Based on resident interview, staff interview and record review, the facility failed to ensure the right to make choices about aspects of life that is important to one (1) of three (3) residents reviewed for choices. Specifically, Resident #35 was not given showers when requested or the choice. Resident identifiers: #19, and #35. Facility census: 54. Findings included: a) Resident #35 During an interview with Resident #35 on 08/19/24 at 2:44 PM, she stated she never received her shower when she prefered. Resident #35 continued to say that she would like to have showers at least every other day. Medical record review revealed, Resident #35's shower schedule was on Saturday, Sunday, Monday, Wednesday, and Thursday on day shift. A review of the 06/07/24 Quarterly Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15). A continued review of Resident #35s ADL documentation found; she was not receiving showers as scheduled. On 08/21/24 at 3:37 PM during an Interview with Assistant Director of Nursing (ADON) stated that they have been working with staff and trying to get resident showers when they prefer. She verified Resident #35 was not getting her showers as scheduled. b) Resident #19 During an interview with, Resident #19 on 08/19/24 at 2:28 PM, the resident stated she had been accustomed to taking a shower every day throughout her life. However, since she had been at the long-term care facility, her shower schedule had been limited to Mondays and Wednesdays. She mentioned that this restriction was due to the shower rooms being reserved for men on Tuesdays and Fridays. The resident expressed her preference for daily showers, and stated that if it were possible, she would prefer to have a shower every day. She went on to state, I know that Tuesdays and Fridays are set aside for men, but I don't understand why I can't get a shower on the other days of the week. Resident's Medical Power of Attorney (MPOA), who was also present during the interview. The MPOA said Resident #19 was meticulous about her cleanliness. She revealed that she had voiced her concerns, about the showers, to the nursing staff on two previous occasions. Document review on 08/19/24 at 2:44 PM of Resident #19's Annual Minimum Data Set (MDS) assessments revealed just one (1) assessment for Section F - Preferences for Routine & Activities on 11/21/23. Resident's answer to the question How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Her response had been very Important. A review of the shower logs revealed that Resident #19 had received approximately three (3) showers a week. Showers were recorded for the following days during the month of July 2024: 07/13/24 (Saturday) 07/15/24 (Monday) 07/17/24 (Wednesday) 07/20/24 (Saturday) 07/22/24 (Monday) 07/24/24 (Wednesday) 07/27/24 (Saturday) 07/28/24 (Sunday) 07/29/24 (Monday) 07/31/24 (Wednesday) Document review further revealed that, for the month of August 2024, she had received showers on: 8/01/24 (Thursday) 08/03/24 (Saturday) 08/05/24 (Monday) 08/07/24 (Wednesday) 08/10/24 (Saturday) 08/12/24 (Monday) 08/15/24 (Thursday) 08/17/24 (Saturday) 08/19/24 (Monday) At 2:56 PM on 08/19/24, during an interview with Nursing Assistants (NA) #36 and #90 they stated that they always tried to accommodate residents' requests. However, due to having only one shower room, staffing constraints, and a high number of residents scheduled for showers, they confirmed that it was not always possible for them to do so. During an interview, on 08/22/24 at approximately 3:30 PM, with the Executive Director (ED) #29, she revealed a shower schedule dated 08/21/24. Showers were scheduled for Resident #19 on Sundays, Mondays, Wednesdays, Thursdays, and Saturdays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the representative/family of an acute hospitalization. This was true for two (2) out of three (3) residents reviewed for the care area of hospitalization during the Long-Term Care Survey process. Resident identifier: Resident #20. Facility census 54. Findings included: a) Resident #20 A record review, completed, on 08/20/24 at 7:09 PM, revealed Resident #20 had capacity to make his own medical decisions. Record review also revealed Resident #20 was transferred to the hospital on [DATE]. A Nurses Note, dated 02/16/2023 at 10:41 PM, noted that Resident #20 had informed the nurse he was not feeling well and that he just wanted to go to the hospital. The physician was notified and new orders were received to send resident to the emergency room for evaluation. There was no evidence resident's daughter was notified. Section E. Key Contacts of the eInteract Transfer form, dated 02/16/24, listed resident as his own Resident Representative. There was no evidence resident's daughter / representative / next of kin / emergency contact was notified of transfer. During an interview, on 08/21/24 at 4:02 PM, the Assistant Director of Nursing (ADON) reported the facility could not produce evidence Resident #20's daughter/ representative / emergency contact was notified. The ADON acknowledged that even though resident was mentally competent, his designated resident representative or family, as appropriate, should have been notified of significant changes in the resident's health status because the resident may not have been able to notify them personally, especially in the case of sudden illness.

