 drop in both eyes at bedtime for wide angle glaucoma ordered eye drops Effective Date: 01/26/2024 22:13 Type: Orders - Administration Note Note Text : Lumigan Ophthalmic Solution 0.01 % Instill 1 drop in both eyes at bedtime for wide angle glaucoma not available. Effective Date: 01/26/2024 22:13 Type: Orders - Administration Note Note Text : Istalol Ophthalmic Solution 0.5 % Instill 1 drop in both eyes two times a day for Wide angle glaucoma not available. Effective Date: 01/26/2024 07:52 Type: Orders - Administration Note Note Text : Istalol Ophthalmic Solution 0.5 % Instill 1 drop in both eyes two times a day for Wide angle glaucoma Awaiting from pharmacy to come. 12/15/2023 20:10- Orders -Administration Note Note Text: Lumigan Ophthalmic Solution 0.01 % Instill 1 drop in both eyes at bedtime for wide angle glaucoma not available. waiting from pharmacy. 12/13/2023 11:56-Orders -Administration Note Note Text: Istalol Ophthalmic Solution 0.5% Instill 1 drop in both eyes two times a day for Wide angle glaucoma Clarification needed. Provider notified. Review of Physicians Orders revealed valid orders for the medication that were not available for administration. On 3/21/2024 at 11:55 a.m., an interview was conducted with the Administrator who stated the Pharmacy should have medications available for administration as per Physicians Orders. A copy of the Pixus Stat Box medications list to determine if the missing medications were available in that supply was requested and received. On 3/21/2024 at 2:42 p.m., an interview was conducted with the Director of Nursing who stated the expectation was for the Pharmacy to make sure medications were available for administration as per Physicians Orders. The Director of Nursing also stated the facility staff should check the Pixus STAT box for medications to see if the missing medication is available in that supply. The Director of Nursing stated the Pharmacy should deliver the missing medication on the next run if it was not available in the Pixus. A copy of the Pixus STAT box contents was requested and received. Review of the Pixus Pixus Medbank STAT box contents revealed no documentation that the eye drops were available in that box. During the end of day debriefing on 3/21/2024, the Administrator, Corporate Nurse Consultant, Director of Nursing and Assistant Director of Nursing were informed of the findings. They stated medications should be available for administration. The Director of Nursing and Corporate Nurse Consultant stated it was important to administer medications (eye drops) as ordered for Glaucoma. According to the Mayo Clinic, damage caused by glaucoma cannot be reversed. Treatment and regular check ups can help slow or prevent vision loss, especially if you catch the disease in its early stages. The website also stated Depending on how low your eye pressure needs to be, you may be prescribed more than one eye drop. Take prescription medicine. Using your eye drops or other medicine as prescribed can help you get the best possible result from your treatment. Be sure to use the drops exactly as prescribed. Otherwise, your optic nerve damage could get worse. www.Mayoclinic.org accessed 3/26/2024. On 3/22/2024 at 9:15 a.m., the Director of Nursing was interviewed and stated medications should be given as ordered by the Physician. She also stated that if medications were not available at the scheduled time, the nurse should notify the physician after verifying that the medication was not available in the Pixus (Stat box) supply. The Director of Nursing stated she reviewed some of the documentation and noticed that several of the entries about medications being unavailable were written by one of the Agency nurses who worked in the facility as needed. The Director of Nursing stated some of those medications were available in the Pixus when that nurse documented they were not available. Regarding the times medications were not administered because the resident was in an activity, the Director of Nursing stated the facility did not administer medications when residents were in activities because the residents get upset. The Director of Nursing was asked if the medications could be given before or after the activities since most scheduled medications had a window of an hour before or an hour after the scheduled time of administration. The Director of Nursing stated Yes, the medications could be given at a different time depending on how the order was written. Once a day medications could be given later. The Director of Nursing stated she would look into the issue. No further information was provided. 5 . For Resident #34, the facility staff failed to ensure medications were available and administered per physician orders. Review of the Progress Notes revealed the following documentation regarding medications being unavailable included more than fifteen opportunities including but not limited to: Effective Date: 03/21/2024 19:53 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG (milligrams) Give 25 mg by mouth at bedtime for agitation on order Effective Date: 03/20/2024 19:45 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG Give 25 mg by mouth at bedtime for agitation on order Effective Date: 03/19/2024 23:07 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG Give 25 mg by mouth at bedtime for medication not available on order Effective Date: 03/19/2024 00:06 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH author contacted pcp (primary care physician) Effective Date: 03/19/2024 00:05 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG Give 25 mg by mouth at bedtime for agitation unavailable at this time author contacted pcp Effective Date: 03/17/2024 19:43 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order Effective Date: 03/17/2024 19:42 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG Give 25 mg by mouth at bedtime for agitation on order Effective Date: 03/14/2024 21:23 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order Effective Date: 03/14/2024 21:22 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG Give 25 mg by mouth at bedtime for agitation on order Effective Date: 03/13/2024 22:13 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order Effective Date: 03/12/2024 21:33 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order Effective Date: 03/11/2024 21:15 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH med not available. Effective Date: 03/09/2024 22:19 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order. Effective Date: 03/08/2024 21:11 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order Effective Date: 03/07/2024 22:09 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order Review of the March 2024 MAR (Medication Administration Record) revealed the medications listed above were not administered as ordered. Seroquel was not administered on 3/14/2024, 3/17/2024, 3/18/2024 (physician was notified), 3/19/20224, 3/20/2024 and 3/21/2024. Tamsulosin was not administered 11 times including on 3/7/2024, 3/8/2024, 3/9/2024, 3/11/2024, 3/12/2024, 3/14/2024, 3/17/2024, 3/18/2024 (physician was notified), 3/19/20224, 3/20/2024 and 3/21/2024. On 3/21/2024 at 2:42 p.m., an interview was conducted with the Director of Nursing who stated the expectation was for the Pharmacy to make sure medications were available for administration as per Physicians Orders. The Director of Nursing also stated the facility staff should check the Pixus STAT box for medications to see if the missing medication is available in that supply. The Director of Nursing stated the Pharmacy should deliver the missing medication on the next run if it was not available in the Pixus. A copy of the Pixus STAT box contents was requested and received. Review of the Pixus Medbank STAT box contents revealed the medications, Tamsulosin 0.4 milligrams- quantity of 10 tablets was available in the box; and the medication Quetiapine (Seroquel) 25 milligrams-quantity of 8 tablets was available in the box. On 3/22/2024 at 9:15 a.m., the Director of Nursing was interviewed who stated medications should be given as ordered by the Physician. She also stated that if medications were not available at the scheduled time, the nurse should notify the physician after verifying that the medication was not available in the Pixus (Stat box) supply. The Director of Nursing stated she reviewed some of the documentation and noticed that several of the entries about medications being unavailable were written by one of the Agency nurses who worked in the facility as needed. The Director of Nursing stated some of those medications were available in the Pixus when that nurse documented they were not available. There was documentation that one nurse notified the physician of medications being unavailable one time out of at least 11 dates when medications were not available. There was no documentation of any additional attempts to inform the physician that Seroquel (an antipsychotic) had not been administered for several consecutive days or days in close succession. Seroquel was not administered on 3/14/2024, 3/17/2024, 3/18/2024 (physician was notified), 3/19/20224, 3/20/2024 and 3/21/2024. Tamsulosin (an alpha blocker for Benign Prostatic Hyperplasia) was not administered 11 times including on 3/7/2024, 3/8/2024, 3/9/2024, 3/11/2024, 3/12/2024, 3/14/2024, 3/17/2024, 3/18/2024 (physician was notified), 3/19/20224, 3/20/2024 and 3/21/2024. The physician was notified only once during the days in close succession of missing medications. No further information was provided.