b) Resident #1 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 10/20/2024 was conducted revealing that on the evening of 10/20/2024 at 6:15 PM, Licensed Practical Nurse (LPN) #85's documented that Resident #1 was hit on the left side of the face multiple times by Resident #301. TheFaxed record of Adult Protective Services Mandated Reporting Form was not sent until 10:28 PM to The Office Of Health Facilities Certification And Licensure The Faxed Record of Adult Protective Services Mandated Reporting Form was not sent until 10:37 PM to Adult Protective Services, On 08/21/2024 at 11:42 AM, in an interview with The Director of Social Services, she confirmed the resident to resident abuse occurred and it was not reported in the 2 hour window for reporting. Based on record review and staff interview the facility failed to timely report allegations of suspected abuse between residents timely within the 2 (two) hour window to the appropriate State Agency. This failed practice was true for 2 (two) of 5 (five) residents reviewed for abuse. Resident Identifiers: Resident #39, Resident #01 and Resident #207. Facility Census: 54. Findings include: a) Resident #39 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 06/18/24 was conducted revealing that on the morning of 06/13/24 during the afternoon Licensed Practical Nurse (LPN) #71 reported that Resident #207 appeared to be touching the private are of Resident #39. LPN #71 stated she immediately separated the residents and re-directed each of them. During the review of this FRI, it was noted the allegation type selected was sexual abuse, which according to the reporting requirements of the Office of Health Facility Licensure and Certification Long Term Care Nursing Home Program must be reported to the appropriate state agency within 2 hours of occurrence. This allegation of sexual abuse was noted to occur on 06/13/24, however it was not reported until 06/18/24, which is outside of the reporting requirements referenced above. In addition, facility Policy and Procedure entitled, West Virginia Abuse, Neglect and Misappropriation was reviewed, revealing that if the events that cause an allegation involve abuse and/or serious bodily injury, the self-report must be made immediately, but not later than 2 hours after the allegation is made. On 08/21/24 at approximately 01:30 PM, an interview was conducted with the Administrator at which time she acknowledged the facility failed to follow the reporting requirements set forth by Office of Health Facility Licensure and Certification Long Term Care Nursing Home Program , in addition to the facility Policy and Procedure entitled, West Virginia Abuse, Neglect and Misappropriation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review and staff interview, the facility failed to provide the resident/resident representative notice of the bed hold policy when Resident #29 was transferred to a local hospital. This was true for one (1) of three (3) residents reviewed for transfers. Resident identifier: #29. Facility census: 54. Findings included: a) Resident #29 Medical Record review on 08/21/24 revealed Resident #29 was discharged to the hospital on [DATE]. Continued review of Resident #29's medical record showed it did not contain documentation that the resident or the resident's representative received a copy of the bed hold policy at the time of transfer. In addition, there was no documentation in the medical record of contacting the resident / resident representative regarding the bed hold policy. In an interview with the Administrator on 08/21/24 at 5:58 PM, the Administrator confirmed there was no documentation regarding staff notifying the resident/resident representative of the bed hold policy for the hospital transfer on 08/13/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interview. The facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with the Residents assessed needs for care. This is true for one (1) of three (3) residents reviewed for ADL care. Resident identifiers: #108. Facility census: 54. Findings included: a) Resident #108 During an interview, on 08/19/24 at 1:02 PM, Resident #108 stated she had never had a bath / shower or had her hair washed since she was admitted . A record review revealed Resident #108 was admitted to the facility on [DATE]. Continued review found no documentation of bathing from 08/14/24 through 08/21/24. On 08/21/24 at 3:37 PM during an Interview with Assistant Director of Nursing (ADON) stated that they have been working with staff and trying to get resident showers when they prefer. She verified Resident #108 was not getting her showers as scheduled.

Based on record review and staff interview the facility failed to follow a physician's order to be notified of blood sugar greater than 400 for Resident #23. This was true for 1 (one) of 1 (one) residents reviewed for the Long Term Care Survey Process. Facility census: 54. Resident identifier: #23. Findings included: a) Resident #23 On 08/19/24 at 03:48 PM, a record review was conducted for Resident #23 revealing orders for the following: Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 48 unit subcutaneously one time a day for DM 2 Obtain blood sugar at 6 AM and PM. Notify physician if blood glucose less than 60 or over 400 two (2) times a day for diabetes On 08/20/24 at 03:06 PM, a review was conducted of Resident #23's progress notes and Medication Administration Record (MAR) revealing the following documentation: 1. 08/03/2024 5:46 PM - Medication Administration Note Note Text: Obtain blood sugar at 6 AM and PM. Notify physician if blood glucose less than 60 or over 400. 2. 08/01/2024 16:38 Nurses Note Note Text: BS 455. Left message with NP. Awaiting message/call back. Had sweets the facility carnival this afternoon. In addition, no further documentation was noted that the Physician or Nurse Practitioner (NP) called back and was notified. On 08/20/24 at 03:30 PM, a review of Resident #23's care plan was conducted which revealed the following: Resident has diabetes Disease process · Resident will be able to articulate potential complications of not following prescribed regimen · Observe for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing, acetone breath, stupor, coma. Report any abnormal findings to medical provider, resident / resident representative. · Observe for s/sx of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, blurred speech, lack of coordination, staggering gait. Report any abnormal findings to medical provider, resident / resident representative. · Obtain and monitor lab / diagnostic studies, as ordered. Report abnormal findings to medical provider, resident / resident representative. · Obtain blood sugars per orders. Report abnormal findings to medical provider, resident / resident representative. On 08/21/24 at 11:39 AM, an interview was conducted with the Assistant Director of Nursing (ADON) acknowledged the Physician and/or NP had not been made aware of blood sugar outside of parameters.

Based on observation, interviews with facility staff, and a review of facility policy and procedures, it was determined that the facility failed to follow acceptable infection control practices that controlled, or prevented, the spread of infection. This practice had the potential to affect all residents that reside in the facility. Facility Census: 54. Findings included: a) Water Management On 08/23/24 at 3:34 PM, during a review of water management, it was discovered that the facility lacked a Water Management Plan. Additionally, there was no text and flow documentation available that detailed the facility's water system, including control points where Legionella control measures, like dead leg water flushes, were required. During a face-to-face interview with Executive Director (ED) #29 on 08/23/24 at 3:52 PM, she stated that she was not aware of the requirement for a text and flow description of the water system. The Regional Director of Clinical Operations (RDCO) #110 overheard the conversation and mentioned that the facility's Emergency Management Plan should contain this information. However, upon review of the Emergency Management Plan, no water management plan or description of the water system was found. At approximately 4:50 PM on 08/23/24, the ED #29 came into the conference room, and referring to the water management plan, stated, we don't have it. b) Laundry Services On 08/23/24 at approximately 2:30 PM, this surveyor requested an inspection of the laundry room from Laundry Aide (LA) #96. At that time, LA #96 was rolling a cart of clean laundry down the corridor, for delivery to residents, and asked for a few minutes to finish delivering the laundry. This surveyor agreed, and waited until the delivery was completed. In the soiled laundry room, a washing machine was found with pillows piled on top of it. LA #96 stated that the washing machine was also not in use due to a breakdown and expressed confusion about the pillows being on top of it. LA #96 reported coming in to work at 2:00 PM, and immediately beginning to deliver laundry to the residents. She confirmed that the pillows should not be on top of the washing machine and stated that all items in the soiled laundry room were supposed to be in the bins.