4. For Resident #11 the facility staff failed to acquire and dispense medications as ordered by physician. On 3/21/24 during clinical record review it was noted that Resident #11 had orders that included: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes - start date 08/30/2022. Tramadol HCl Oral Tablet 50 MG- Give 1 tablet by mouth every 8 hours for pain -start date 02/19/2024. A review of the MAR (Medication Administration Record) for February and March of 2024 revealed the following: Refresh Tears -2/27/24 - 8:00 a.m. dose was not administered and on 2/28/24 and 2/29/24 the 8:00 a.m. and 8:00 p.m. doses were not administered. On 3/4/24 and 3/7/24 the 8:00 a.m. doses were not administered. A review of the clinical record revealed the following progress notes: 2/27/2024 8:48 am Orders - Administration Note Text: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes drug unavailable. 2/28/2024 9:36 Orders - Administration Note Text: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes drug unavailable. 2/28/2024 8:40 pm Orders - Administration Note Text: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes drug unavailable. 2/29/2024 10:14 pm- Orders - Administration Note Text: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes med unavailable. 3/4/2024 07:58 Orders - Administration Note Text: Refresh Tears soln. 0.5% Instill 1 drop in both eyes two times a day for dry eyes eye drops not on cart- shown in system as already ordered and received. Tramadol 50 mg-2/19/24 6 a.m. and 2 p.m. dose not given and on 3/7/24 the 2 p.m. dose was not given. A review of the clinical record revealed the following progress notes: 2/19/2024 16:28 Orders - Administration Note Text: Tramadol HCl Oral Tablet 50 MG Give 1 tablet by mouth every 8 hours for pain Order entered after time window, medication not given. On 3/21/24 at 11:00 AM an interview was conducted with the DON who stated that if a medication is not in the cart the nurses are expected to look in the Med Bank (stat box) and notify the pharmacy, if it is not available in the Med Bank, the nurse should notify the physician to get an alternative therapy or notify supervisor to get it from the backup pharmacy. When asked about the time window referred to in the nursing note on 2/19/24 the DON explained that There is a window of time in which we have to order medications to be delivered, if you miss the window of time they will not be delivered until the next day or possibly later. On 3/22/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 5. For Resident #102 the facility staff failed to acquire and dispense medications as ordered by physician. On 3/21/24 during the clinical record review it was found that Resident #102 had orders that included: Cholecalciferol Oral Tablet 50 MCG (2000 UT) (Cholecalciferol) Give 0.5 tablet by mouth one time a day for Supplement -Start Date 03/07/2024 800. Fish Oil Oral Capsule 500 MG (Omega-3 Fatty Acids) Give 1 capsule by mouth at bedtime for Supplement -Start Date 03/06/2024 800pm. Latanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill 1 drop in both eyes at bedtime for Glaucoma -Start Date 3/06/2024 Multiple Vitamins Minerals Capsule Give 1 capsule by mouth one time a day for Supplement -Start Date 03/07/2024 800 am. Oyster Shell Calcium/Vitamin D Tablet 500-200 MG UNIT (Calcium Carb Cholecalciferol) Give 1 tablet by mouth one time a day for Supplement -Start Date 03/07/2024 . Super B-Complex Oral Tablet (B Complex w/Biotin & Folic Acid) Give 1 tablet by mouth one time a day for Supplement. Norco Oral Tablet 5- 325 MG (Hydrocodone Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain -Start Date 03/06/2024 Hydrocodone Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours for Pain for 10 Days -Start Date 03/06/2024 A review of the MAR (Medication Administration Record) revealed that the following medications were not administered as ordered: Latanoprost Ophthalmic solution - Not administered on 3/6/24 at 8 PM Fish Oil Capsule 500 mg - Not administered on 3/6/24 at 8 PM Super B Complex - Not administered on 3/7/24 at 8 AM Oyster Shell Calcium - not administered on 3/7/24 at 8 AM Multiple-Vitamin -Mineral - Not administered on 3/7/24 at 8 AM Cholecalciferol Oral Tablet 50 MCG - Not administered on 3/7/24 at 8 AM A review of the clinical record revealed the following progress notes: 3/6/2024 21:24 Orders - Administration Note Text: Latanoprost Ophthalmic Solution 0.005 Instill 1 drop in both eyes at bedtime for Glaucoma medication unavailable. 3/6/2024 21:24 Orders - Administration Note Text: Fish Oil Oral Capsule 500 MG Give 1 capsule by mouth at bedtime for Supplement medication unavailable. 3/7/2024 11:09 Orders - Administration Note Text: Super B-Complex Oral Tablet Give 1 tablet by mouth one time a day for Supplement Needs to be ordered. 3/7/2024 11:10 Orders - Administration Note Text: Oyster Shell Calcium/Vitamin D Tablet 500-200 MG-UNIT Give 1 tablet by mouth one time a day for Supplement Needs to be ordered. 3/7/2024 11:10 Orders - Administration Note Text: Cholecalciferol Oral Tablet 50 MCG (2000 UT) Give 0.5 tablet by mouth one time a day for Supplement Needs to be ordered. 3/7/2024 11:10 Orders - Administration Note Text: Multiple Vitamins-Minerals Capsule Give 1 capsule by mouth one time a day for Supplement Needs to be ordered. A review of the med bank list revealed that Calcium + D 600/400 was available, and Calcium 600 mg was available, however, progress notes do not indicate that the physician was made aware of the available alternatives. On 3/21/24 at 11:00 AM an interview was conducted with the Director of Nursing (DON) who stated that if a medication is not in the cart the nurses are expected to look in the Med Bank (stat box) and notify the pharmacy, if it is not available in the Med Bank, the nurse should notify the physician to get an alternative therapy or notify supervisor to get it from the backup pharmacy. When asked if the nurses are expected to document when notifying a physician, she stated that they are supposed to document physician communications. On 3/22/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure medications were available for administration for five residents (Residents #99, # 36, #34, #11, and #102) in a survey of 17 residents. Findings included: 1. For Resident # 99,, the facility failed to ensure medications were available for administration as ordered by the physician. Review of the Progress Notes revealed the following documentation regarding medications being unavailable: Review of the MAR revealed Prednisone 10 milligrams for 5 days was ordered on 3/15/2024 and scheduled to be administered on 3/16/2024 at 8:00 a.m. It was not administered on 3/16/2024 and documented as unavailable from the Pharmacy. Prednisone Oral Tablet 10 MG (milligrams) (Prednisone) Give 1 tablet by mouth in the morning for Rash for 5 Days -Start Date 03/16/2024 0800 (8:00 a.m.) Review of the March 2024 Medical Administration Record (MAR) revealed the medication, Prednisone was documented as not available for administration on 3/16/2024. Review of the Progress Notes revealed that an order was written on 3/15/2024 at 8 p.m. for Resident # 99. The medication was to be started on the next morning (3/26/2024) at 8:00 a.m. and continued daily until 3/20/2024. Review of the MAR revealed the medication was not started on 3/16/2024 and the 5th day of administration was not adjusted to end on 3/21/2024. Further review revealed that the Prednisone was not started until the scheduled dose on 3/17/2024 at 8:00 a.m. There was documentation that the last scheduled dose was not adjusted to reflect the 5th day as 3/21/2024. Review of the MAR and Progress Notes on 3/22/2024 revealed that the 5th dose of Prednisone was not administered as ordered by the Physician. There was no documentation of the Physician being informed that the medication was not started on 3/16/2024 as ordered. And, there was no documentation of the Physician being notified that the 5th dose of Prednisone had been omitted. Review of Physicians Orders revealed valid orders for the medication not available for administration. On 3/21/2024 at 11:48 a.m., an interview was conducted with LPN (Licensed Practical Nurse) D who stated the staff should notify the Pharmacy when medications are not available for administration, check the Pixus STAT box, notify the MD (Medical Doctor) and make sure the Pharmacy sends the medication STAT. On 3/21/2024 at 3:05 p.m., an interview was conducted with the Director of Nursing who stated the Pharmacy was responsible for delivery of medications. The Director of Nursing stated the nurses had access to medications that were delivered to the facility, if a medication was not available at the time of scheduled administration, the nurses should go to the Pixus (on-site Stat box) to see if the medication was available in that stock. The Director of Nursing stated if the medication was not in the Pixus, the nurse was expected to inform the physician to see if there was another medication order or if the doctor would give the approval for the medication to be started later when available from the Pharmacy. Review of the Pixus Pixus Medbank STAT box contents revealed the medication, Prednisone 10 milligrams, was on hand. There was a quantity of 8 tablets in the box. The nurses could have retrieved the medication from the Pixus Pixus Medbank STAT box. Review of Physicians Orders revealed valid orders for the medication not available for administration. During the end of day debriefing on 3/21/2024, the Corporate Director of Clinical Services, Director of Nursing, Staff Development Coordinator and Assistant Director of Nursing were informed of the findings. They stated medications should be available for administration. During the end of day debriefing on 3/22/2024, the Corporate Director of Clinical Services, Director of Nursing, Staff Development Coordinator and Assistant Director of Nursing were informed again of the findings. They stated medications should be available for administration. They also stated the facility's nursing staff were being inserviced on the procedures to follow when medications were not available as ordered by the physician. No further information was provided. 