Based on record review and staff interview the facility failed to implement the facility Policy and Procedure entitled, West Virginia Abuse, Neglect and Misappropriation by failing to thoroughly investigate incidents of abuse between residents. The facility failed to obtain statements from staff who were working at the time of the incident. Furthermore, the facility failed to assess and interview like residents of the facility. This failed practice was true for three (three) of 5 (five) residents reviewed for abuse. Resident identifiers: #30, #54, and #1. Facility census: 54. Findings included: a) Resident #30 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 07/26/24 was conducted revealing that on the morning of 07/26/24 at 10:30 AM. Licensed Practical Nurse (LPN) #82 witnessed Resident #207 pat Resident #30's mid section through his clothing. Further review of this investigation revealed 3 (three) statements which are typed as written and read as follows: Statement from LPN #82: I witnessed Resident #207 touching Resident #30 on his genital area outside his pants. I immediately removed Resident #207 from Resident #30. Administrator walking down hall during incident. She made Social Worker (SW) aware. Statement from Resident #30: I don't remember that. Statement from Resident #207: I did not do that. Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. In addition, a review of the policy and procedure entitled, West Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. On 08/21/24 at 12:00 PM, an interview was conducted with the facility SW. At this time, the SW acknowledged that she had not interviewed and obtained statements from other staff working on 07/26/24, nor had other residents who may have had contact with Resident #207 been interviewed or assessed. In addition, the SW acknowledged she had not followed the policy and procedure. b) Resident #54 On 08/20/24 at 09:05 AM, a review of the Facility Reported Incident (FRI) dated 07/17/24, for Resident #54 was conducted revealing that on the night of 07/17/24 at 11:30 PM, Resident #54 was seen in the activity room with Resident #39 by Licensed Practical Nurse (LPN) #98. Resident #39 was massaging Resident #54's neck. LPN #98 asked Resident #39 to stop. Resident #54 was crying and said Resident #39 had asked to touch her all day on the butt and thigh. On 08/21/24 at approximately 10:00 AM, review of this investigation revealed 3 (three) statements which are typed as written and read as follows: Statement from LPN #98: Nurse saw Resident #39 rubbing Resident #54's shoulders. Resident #39 redirected to his room. Resident #39 went to his room and to bed. Resident #54 stated Resident #39 tried to touch her earlier in the day. Statement from Resident #54 (which was obtained by a face to face interview with Resident #54 and written by facility Social Worker (SW)): Resident #54 stated, that man was rubbing my shoulders. My mom told me that a man should never touch me unless it's my doctor. When asked if it happened any other time, Resident #54 stated that Resident #39 patted her leg twice while sitting on couch watching TV. Resident #53 stated she went to bingo and Resident #39 asked her is she was a kid or retarded. Statement from Resident #39 (which was obtained by a face to face interview with Resident #39 and written by facility SW): I was trying to console that lady, she was crying. Resident #39 acknowledged he probably shouldn't touch people without permission. Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. In addition, a review of the policy and procedure entitled, West Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. On 08/21/24 at 12:00 PM, an interview was conducted with the facility SW. At this time, the SW acknowledged that she had not interviewed and obtained statements from other staff working the night of 07/17/24, nor had other residents who may have had contact with Resident #39 been interviewed and assessed. In addition, the SW acknowledged the allegation Resident #54 made that Resident #39 asked to touch her all day on the butt was not addressed in the investigation and she had not followed the policy and procedure. c) Resident #1 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 10/20/2024 was conducted revealing that on the evening of 10/20/2024 at 18:15 PM, Licensed Practical Nurse (LPN) #85 's written report of the allegation which is typed as written and reads as folllows: Resident #1 was hit resident by Resident #301 on the left side of the face multiple times and on the back of the head. DON made aware. Resident # 301 was sent to hosipital for evaluation. On 08/21/24 at approximately 10:00 AM, review of this investigation revealed 2 (two) statements dated 10/21/23, which are typed as written and read as follows: Resident #1: That woman hit me. That woman mean. Resident # 20: That woman hit him. I saw it Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. On 08/21/2024 at 11:42 AM, an interview was conducted with the Director of Social Services. At this time, she acknowledged that she had not interviewed and obtained statements from other staff working the night of 10/20/24, nor had she interviewed other residents who may have had contact with Resident #301. A review of the policy and procedure entitled, West Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses.

c) Resident #1 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 10/20/2024 was conducted revealing that on the evening of 10/20/2024 at 18:15 PM, Licensed Practical Nurse (LPN) #85 's written report of the allegation which is typed as written and reads as folllows: Resident #1 was hit resident by Resident #301 on the left side of the face multiple times and on the back of the head. DON made aware. Resident # 301 was sent to hosipital for evaluation. On 08/21/24 at approximately 10:00 AM, review of this investigation revealed 2 (two) statements dated 10/21/23, which are typed as written and read as follows: Resident #1: That woman hit me. That woman mean. Resident # 20: That woman hit him. I saw it Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. On 08/21/2024 at 11:42 AM, an interview was conducted with the Director of Social Services. At this time, she acknowledged that she had not interviewed and obtained statements from other staff working the night of 10/20/24, nor had she interviewed other residents who may have had contact with Resident #301. A review of the policy and procedure entitled, West Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. Based on record review and staff interview the facility failed to thoroughly investigate thoroughly investigate 2 (two) instances of resident-to-resident sexual abuse and one instance of resident-to-resident physical abuse by failing to obtain statements from staff who were working at the time of the incidents, furthermore the facility failed to assess and interview like residents of the facility. This failed practice was true for 3 (three) of 5 (five) residents reviewed for abuse. Resident identifiers: #30, #54, #1 and #39. Facility Census: 54. Findings included: a) Resident #30 On 08/21/24 at approximately 10:00 AM, a review of the Facility Reported Incident (FRI) dated 07/26/24 was conducted revealing that on the morning of 07/26/24 at 10:30 AM, Licensed Practical Nurse (LPN) #82 witnessed Resident #207 pat Resident #30's mid section through his clothing. Further review of this investigation revealed 3 (three) statements which are typed as written and read as follows: Statement from LPN #82: I witnessed Resident #207 touching Resident #30 on his genital area outside his pants. I immediately removed Resident #207 from Resident #30. Administrator walking down hall during incident. She made Social Worker (SW) aware. Statement from Resident #30: I don't remember that. Statement from Resident #207: I did not do that. Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. In addition, a review of the policy and procedure entitled, West Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. On 08/21/24 at 12:00 PM, an interview was conducted with the facility SW. At this time, the SW acknowledged that she had not interviewed and obtained statements from other staff working 07/26/24, nor had other residents who may have had contact with Resident #207. In addition, the SW acknowledged she had not followed the policy and procedure. b) Resident #54 On 08/20/24 at 09:05 AM, a review of the Facility Reported Incident (FRI) dated 07/17/24, for Resident #54 was conducted revealing that on the night of 07/17/24 at 11:30 PM, Resident #54 was seen in the activity room with Resident #39 by Licensed Practical Nurse (LPN) #98. Resident #39 was massaging Resident #54's neck. LPN #98 asked Resident #39 to stop. Resident #54 was crying and said Resident #39 had asked to touch her all day on the butt and thigh. On 08/21/24 at approximately 10:00 AM, review of this investigation revealed 3 (three) statements which are typed as written and read as follows: Statement from LPN #98: Nurse saw Resident #39 rubbing Resident #54's shoulders. Resident #39 redirected to his room. Resident #39 went to his room and to bed. Resident #54 stated Resident #39 tried to touch her earlier in the day. Statement from Resident #54 (which was obtained by a face to face interview with Resident #54 and written by facility Social Worker (SW)): Resident #54 stated that man was rubbing my shoulders. My mom told me that a man should never touch me unless it's my doctor. When asked if it happened any other time, Resident #54 stated that Resident #39 patted her leg twice while sitting