2. For Resident # 36, the facility staff failed to ensure the medications (eye drops) for Glaucoma were available for administration as ordered by the physician. Review of the Progress Notes revealed the following documentation regarding medications being unavailable: Effective Date: 02/26/2024 20:43 Type: Orders - Administration Note Note Text : Lumigan Ophthalmic Solution 0.01 % Instill 1 drop in both eyes at bedtime for wide angle glaucoma not available. Effective Date: 01/31/2024 08:10 Type: Orders - Administration Note Note Text : Istalol Ophthalmic Solution 0.5 % Instill 1 drop in both eyes two times a day for Wide angle glaucoma Medication on order. Effective Date: 01/30/2024 19:56 Type: Orders - Administration Note Note Text : Lumigan Ophthalmic Solution 0.01 % Instill 1 drop in both eyes at bedtime for wide angle glaucoma ordered eye drops. :Effective Date: 01/26/2024 22:13 Type: Orders - Administration Note Note Text : Lumigan Ophthalmic Solution 0.01 % Instill 1 drop in both eyes at bedtime for wide angle glaucoma not available. Effective Date: 01/26/2024 22:13 Type: Orders - Administration Note Note Text : Istalol Ophthalmic Solution 0.5 % Instill 1 drop in both eyes two times a day for Wide angle glaucoma not available. Effective Date: 01/26/2024 07:52 Type: Orders - Administration Note Note Text : Istalol Ophthalmic Solution 0.5 % Instill 1 drop in both eyes two times a day for Wide angle glaucoma Awaiting from pharmacy to come. 12/15/2023 20:10- Orders -Administration Note Note Text: Lumigan Ophthalmic Solution 0.01 % Instill 1 drop in both eyes at bedtime for wide angle glaucoma not available. waiting from pharmacy. 12/13/2023 11:56-Orders -Administration Note Note Text: Istalol Ophthalmic Solution 0.5% Instill 1 drop in both eyes two times a day for Wide angle glaucoma Clarification needed. Provider notified. On 3/21/2024 at 11:48 a.m., an interview was conducted with LPN (Licensed Practical Nurse) D who stated the staff should notify the Pharmacy when medications are not available for administration, check the Pixus STAT box, notify the MD (Medical Doctor) and make sure the Pharmacy sends the medication STAT. On 3/21/2024 at 11:55 a.m., an interview was conducted with the Administrator who stated the Pharmacy should have medications available for administration as per Physicians Orders. A copy of the Pixus Stat Box medications list to determine if the missing medications were available in that supply was requested and received. On 3/21/2024 at 2:42 p.m., an interview was conducted with the Director of Nursing who stated the expectation was for the Pharmacy to make sure medications were available for administration as per Physicians Orders. The Director of Nursing also stated the facility staff should check the Pixus STAT box for medications to see if the missing medication is available in that supply. The Director of Nursing stated the Pharmacy should deliver the missing medication on the next run if it was not available in the Pixus. A copy of the Pixus STAT box contents was requested and received. Review of the Pixus Pixus Medbank STAT box contents revealed no documentation that the eye drops were available in that box. During the end of day debriefing on 3/21/2024, the Administrator, the Corporate Nurse Consultant, Unit Manager and Assistant Director of Nursing were informed of the findings. They stated medications should be available for administration. They stated it was important to give eye drops as ordered for Glaucoma. On 3/22/2024 at 9:15 a.m., the Director of Nursing was interviewed and stated medications should be given as ordered by the Physician. She also stated that if medications were not available at the scheduled time, the nurse should notify the physician after verifying that the medication was not available in the Pixus (Stat box) supply. The Director of Nursing stated she reviewed some of the documentation and noticed that several of the entries about medications being unavailable were written by one of the Agency nurses who worked in the facility as needed. No further information was provided. 3. For Resident # 34, the facility staff failed to ensure medications were available for administration as ordered by the physician. Review of the Progress Notes revealed the following documentation regarding medications being unavailable included more than fifteen opportunities including but not limited to: Effective Date: 03/21/2024 19:53 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG (milligrams) Give 25 mg by mouth at bedtime for agitation on order Effective Date: 03/20/2024 19:45 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG Give 25 mg by mouth at bedtime for agitation on order Effective Date: 03/19/2024 23:07 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG Give 25 mg by mouth at bedtime for medication not available on order Effective Date: 03/19/2024 00:06 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH author contacted pcp (primary care physician) Effective Date: 03/19/2024 00:05 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG Give 25 mg by mouth at bedtime for agitation unavailable at this time author contacted pcp Effective Date: 03/17/2024 19:43 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order. Effective Date: 03/17/2024 19:42 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG Give 25 mg by mouth at bedtime for agitation on order Effective Date: 03/14/2024 21:23 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order Effective Date: 03/14/2024 21:22 Type: Orders - Administration Note Note Text : Seroquel Oral Tablet 25 MG Give 25 mg by mouth at bedtime for agitation on order Effective Date: 03/13/2024 22:13 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order. Effective Date: 03/12/2024 21:33 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order. Effective Date: 03/11/2024 21:15 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH med not available. Effective Date: 03/09/2024 22:19 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order. Effective Date: 03/08/2024 21:11 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order Effective Date: 03/07/2024 22:09 Type: Orders - Administration Note Note Text : Tamsulosin HCl Capsule 0.4 MG Give 1 capsule by mouth at bedtime for BPH on order Review of the March 2024 MAR (Medication Administration Record) revealed the medications listed above were not administered as ordered. Seroquel was not administered on 3/14/2024, 3/17/2024, 3/18/2024 (PCP was notified), 3/19/20224, 3/20/2024 and 3/21/2024. Tamsulosin was not administered more than 10 times including on 3/7/2024, 3/8/2024, 3/9/2024, 3/11/2024, 3/12/2024, 3/14/2024, 3/17/2024, 3/18/2024 (PCP was notified), 3/19/20224, 3/20/2024 and 3/21/2024. On 3/21/2024 at 11:48 a.m., an interview was conducted with LPN (Licensed Practical Nurse) D who stated the staff should notify the Pharmacy when medications are not available for administration, check the Pixus STAT box, notify the MD (Medical Doctor) and make sure the Pharmacy sends the medication STAT. On 3/21/2024 at 2:42 p.m., an interview was conducted with the Director of Nursing who stated the expectation was for the Pharmacy to make sure medications were available for administration as per Physicians Orders. The Director of Nursing also stated the facility staff should check the Pixus STAT box for medications to see if the missing medication is available in that supply. The Director of Nursing stated the Pharmacy should deliver the missing medication on the next run if it was not available in the Pixus. A copy of the Pixus STAT box contents was requested and received. Review of the Pixus Medbank STAT box contents revealed the medication, Tamsulosin 0.4 milligrams- quantity of 10 tablets was available in the box. The medication, Quetiapine (Seroquel) 25 milligrams-quantity of 8 tablets was available in the box. On 3/22/2024 at 9:15 a.m., the Director of Nursing was interviewed and stated medications should be given as ordered by the Physician. She also stated that if medications were not available at the scheduled time, the nurse should notify the physician after verifying that the medication was not available in the Pixus (Stat box) supply. The Director of Nursing stated she reviewed some of the documentation and noticed that several of the entries about medications being unavailable were written by one of the Agency nurses who worked in the facility as needed. The Director of Nursing stated some of those medications were available in the Pixus when that nurse documented they were not available. No further information was provided.