on couch watching TV. Resident #53 stated she went to bingo and Resident #39 asked her is she was a kid or retarded. Statement from Resident #39 (which was obtained by a face to face interview with Resident #39 and written by facility SW): I was trying to console that lady, she was crying. Resident #39 acknowledged he probably shouldn't touch people without permission. Further review of this investigation revealed there were no statements obtained from other staff working and that no other resident's were assessed or interviewed. In addition, a review of the policy and procedure entitled, West Virginia Abuse, Neglect and Misappropriation was conducted revealing that when conducting an investigation of abuse, the facility will obtain statements from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. On 08/21/24 at 12:00 PM, an interview was conducted with the facility SW. At this time, the SW acknowledged that she had not interviewed and obtained statements from other staff working the night of 07/17/24, nor had other residents who may have had contact with Resident #39. In addition, the SW acknowledged the allegation Resident #54 made that Resident #39 asked to touch her all day on the butt was not addressed in the investigation and she had not followed the policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. The facility also failed to provide evidence that a copy of the Notice of Transfer was sent to the Ombudsman. This was true for three (3) out of four (4) hospital transfers reviewed during the long-term care process. This had the potential to affect all residents being transferred or discharged . Resident identifiers: #20, #38, and #29. Facility census: 54. Findings included: a) Resident #29 Medical Record review on 08/21/24 revealed resident #29 was discharged to the hospital on [DATE]. Subsequent review of Resident #29's medical record showed it did not contain documentation that the Notice of Transfer or Discharge was provided to the Resident Representative, or the Ombudsman was notified of the discharges on 08/13/24. On 08/21/24 at 5:58 PM during an interview the Administrator verified, there was no evidence that the Notice of Transfer or Discharge was completed and provided to the Resident's Representative for the discharges on 08/13/24. The Administrator also confirmed the Ombudsman was not notified of the discharges on 08/02/24. b) Resident #20 A medical record review was completed on 08/21/24 at 9:14 AM. The record review revealed Resident #20 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer. During an interview with the Administrator on 08/21/24 at approximately 4:40 PM, the Administrator reported the correct Notice of Transfer/Discharge was not provided to resident upon transfer. c) Resident #38 A medical record review was completed on 08/21/24 at 9:53 AM. The record review revealed Resident #38 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer, nor did the record reflect the Notice of Transfer was sent to the Ombudsman. During an interview with the Administrator on 08/21/24 at approximately 4:40 PM, the Administrator reported the correct Notice of Transfer / Discharge was not provided to resident upon transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c) Resident #157 During an interview on 08/19/24 at 3:21 PM, Resident #157 stated he received PRN (as needed) oxycodone for pain management. A record review was completed on 08/20/24 at 8:51 PM. Resident #157 was admitted to the facility on [DATE]. A review of the August 2024 Medication Administration Record (MAR) revealed the following order: Oxycodone Hcl Oral Tablet 5 MG. Give 1 tablet by mouth every 4 hours as needed for pain. Additionally, the August MAR revealed the following dates and times Resident #157 was given oxycodone one (1) time for pain rated at 0 and eight (8) times for mild pain rated between 1-2: -08/05/24 at 9:15 PM for a Pain Level of 2 -08/07/24 at 10:25 PM for a Pain Level of 1 -08/08/24 at 5:40 AM for a Pain Level of 0 -08/09/24 at 2:05 PM for a Pain Level of 2 -08/10/24 at 00:59 AM for a Pain Level of 2 -08/12/24 at 4:35 PM for a Pain Level of 2 -08/13/24 at 00:30 AM for a Pain Level of 2 -08/14/24 at 8:46 PM for a Pain Level of 1 -08/18/24 at 10:45 AM for a Pain Level