Based on interview, facility documentation and clinical record review the facility staff failed to provide adequate bathing to 1 Resident (# 42) in a survey sample of 28 Residents. The findings include: For Resident # 42 the facility staff did not ensure she received her shower on Mondays and Thursdays. On 9/27/21 at approximately 7:25 PM Resident #42 was observed in bed watching television. An interview was conducted and she stated The medical care is good, the nurses are good, the food is even good but the CNA's leave a lot to be desired. The Resident stated that she has not had a shower since arriving to the facility a month ago. The Resident stated she asked one CNA to help her wash her legs and feet and Resident #42 said the CNA told her she should be able to do it herself. The Resident did not supply a name and she said she didn't remember what the CNA looked like. On 9/28/21 an interview was conducted with CNA B who stated if a Resident refuses a bath I personally let the nurse know and then document it. On 9/28/21 an interview was conducted with the DON who stated that the expectation is that Residents are offered showers twice a week. If a Resident does not like the time of day they have been assigned they can switch to a different time. The Nurses and CNA's know they should document refusals. On 9/28/21 a Review of the clinical record was conducted and the care plan did not reveal any behaviors of refusal of care, or refusal of showers. A review of the progress notes did not reveal a refusal of care or refusal of showers. On 9/28/21 a review of the care plan read Resident requires assistance with: Bed Mobility, Transfers, Locomotion, Walking, Dressing, Toilet Use, Personal Hygiene and Bathing. On 9/28/21 a review of the facility shower schedule revealed that Resident #42 was supposed to receive showers on Monday and Thursday during the day shift. A review of the ADL Verification Worksheet revealed that between 8/27/21 and 9/21/21 Resident #42 received 4 Partial Bed Baths. On 9/29/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide oxygen therapy consistent with infection control measures for 2 Residents (Resident # 36 and # 41) in a survey sample of 28 Residents. Findings included: 1. For Resident # 36, the facility staff failed to label and date the oxygen tubing and failed to store a nebulizer mask in a bag. On 09/27/2021 at 07:55 PM during the initial tour of the facility, an Oxygen (O2) concentrator was noted sitting near the air conditioner unit with no date on the tubing in the room where Resident # 36 resided. A nebulizer mask was lying on bedside table, not dated and not in a bag. Resident # 36 was lying in bed and stated the nebulizer mask was his mask and that it was used for nebulizer treatments. On 09/27/2021 at 07:57 PM, LPN (Licensed Practical Nurse)-B was observed in the hall passing medications to another resident on the unit. An interview was conducted with LPN B who came into the room, confirmed that there was no date on the oxygen tubing and the nebulizer mask was not in a bag. LPN B stated the oxygen tubing should be labeled and dated and changed weekly. LPN B also stated the nebulizer mask should be kept in a bag when not in use. Nurse stated her shift had just started a 7 PM and she had not looked at the oxygen tubing but would look at the oxygen tubing while making rounds and passing medications that were due for administration at 7 or 8 PM. LPN B stated the nurses were expected to ensure oxygen equipment was stored in a manner to prevent the spread of infection. On 09/27/2021 at 09/27/2021 at 9:01 PM, during the end of day debriefing, the Director of Nursing, Assistant Director of Nursing, Regional Educator and Administrator were informed of the findings of oxygen tubing not labeled and dated and a nebulizer mask not stored in a bag. The Director of Nursing stated the oxygen tubing should be labeled and dated and changed weekly. The Director of Nursing also stated nebulizer masks should be kept in a bag when not in use. She stated these efforts would reduce the risk of spreading infection. The Director of Nursing stated she immediately provided education to the nursing staff and would provide ongoing education to the other nurses about labeling/dating oxygen tubing and review of infection control precautions. Review of the clinical record was conducted on 09/28/2021. Review of the Physicians Orders revealed an order for 1/22/2021 Oxygen (O2) at 2 L/min (2 liters per minute) per nasal cannula PRN (as needed). On 09/28/2021 at approximately 09:25 AM, tour of Resident 36's room was conducted. It was observed that the oxygen tubing was labeled and dated. The nebulizer mask was in a bag on the bedside table. On 09/28/2021 at 9:45 AM, an interview was conducted with the Director of Nursing who stated rounds were conducted on all of the residents receiving oxygen. All of the tubing was discarded and replaced with new tubing, labeled and dated. All of the nebulizer masks were placed in plastic bags. When asked why the tubing and mask were discarded, the Director of Nursing stated because there was no way to know when the items had been opened and to reduce the risk of spread of infection. On 09/29/2021, Director of Nursing provided a copy of the Oxygen Administration policy as requested. Review of the policy on Oxygen Administration revealed: Date of Origin: March 1996 Last Date of Review: 02/01/2021 Last Revision Date: 11/08/2020 Authorized By: [Facility Administrator] Infection Control for Oxygen Administration/Nebulization: A. Oxygen Cannula/Mask/Filter . 4. Change humidifier, oxygen cannula/mask and tubing weekly. 5. Keep oxygen cannula and tubing used prn in a plastic bag when not in use. B. Medication Nebulizer/Continuous Aerosol . 4. Rinse container with normal saline after completion of therapy. Store in plastic wrapper, making sure mouthpiece is covered. Replace nebulizer and aerosol tubing weekly. On 09/30/2021 at 11:10 AM, the Director of Nursing provided a copy of the staff education Attendance Record dated 09/27/2021-ongoing. The title of the training program was Oxygen Maintenance/Respiratory Equipment to include but limited to labeling/dating oxygen tubing and review of infection control precautions. There were 8 licensed nurses' signatures on the form including one RN (Registered Nurse) and seven LPNs (Licensed Practical Nurses.) During the end of day debriefing on 09/30/2021, the facility Administrator, Regional Nurse Consultant and Director of Nursing were informed again of the findings. They stated the oxygen tubing should be labeled and dated and the nebulizer should be stored in a bag when not in use. No further information was provided. 2. For Resident # 41, the facility staff failed to ensure the oxygen tubing on the oxygen concentrator was labeled and dated. On initial tour of the facility on 9/27/2019 at 8:29 PM, in the room where Resident # 41 resided, an oxygen concentrator with nasal cannula tubing attached was observed near the nightstand in the room. There was no label with a date on the oxygen tubing. An interview was conducted with Resident # 41 who was sitting up in bed and stated the oxygen had not been used in a while but was there when and if it was needed. On 09/27/2021 at 08:31 PM, LPN (Licensed Practical Nurse)-B was observed in the hall passing medications to another resident on the unit. An interview was conducted with LPN B who came into the room, confirmed that there was no date on the oxygen tubing. LPN B stated the oxygen tubing should be labeled and dated and changed weekly. Nurse stated her shift had just started a 7 PM and she had not looked at the oxygen tubing but would look at the oxygen tubing while making rounds and passing medications that were due for administration at 7 or 8 PM. LPN B stated the nurses were expected to ensure oxygen equipment was stored in a manner to prevent the spread of infection. On 09/27/2021 at 09/27/2021 at 9:01 PM, during the end of day debriefing, the Director of Nursing, Assistant Director of Nursing, Regional Educator and Administrator were informed of the findings of oxygen tubing not labeled and dated and a nebulizer mask not stored in a bag. The Director of Nursing stated the oxygen tubing should be labeled and dated and changed weekly. The Director of Nursing also stated nebulizer masks should be kept in a bag when not in use. She stated these efforts would reduce the risk of spreading infection. The Director of Nursing stated she immediately provided education to the nursing staff and would provide ongoing education to the other nurses about labeling/dating oxygen tubing and review of infection control precautions. Resident # 41's clinical record was reviewed on 9/28/2021. Review of the Physicians orders revealed an order for Oxygen at 2 liters per minute via nasal cannula PRN (as needed). On 09/28/2021 at approximately 09:25 AM, tour of Resident 41's room was conducted. It was observed that the oxygen tubing was labeled and dated. On 09/29/2021, Director of Nursing provided a copy of the Oxygen Administration policy as requested. Review of the policy on Oxygen Administration revealed: Date of Origin: March 1996 Last Date of Review: 02/01/2021 Last Revision Date: 11/08/2020 Authorized By: [Facility Administrator] Infection Control for Oxygen Administration/Nebulization: A. Oxygen Cannula/Mask/Filter . 4. Change humidifier, oxygen cannula/mask and tubing weekly. 5. Keep oxygen cannula and tubing used prn in a plastic bag when not in use. B. Medication Nebulizer/Continuous Aerosol . 4. Rinse container with normal saline after completion of therapy. Store in plastic wrapper, making sure mouthpiece is covered. Replace nebulizer and aerosol tubing weekly. On 09/30/2021 at 11:10 AM, the Director of Nursing provided a copy of the staff education Attendance Record dated 09/27/2021-ongoing. The title of the training program was Oxygen Maintenance/Respiratory Equipment to include but limited to labeling/dating oxygen tubing and review of infection control precautions. There were 8 licensed nurses' signatures on the form including one RN (Registered Nurse) and seven LPNs (Licensed Practical Nurses.) During the end of day debriefing on 09/30/2021, the facility Administrator, Regional Nurse Consultant and Director of Nursing were informed again of the findings. They stated the oxygen tubing should be labeled and dated. No further information was provided.