of 2 Subsequently, the numeric pain rating scale (NPRS) was reviewed. It is a 0-10 scale that is often used by clinicians to assess pain intensity in clinical settings. On the scale, 0 means no pain and 10 means the worst pain imaginable. The NPRS can be administered verbally or graphically, and patients can complete it themselves. The NPRS is often categorized into the following ranges: No pain: 0 Mild pain: 1-3 Moderate pain: 4-6 Severe pain: 7-10 During an interview, on 08/21/24 at 3:02 PM, the ADON was asked how a nurse would know it was OK to administer the ordered oxycodone for pain. She responded the resident would be asked to rank their pain. The ADON was then asked if any pain level was reported, would the oxycodone be ordered. The ADON stated that oxycodone is typically utilized for more severe pain. When the above-mentioned dates where oxycodone was administered for a pain between 0 - 3 were reviewed with the ADON, she reported the nurses should have called the physician to question if he wanted to prescribe a different medication for a lesser level of pain. Based on record review, resident, and staff interview. The facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for three (3) of five (5) residents reviewed for pain during the Long-Term Survey Process. Resident Identifier: #26, #29, and #157. Facility census: 54. Findings included: a) Resident #29 Medical record review revealed Resident #29 had a broken hip. The resident had a physician orders for pain management. The oder was for Acetaminophen Oral Tablet (Acetaminophen). Give 500 mg by mouth every six (6) hours as needed for pain. The order stated, Do not exceed 3000mg total dose in a 24-hour period from any medication with a state date 08/02/24. A continued review of Medication Administration Record (MAR) revealed: --08/13/24 at 8:06 AM pain level 8 - Acetaminophen 500 mg tablet given. --08/14/24 at 7:09 AM pain level 8 - Acetaminophen 500 mg tablet given. An interview on 08/21/24 at 5:12 PM with Assistant Director of Nursing (DON), she confirmed Resident #29's Pain medication did not have perameters, and she was not receiving pain medication per nursing standards. b) Resident #26 During an interview on 08/19/24 at 2:42 PM Resident #29 stated that he has a good bit of pain. Medical record review revealed Resident #26's physician orders for pain management: --Acetaminophen Oral Tablet (Acetaminophen), Give 2 tablet by mouth every 8 hours as needed for pain with a start date 02/28/24. --Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain, with a start date 06/29/24. Continued review found no parameters were on the pain management orders. A continued review of Medication Administration Record (MAR) revealed: --06/03/24 at 7:28 AM pain level 3- Oxycodone HCL tablet given. --06/03/24 at 3:37 PM pain level 3 - Oxycodone HCL tablet given. --06/08/24 at 7:25 AM pain level 3 - Oxycodone HCL tablet given. --06/08/24 at 8:27 PM pain level 3 - Oxycodone HCL tablet given. --06/09/24 at 7:33 AM pain level 3 - Oxycodone HCL tablet given. --06/13/24 at 8:15 PM pain level 3 - Oxycodone HCL tablet given. --06/17/24 at 7:20 AM pain level 3 - Oxycodone HCL tablet given. --06/18/24 at 7:12 AM pain level 3 - Oxycodone HCL tablet given. --06/22/24 at 7:40 AM pain level 3 - Oxycodone HCL tablet given. --07/06/24 at 7:35 AM pain level 3 - Oxycodone HCL tablet given. --07/06/24 at 8:19 PM pain level 3 - Oxycodone HCL tablet given. --07/07/24 at 7:27 AM pain level 3 - Oxycodone HCL tablet given. --07/13/24 at 7:26 AM pain level 4 - Oxycodone HCL tablet given. --07/14/24 at 7:39 PM pain level 3 - Oxycodone HCL tablet given. --07/22/24 at 6:46 AM pain level 4 - Oxycodone HCL tablet given. --07/23/24 at 6:47 AM pain level 4 - Oxycodone HCL tablet given. --08/13/24 at 8:06 AM pain level 2 - Oxycodone HCL tablet given. --08/14/24 at 7:09 AM pain level 4 - Oxycodone HCL tablet given. Subsequent review revealed no acetaminophen tablets were given from 06/01/24 through 08/21/24. Also, no milligram was noted on the ordered acetaminophen. An interview on 08/21/24 at 3:21 PM with Assistant Director of Nursing (DON), she confirmed Resident #26's pain medication did not have perameters, and he was not receiving pain medication per nursing standards.