Based on observation, interview, and facility documentation the facility staff failed to properly store medications on 1 of the 3 medication carts also, for the month of September the facility did not check the temperatures of the medication refrigerator until 9/27/21. The findings included: On 9/29/21 at approximately 12:00 PM, while performing the medication storage task, Surveyor D discovered that the locked medication refrigerator in the medication room, had a temperature log on the front of it for September 2021 that only had 2 dates and temperatures recorded. The dates were 9/27/21 and 9/28/21, and both of the temperatures were 40 degrees. At that time, an interview was conducted with LPN C. LPN C stated that the night shift should be checking the temperatures every night and recording them on the log. On 9/29/21 at approximately 12:50 PM while inspecting the medication cart for the Cypress Hall, 2 bottles of medication were found to be expired. The first medication was Meclizine (an antihistamine to treat vertigo) which expired 6/29/21 and Citalopram (an antidepressant) which expired 9/4/21. At that time an interview was conducted with LPN C. LPN C stated that all the nurses should be checking for expired medications. On 9/29/21 at approximately 3:00 PM an interview was conducted with the Director of Nursing (DON) who stated that she checked the MAR (medication administration record) and the Resident did not receive any of the Citalopram as the order was discontinued. The DON stated that the Meclizine was PRN and he (the resident) had not received any of them in June, July, or Aug. When asked what the expectation is for medications no longer in use, the DON stated that they are to be returned to the pharmacy to be destroyed. When asked who is supposed to check for expired medications, the DON stated that all nurses on all shifts should be looking out for any expired drugs and should be removing drugs from the cart when they are discontinued. On 9/29/21 a review of the facility policy entitled Medication Storage revealed the following excerpts: Medication Storage [page 2 number 10] 10. Expired and discontinued medications are returned/destroyed in a timely manner, in accordance with facility policies and time frames. 14. Medication's that require refrigeration are refrigerated. Medication refrigerator temperature is between 36 and 46°F. Refrigerator temperatures are checked and locked daily. On 9/29/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review the facility staff failed to issue an ABN (Advanced Beneficiary Notice) timely for one Resident (Resident #292) in a sample of 18 Residents. The findings included: Resident #292 was admitted to the facility on [DATE], with a most recent readmission date of 6/20/19. Diagnoses for Resident #292 included but were not limited to: acute pancreatitis, pancreatic cancer, and obstruction of bile duct. Resident #292's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 6/27/19 was coded as an admission assessment. Resident #292 was coded as having had a BIMS (brief interview for mental status) score of 14, which indicated cognitively intact. He was coded as being dependent upon one staff person for extensive assistance with bed mobility, transfers, walking, dressing, toilet use and personal hygiene. Review of the SNF ABN (skilled nursing facility advance beneficiary notice) for Resident #292, revealed that it was signed on 7/5/19 and indicated that the Resident's skilled care would end on 7/9/19. However, an option was not identified as to if the Resident wanted to continue to receive services and have the fiscal intermediary make the coverage determination. On 9/5/19 during a clinical record review it was revealed that Resident #292 came off of skilled care (Medicare Part A reimbursed stay) on 7/4/19 and became self pay on 7/5/19, which was prior to the issuance of the ABN. The ABN is to be issued prior to skilled care services ending, which would have allowed Resident #292 or his representative, to make a decision about continuation of services and have Medicare make the coverage determination; or the option to continue services and pay privately for them. Resident #292 was not given this option since the notice was issued after the payer change had taken place. On 9/5/19 at 12:31 PM an interview was conducted with Employee H, the social worker. The social worker was asked if Resident #292 went private pay on 7/5/19 why the SNF ABN indicated skilled services would end on 7/9/19. Employee H, stated I don't know I will have to look at my notes she then turned to her computer and started reviewing her notes. The social worker stated, on 7/4/19 I spoke with the son and discussed going hospice. I then asked when his skilled services ended, the social worker stated he was supposed to come off on 7/10/19. When asked how she knew this she stated because I issued the NOMNC on 7/9/19 and the ABN started 7/10/19. The social worker then stated, well a significant change MDS was done on 7/9/19. On 9/5/19 at 1:38 PM the Social Worker, (employee H) came into the conference room with the survey team and stated these are my PPS (prospective payment system) (reimbursement by Medicare) sheets, he was scheduled to discharge on [DATE] but they said they wanted to stay until 7/12/19. When the social worker was asked to explain what she reviews with Residents, the social worker stated, it says if they stay past their last covered non-covered day they have to become private pay. She was then asked to read the ABN form options. She read it and replied, I forgot to have him sign it. The survey team asked social worker to identify what the options were telling the Resident; and she stated this form is new, we tell the people they can't choose option 1. She was then asked to say that again, she said, well, I have been told to tell them if they choose option 1 they are going to loose anyway and it is no need to check it, I usually go to option 2 that they will be billed private pay for the room. During this interview the facility Administrator came into the room and was advised that the social worker was advising Resident's not to choose option 1. The Social worker then said I was told to say that if they choose #1 to bill Medicare but when Medicare looks and sees that the services have stopped they aren't going to cover the cost of the room, so why bother with option 1. The social worker and Administrator were advised that option 1 gives the resident the option to continue to receive the services and have the fiscal intermediary make the coverage determination. On 9/5/19 at 2:20 PM the facility Administrator, Employee A stopped this writer, (Surveyor E) in the lobby and stated the ABN notices have been an ongoing issue with her, referencing Employee H, the social worker. The Administrator had in her hand the employee file of Employee H and showed the surveyor two disciplinary actions as well as, education that had been provided to Employee H, with regard to the ABN notices. On 9/5/19 at 2:36 PM the Administrator came into the conference room with the survey team and provided this writer with a copy of the education Employee H, the social worker, received on 6/26/18 regarding the CMS (Centers for Medicare & Medicaid Services) SNF ABN form. The training included the following information to include but not limited to: * a flow chart of when to issue the SNF ABN form. * the statement The NOMNC [notice of medicare non-coverage] is given > 2 calendar days before the last covered day or 3 days prior to discharge from skilled services. *this applies to ABNs as well* * the statement, the revised SNF ABN will be mandatory for use on May 7, 2018. * CMS guidance on the form, including how and when to use the form * the facility policy. On 9/5/19 at 2:36 PM an interview was conducted with the facility Administrator, Employee A, in the conference room with the entire survey team present. When the Administrator was asked when the issue had been identified, the Administrator stated, it was identified during a mock survey in January. I asked for another mock survey in May and the same issues were identified. She was re-educated with these documents. When Employee A was asked who supervises the Social Worker, the Administrator stated I do. When asked since this has been identified as an issue in the past what was being done to monitor her progress, the Administrator stated, I was doing an audit ever week, she has to give me the ones she completes. The Administrator was asked if she had identified any issues, she stated 1 or 2 with dates. Review of the facility policy titled, Notification of Non-Coverage: Medicare Part A Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) stated in the purpose statement: To notify the resident, who has Medicare Part A or Part B coverage that it is the facilities opinion that individualized service required does not meet Medicare coverage criteria required for payment and the resident may be responsible for charges. Provides the resident the right to appeal to the fiscal intermediary. All Residents who are discharged from Medicare Part A without utilizing their 100 day benefit and remain in the building must be issued an SNF ABN. This may be issued to the resident or resident representative and must have a signature with a date completed on or before the date of discharge. This includes SNF to hospice. CMS defines the use of the SNF ABN in the section 70.3 of the Medicare Claims Processing Manual in chapter 30 on page 84, it read A SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay. If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in §70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. The table on page 85 stated, In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed for 1 resident (Resident #39) in the survey sample of 18 residents, to implement their abuse policy for an injury of unknown origin. Specifically, they failed to report and investigate. The Findings included: Resident #39 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #39's diagnoses included Coronary Artery Disease, High Blood Pressure, and Dementia. On 9/4/19 a review was conducted of Resident #39's clinical record. A Licensed Practical Nurse's (LPN H) progress note dated 7/21/19 at 9:14 P.M. read, Tonight during medpass resident came up to me and showed me a skin tear he had on his right elbow. Skin tear is 1.5 cm x 0.25 cm. Red in color and bleeding. Resident could not explain what happened, and denied any pain. Skin tear was cleaned per protocol and dressing was applied. Provider notified. LPN H was not available for an interview. In addition, the following number of incidents, over time, were documented: 7/25/17: Skin tear to right hand from fall 4/13/18: Skin tear to right inner calf 5/31/18: Skin tear to right lower leg from bumping into something into his room 8/23/18: bruising to left wrist and right upper arm 9/14/18: injury to right knee, right upper arm, right elbow 10/4/18: hematoma of the left lateral forearm 10/12/18: 2 skin tears right lateral leg and right knee 3/20/19: skin tear on right lower leg just below knee 6/1/19: abrasion to right temporal. Skin tears right lower arm and left inferior arm 6/4/19: 2 skin tears right posterior leg 6/26/19: skin tear to left shin and new skin tear to right elbow 7/1/19: skin tear to left upper anterior arm 7/17/19: laceration noted above left temporal above left eye. 2 skin tears noted to left leg. Staples were placed in ER to left forehead wound The clinical record did not contain any documentation of reporting, or investigating of the injury that occurred on 7/21/2019. On 9/4/19 a review was conducted of facility documentation. There was no documentation that the injury of unknown origin had been reported to the state agency. The facility Abuse Prevention and Management Policy dated 8/15/19 was reviewed. An excerpt read, The facility is committed to developing and denationalizing 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. On 9/5/19 at approximately 3:30 P.M. an interview was conducted in the conference room, with the facility Administrator (Employee A) and Surveyors B, D, and E present. The Administrator was asked why the injury of unknown origin had not been reported, and investigated, and why their abuse policy hadn't been implemented. The Administrator stated that she usually reports when she has something solid. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed for 1 resident (Resident #39) in the survey sample of 18 residents, to report an injury of unknown origin to the State Survey Agency. The Findings included: Resident #39 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #39's diagnoses included Coronary Artery Disease, High Blood Pressure, and Dementia. On 9/4/19 a review was conducted of Resident #39's clinical record. A Licensed Practical Nurse's (LPN H) progress note dated 7/21/19 at 9:14 P.M. read, Tonight during medpass resident came up to me and showed me a skin tear he had on his right elbow. Skin tear is 1.5 cm x 0.25 cm. Red in color and bleeding. Resident could not explain what happened, and denied any pain. Skin tear was cleaned per protocol and dressing was applied. Provider notified. LPN H was not available for an interview. In addition, the following number of incidents, over time, were documented: 7/25/17: Skin tear to right hand from fall 4/13/18: Skin tear to right inner calf 5/31/18: Skin tear to right lower leg from bumping into something into his room 8/23/18: bruising to left wrist and right upper arm 9/14/18: injury to right knee, right upper arm, right elbow 10/4/18: hematoma of the left lateral forearm 10/12/18: 2 skin tears right lateral leg and right knee 3/20/19: skin tear on right lower leg just below knee 6/1/19: abrasion to right temporal. Skin tears right lower arm and left inferior arm 6/4/19: 2 skin tears right posterior leg 6/26/19: skin tear to left shin and new skin tear to right elbow 7/1/19: skin tear to left upper anterior arm 7/17/19: laceration noted above left temporal above left eye. 2 skin tears noted to left leg. Staples were placed in ER to left forehead wound The clinical record did not contain any documentation of reporting of the injury that occurred on 7/21/2019. On 9/4/19 a review was conducted of facility documentation. There was no documentation that the injury of unknown origin had been reported to the state agency. The facility Abuse Prevention and Management Policy dated 8/15/19 was reviewed. An excerpt read, The facility is committed to developing and denationalizing 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. On 9/5/19 at approximately 3:30 P.M. an interview was conducted in the conference room, with the facility Administrator (Employee A) and Surveyors B, D, and E present. The Administrator was asked why the injury of unknown origin had not been reported, and investigated, and why their abuse policy hadn't been implemented. The Administrator stated that she usually reports when she has something solid. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed for 1 resident (Resident #39) in the survey sample of 18 residents, to investigate an injury of unknown origin. The Findings included: Resident #39 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #39's diagnoses included Coronary Artery Disease, High Blood Pressure, and Dementia. On 9/4/19 a review was conducted of Resident #39's clinical record. A Licensed Practical Nurse's (LPN H) progress note dated 7/21/19 at 9:14 P.M. read, Tonight during medpass resident came up to me and showed me a skin tear he had on his right elbow. Skin tear is 1.5 cm x 0.25 cm. Red in color and bleeding. Resident could not explain what happened, and denied any pain. Skin tear was cleaned per protocol and dressing was applied. Provider notified. LPN H was not available for an interview. In addition, the following number of incidents, over time, were documented: 7/25/17: Skin tear to right hand from fall 4/13/18: Skin tear to right inner calf 5/31/18: Skin tear to right lower leg from bumping into something into his room 8/23/18: bruising to left wrist and right upper arm 9/14/18: injury to right knee, right upper arm, right elbow 10/4/18: hematoma of the left lateral forearm 10/12/18: 2 skin tears right lateral leg and right knee 3/20/19: skin tear on right lower leg just below knee 6/1/19: abrasion to right temporal. Skin tears right lower arm and left inferior arm 6/4/19: 2 skin tears right posterior leg 6/26/19: skin tear to left shin and new skin tear to right elbow 7/1/19: skin tear to left upper anterior arm 7/17/19: laceration noted above left temporal above left eye. 2 skin tears noted to left leg. Staples were placed in ER to left forehead wound The clinical record did not contain any documentation of investigating the injury that occurred on 7/21/2019. On 9/4/19 a review was conducted of facility documentation. There was no documentation that the injury of unknown origin had been reported to the state agency. The facility Abuse Prevention and Management Policy dated 8/15/19 was reviewed. An excerpt read, The facility is committed to developing and denationalizing 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. On 9/5/19 at approximately 3:30 P.M. an interview was conducted in the conference room, with the facility Administrator (Employee A) and Surveyors B, D, and E present. The Administrator was asked why the injury of unknown origin had not been reported, and investigated, and why their abuse policy hadn't been implemented. The Administrator stated that she usually reports when she has something solid. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to provide one Resident (Residents #14) with physician ordered medications in a survey sample of 18 Residents. The findings included: For Resident #14, the facility failed to provide an antibiotic medication which was unavailable for 3 doses. Resident #14, was admitted to the facility on [DATE]. Diagnoses included; metabolic encephalopathy, weakness, heart failure, diabetes, chronic obstructive pulmonary disease, hypothyroidism, essential hemorrhagic thrombocytopenia, and obstructive uropathy. Resident #14's most recent MDS (minimum data set) with an ARD (assessment reference date) of 7-9-19 was coded as an admission assessment. Resident #14 was coded as having a BIMS (brief interview of mental status) score of 14 out of a possible 15, revealing no cognitive impairment. Resident #14 was also coded as requiring extensive assistance of staff to perform activities of daily living, such as bed mobility, transferring, locomotion, and toileting. Review of Resident #14's clinical record revealed no evidence the following antibiotic medication was administered on the days and times indicated: Erythromycin 5 mg (milligram)/per gram (0.5%) eye ointment (1 cm (centimeter) ribbon) right eye for blepharitis four times daily at (8 to 10-a.m., 12 to 2 p.m., 4 to 6 p.m., and 9 to 10 p.m.) for seven days, ordered to start 8-27-19. Valid physician's orders were evident for the medication in question, and was written by the doctor on the morning of 8-27-19. The Medication Administration History report was requested and received. The facility audit document revealed the times that the medication was actually administered, and notes written by nursing staff about that administration. On 8-27-19, the document showed that the order was put into the system after the 8:00 a.m., administration time, and before the 12 noon administration time. The 12 noon administration time was in the system for the medication to be administered, however, the 8:00 a.m., dose was not in the order history. For 8-27-19, at 12:00 noon, 4:00 p.m., and 9:00 p.m., the document revealed that the medication was not administered, and the nurse documented awaiting from pharmacy, pharmacy called. This means that the medication was unavailable for those 3 doses. On 9-5-19 the DON (director of nursing) was interviewed in the conference room and stated she was aware that medications had not been given. On 9-5-19 at approximately 4:15 p.m., at the end of day debrief, the Administrator and DON were made aware. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure one Resident was free from significant medication errors for one resident (Residents #14) in a survey sample of 18 Residents. The findings included: For Resident #14, the facility failed to administer antibiotic medication for an active eye infection as ordered by a physician. Resident #14, was admitted to the facility on [DATE]. Diagnoses included; metabolic encephalopathy, weakness, heart failure, diabetes, chronic obstructive pulmonary disease, hypothyroidism, essential hemorrhagic thrombocytopenia, and obstructive uropathy. Resident #14's most recent MDS (minimum data set) with an ARD (assessment reference date) of 7-9-19 was coded as an admission assessment. Resident #14 was coded as having a BIMS (brief interview of mental status) score of 14 out of a possible 15, revealing no cognitive impairment. Resident #14 was also coded as requiring extensive assistance of staff to perform activities of daily living, such as bed mobility, transferring, locomotion, and toileting. Review of Resident #14's clinical record revealed a valid physician's order, written by the doctor on the morning of 8-27-19 for the following medication. Erythromycin 5 mg (milligram)/per gram (0.5%) eye ointment (1 cm (centimeter) ribbon) right eye for blepharitis four times daily at (8 to 10-a.m., 12 to 2 p.m., 4 to 6 p.m., and 9 to 10 p.m.) for seven days, ordered to start 8-27-19. The Medication and Treatment Administration Record (MAR/TAR) was reviewed and revealed nursing signatures indicating the medication had been administered from 8-27-19 at 12 noon through 9-2-19 at 9 p.m. This particular document showed nurse initials on it which indicated that the Resident missed only one dose of the antibiotic which was ordered four times per day for 7 days. The Medication Administration History report was requested and received. The facility audit document revealed the times that the medication was actually administered, and notes written by nursing staff about that administration. On 8-27-19, the document showed that the order was put into the system after the 8:00 a.m., administration time but before the 12 noon administration time. The 12 noon administration time was in the system for the medication to be administered, however, the 8:00 a.m., dose was not in the order history. On 8-27-19, at 12:00 noon, 4:00 p.m., and 9:00 p.m., the document revealed that the medication was not administered, and the nurse documented awaiting from pharmacy, pharmacy called. This means the medication was unavailable for those 3 doses. The document also revealed that the antibiotic medication was not administered therapeutically nor timely, for 5 of the 6 days when it was administered. During the seven days it was ordered to be given, the Erythromycin eye ointment antibiotic was at times, administered too closely to the previous dose, or was administered too early, or too late, or was omitted entirely. The medication should have been given for 7 days, on time, and at equally spaced intervals, and was not. The medication was discontinued after the evening dose on 9-2-19 after only 6 days of administration. The medication was ordered four times daily (8 am, 12 pm (noon), 4 pm, and 9 pm). The following shows the medication actual administration times: (Day 1) 8-27-19 - omitted for 3 doses, (due to being unavailable). The fourth dose was never scheduled at the end of the 7 days to complete the regimen, nor were the other 3 missed doses scheduled. (Day 2) 8-28-19 - administration begins - 9:27 a.m., 3:34 p.m., 4:18 p.m., 8:40 p.m. Late for the noon dose, and too close to the 4p dose. (6 hrs, 44 minutes, 4 hrs) between doses. (Day 3) 8-29-29 - 9:14 a.m., 2:22 p.m., 4:42 p.m., 10:53 p.m. Late for the noon dose, and too close to the 4p dose, and late for the 9p dose. (5 hrs, 2hrs, 6 hrs) between doses. (Day 4) 8-30-19 - 7:58 a.m., 3:54 p.m., 4:14 p.m., 1:05 a.m. Late for the noon dose, and too close to the 4p dose, late for the 9p dose. (8 hrs, 20 minutes, 8 hrs) between doses. (Day 5) 8-31-19 - 10:04 a.m., 12:49 p.m., 6:45 p.m., 8:20 p.m. Late for the 8a dose, too close to the noon dose, and too close to the 9p dose. (2.75 hrs, 6 hrs, 1.5 hrs) between doses. (Day 6) 9-01-19 - 7:52 a.m., 11:49 p.m., 4:11 p.m., 8:43 p.m. This was the only day in 6 days relatively evenly spaced, and relatively on time. (Day 7) 9-02-19 - 7:37 a.m., 2:57 p.m., 4:36 p.m., 11:42 p.m. Too long between the 8a and noon dose, the noon dose was late, too close between the noon dose, and the 4p dose, and too long between the 4p dose and the 9p dose, and late for the 9p dose. (7.5 hrs, 1.5 hrs, 7 hrs) between doses. Guidance for the administration of Erythromycin eye antibiotic is given by The National Institutes of Health (NIH) & Medline.gov, and are as follows; Using medication: Using antibiotics correctly and avoiding resistance. What's important to consider when taking antibiotics? Antibiotics should be taken for as long as the doctor has prescribed them. Just because the symptoms of the illness subside, it doesn't mean that all of the germs have been killed. Remaining bacteria may cause the illness to start up again. Medications can only work properly if they are used correctly. It's important to know the following things when taking antibiotics: When should you take antibiotics? Some antibiotics are always meant to be taken at the same time of day, others are meant to be taken before, with or after a meal. If you are supposed to take the medicine three times a day, for example, it usually needs to be taken at set times so that the effect is spread out evenly over the course of the day. You could remember the regular times of 6 a.m., 2 p.m. and 10 p.m. for an antibiotic that needs to be taken every 8 hours, for example. How should this medicine be used? Ophthalmic erythromycin comes as an ointment to apply to the eyes. It is usually applied up to six times a day for eye infections. Use erythromycin eye ointment exactly as directed. Do not use more or less of it or use it more often than prescribed by your doctor. You should expect your symptoms to improve during your treatment. Call your doctor if your symptoms get worse or do not go away, or if you develop other problems with your eyes during your treatment. Use ophthalmic erythromycin until you finish the prescription, even if you feel better. If you stop using ophthalmic erythromycin too soon, your infection may not be completely cured and the bacteria may become resistant to antibiotics. What should I do if I forget a dose? Apply the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not apply extra ointment to make up for a missed dose. Further review of the MAR indicated that the Resident could have only ever received 6 days of the antibiotic, instead of the 7 days which was ordered by the physician, as it was discontinued on 9-2-19 after the 9p.m. dose. Physician's progress notes were reviewed and revealed no indication that the physician was ever notified or aware of the 4 missing doses of antibiotic for Resident #14. Review of the facility's policy entitled, Medication Administration Procedure revealed that the purpose of the procedure was The applying, dispensing, or giving of drugs or medicines as prescribed by a physician. The document further stated; Chart medications during the med pass in a consistent manner before going to the next resident. On 9-5-19 the DON (director of nursing) was interviewed in the conference room and stated she was aware that medications had not been given and were late. On 9-5-19 at approximately 4:15 p.m., at the end of day debrief, the Administrator and DON were made aware of the failure of staff to administer the antibiotic medication as ordered. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide a diet to accommodate food preferences for 1 resident (Resident #342) in a sample size of 18 residents. The Findings included: For Resident #342, the facility staff failed to provide a diet to accommodate her food preferences as a vegetarian. Resident #342, an [AGE] year old female, was admitted to the facility on [DATE]. On 09/04/2019 at approximately 1:45 PM, during initial tour, Resident #342 voiced her concern that she is a vegetarian however the facility was still serving her meat. She stated that she had received a barbeque sandwich earlier at lunch, adding the food is good but I am a vegetarian and the choices are very limited, they have been putting meat on some of my meal trays, I won't eat that, they have not offered me anything different. Resident #342 stated that she met with the Dietician the previous afternoon, 9/3, and had indicated that she is vegetarian and prefers to adhere to a vegetarian diet. On 09/04/2019 at approximately 2:10 PM, a staff interview was conducted with Dining Room Supervisor (Employee G) who confirmed the current dinner ticket for Resident #342 reflected a mechanical soft, no added salt diet. Employee G stated it was possible Resident #342 could have received a barbeque sandwich at lunch, however he could not confirm it because the lunch tickets had been thrown away. Employee G stated he was unaware that she was a vegetarian and would not know by looking at the meal tickets currently being generated by Dining Services. On 09/04/2019 at approximately 2:20 PM, a staff interview was conducted with the Director of Dining Services (Employee D) who provided a Resident Dining Details Report dated 9/4/2019 and confirmed that Resident #342 received a mechanical soft, no salt added diet for breakfast and lunch on 09/04/2019. Employee D stated that diet changes need to be communicated to Dietary Services using a Nutrition Services Communication Form because the Resident Dining Details Report is generated the day prior to the Kitchen providing meals to the residents. Employee D indicated that when a diet change is received using the Nutrition Services Communication Form, the Dining Services staff will manually change the pre-printed, individual meal tickets to ensure that the affected resident receives the appropriate diet as ordered. On 09/04/2019 at approximately 2:30 PM, a staff interview was conducted with the RD (Registered Dietician, Employee F) who confirmed she had assessed Resident #342 in the afternoon of 09/03/2019 and Resident #342 requested a vegetarian diet. An order for a Mechanical Soft, Vegetarian diet was entered for Resident #342 on 09/03/2019 at 6:52 PM. The RD stated, I put an order in for the diet modification and that alerts nursing staff in the computer, nursing acknowledges the order and notifies the kitchen by putting in a Nutrition Services Communication Form, this is done immediately so the Resident's next meal will be correct. On 09/04/2019 at approximately 2:40 PM, a staff interview was conducted with RN A who confirmed that she was aware of the change to Resident #342's diet as she had electronically acknowledged the order in the medical record on 09/03/2019 at 6:52 PM. RN A stated, I did not fill out a slip [Nutrition Services Communication Form] for the Kitchen, normally I would but the Dietician should have done it, she made the order. On 09/05/2019 at approximately 1:50 PM, the DON (Director of Nursing, Employee B) was interviewed regarding the communication process and expectations for ordered dietary changes. She stated, I had a mandatory nursing meeting just this past Friday, 8/30, and I spoke about the procedure for the dietary slips [Nutrition Services Communication Form] which is, whoever activates or acknowledges the order is responsible to notify Dietary. The DON confirmed that RN A attended the meeting and stated, she [RN A] is a Nurse Supervisor and is expected to know this procedure, I would have expected her to complete the Nutrition Services Communication Form and take it to Dietary.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards in 2 of 2 kitchens serving nursing home Residents. The findings included: 1. The facility staff failed to properly dry dishes to prevent the development of microorganism growth. On 9/4/19 at approximately 1:00 PM during observation of the facility main kitchen observation revealed wet nesting of ramekins. When asked what is the proper way to dry the ramekins, Employee D, the director of dining services stated, that he expects facility kitchen staff to place ramekins separate on a sheet pan like we do over here and pointed to other dishes that were air drying separately. On 09/05/19 at 11:16 AM an interview was conducted in the conference room in the presence of the survey team with Employee D, Director of Dining Service and Employee E, the Executive Chef. When asked what the concern was with the ramekins wet nesting, Employee D stated, because they don't effectively air dry and bacteria can grow between them. When asked what they expectation is, Employee D stated, form them to be properly air dried. Review of the facility policy titled, Dietary Services dish machine and manual ware washing policy stated on page 2, to avoid recontamination of clean and sanitary items: a. air dry all items on a drain board or drying rack. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 4, section 4-901.11, titled Equipment and Utensils, Air-Drying Required pages 151-152 stated: After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry. 2. The facility staff failed to store and maintain kitchen equipment in a clean and sanitary manner. On 9/4/19 at approximately 13:05 during observation of the facility kitchen a metal pan was observed with multiple, various serving utensils such as ladles, spoons, etc. Observed was a significant amount of debris in the bottom of the metal pan as well as dried rice on some of the utensils. The Director of Dining Services agreed he observed it as well and asked the Executive Chef, (Employee E) to have facility dining staff to re-wash the items. When the Chef was asked how often the pan and utensils are washed he stated the expectation is daily but they are not being washed daily. On 9/4/19 it was observed that the electric meat slicer was open to air had dust as well as food crumbs on the surface. The Director of Dining Services, (Employee D) and the facility Executive Chef stated, we would have to re-clean it, there is a little bit of dust on it. Observation of the sugar storage bin revealed heavy build up of grime on the lid. When the Director of Dining Services was asked about this observation he stated, it needs to be cleaned obviously. The Dining Director then asked the Executive Chef how often this is cleaned, the Executive Chef stated they clean it weekly. When the surveyor asked the Executive Chef if it had been cleaned in the past week, he stated no. Review of the facility kitchen cleaning scheduled revealed, that the daily hot prep cleaning list stated daily cleaning, clean and cover slicer. Review of facility document provided titled, Cold Prep Tasks stated, Sugar/flour bin lids sent to dish when needed. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 4, section 4-601.11 titled Equipment, Food-Contact Surfaces, Non-food Contact Surfaces, and Utensils read: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 3. The facility staff failed to maintain a sanitizing solution that would sanitize food surface areas to prevent food contamination. On 9/4/19 at 1:13 PM during an observation of the main kitchen in the food prep area located by the floor mixer, a red sanitizing bucket was observed with a cleaning cloth in the solution. The Director of Dining Services was asked what this was used for and he stated, it is used to wipe down food contact surfaces. The Director of Dining Services was then asked to check the sanitation level and it revealed a sanitation level of 0 ppm. The Director of Dining Services re-checked the solution in the red sanitizer bucket and when asked what it showed he stated less than 150 ppm. When asked what it should be, he stated at least 200 ppm. On 9/4/19 at 1:30 PM during observation of the convalescent kitchen a red sanitizing bucket was observed. The Director of Dining Services again stated, it is used to wipe down food contact surfaces. The Director of Dining Services was then asked to check the sanitation level and it was observed to test less than 150 ppm, when the Director of Dining Services was asked, he stated it is a little weaker than I like. He then asked the staff member to replace it with new sanitizing solution. On 09/05/19 at 11:16 AM an interview was conducted in the conference room in the presence of the survey team with Employee D, Director of Dining Service and Employee E, the Executive Chef. When asked the purpose of the red sanitation buckets, Employee D stated, it is used to sanitize the surfaces, countertops. When asked why you would want sanitizer in the bucket, Employee E stated, to properly be able to clean and sanitize at the proper ppm to make sure food contact surfaces are sanitized before use. When asked what the risk is of not using a proper parts per million sanitation solution, Employee E stated, the risk of bacteria and to prevent food borne illness. When asked about the red sanitizing buckets observed on 9/4/19, Employee E, agreed that the sanitizer buckets contained less than 150 ppm of sanitizing solution. Review of the facility policy titled, Dietary services cleaning and sanitizing food contact surfaces read, Food service employee who prepare, serve food or who clean areas where foods is [sic] prepared and served will be trained on the proper procedures used to clean and sanitize food contact surfaces. Manufacturer's instructions regarding the use and maintenance of equipment, use of chemicals for cleaning and sanitizing food contact surfaces will be followed. Wash, rinse, and sanitize food contact surfaces of sinks, tables, cutting boards, equipment, utensils, thermometers, carts and equipment, before each use, between uses, any time contamination occurs or is suspected. Review of a product specification document provided by the Director of Dining Services, titled Oasis 146 Multi-Quat Sanitizer read, to sanitize food contact surfaces, food processing equipment and other hard surfaces in (food processing locations, dairies or restaurants): Use Oasis 146 Multi-Quat sanitizer to sanitize pre-cleaned hard non-porous surfaces of food processing equipment, countertops in federally inspected restaurants. Apply a use-solution of (150-400 ppm [parts per million] active quat). Expose all surfaces to the sanitizing solution. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-304.14, page 77 stated: cloths in-use for wiping counters and other equipment surfaces shall be: held between uses in a chemical sanitizer solution at a concentration specified under 4-501.114 4. The facility staff failed to store food in a manner to maintain the integrity of the product. On 9/4/19 at approximately 1:20 PM during observation of the walk-in freezer multiple items were observed to be in open, unclosed bags, and were not labeled to indicate what the product was or when it was placed in the freezer. Items were identified by the Director of Dining Services and the Executive Chef as breaded shrimp which contained no label or date. French Fries which were open to air and contained no label or date. Chicken tenders which were open to air and contained no label or date. On 9/4/19 at 1:20 PM during the observation, when the Director of Dining Services was asked about the importance of labeling, he stated, it is important so that we know how fresh the product is, and if we can use it or not and if it is safe to use. Review of the facility policy titled , Dietary Services Dating and Labeling Food Supplies Policy it read, All foods, including ready-to-eat and TCS foods, that are prepared on site, must be labeled and dated with the product name and expiration date. All foods, including ready-to-eat and TCS foods will be labeled and dated when opened. Products will be labeled by using a use by date. Review of the facility policy titled Dietary Services Food Storage Policy stated, food must be stored in a way to prevent cross-contamination and to comply with all required regulations. Page 2 of this document stated, dates and labels should be facing forward to allow for easier identification and ease of following FIFO (first in, first out). Place food in covered containers or packages, except during cooling, and store in the walk-in refrigerator or cooler. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-302.12, pages 73-74 stated: Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food service establishment, shall be identified with the common name of the food. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-302.15, page 64 stated: Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. No further information was provided.