Based on observation, resident interview, staff interview, and Resident council meeting. The facility failed to meet the needs and Preferences of each resident, through an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This failed practice had the potential to affect more than a limited number of residents that currently reside in the facility. Resident identifiers: #41, #32, #17, #3, #40, #31, #8, #26, #11, #37, and #39. Facility census 60. Findings included: a) Resident #26 b) Resident council On 10/04/23 at 2:30 PM a Resident Council meeting was held and the following members were present: Resident: #41, #32, #17, #3, #40, #31, #8, #11, #37, and #39. The residents said they do not feel like they have enough activities and even less on the weekends. All of the residents were in agreement that one hour of Bingo is not long enough and it is only on Wednesdays and Saturdays. On one Wednesday a month they play three (3) times for an hour or less, it is called Bingothon. They said it would be great to play Bingo longer and more often. During month of October there was nine (9) evening activities offered and one (1) of those activities was a video. A review of the activity calender found, on 22 days the last activity offered was at 2:00 or 2:30 PM. Many of the residents complained about having nothing to do in the evenings. Every Thursday on the activity schedule it is noted that at 11:00 AM Shopping for the Residents is listed, however, none of the residents actually go shopping themselves. Also, at 2:00 PM it is Cookie Cart Activity Director (AD) #11 said this activity was having a cookie the kitchen made and a glass of milk. The Members also complained about the only community TV being in the activity room (which was set up like a dining area with tables and chairs.) The Members said there was a nice TV in the living room that has nice sofas and comfortable chairs, but when it broke, the facility did not want to replace the TV. They said that they are told the area is now a quiet area. The only other TVs are in the rooms so there is nowhere to watch TV as a group or a community. During an interview on 10/04/23 at 4:00 PM with the Administrator and the Director of Activities #11 were informed of the above findings. Administrator said they did not tell them they wanted to have Bingo more often and longer. AD #11 said she did not do activities longer than an hour so the nurse aides could provide personal care. During exit on 10/04/23 at 5:00 PM the Administrator said they are discussing getting another TV.

Based on employee record review, and staff interview the facility failed to ensure all dietary staff had a food handlers' card, to ensure the safe handling of the food for the Residents. This failed practice had to potential to affect more than a limited number of Residents that currently reside at the facility. Facility census 60. Findings included: a) Food handlers' cards On 10/04/23 at 10:00 AM a review of the facility's food handler cards for all dietary staff found, [NAME] #25 did not have a food handlers card. Cook #25 was hired on 09/08/23 and does not have a food handler card. An interview with Culinary Director on 10/04/23 at 10:20 AM said [NAME] #25 is signed up to have a class on 10/16/23. However, she can take the course online today.

. Based on staff interview, observation, and facility documents the facility failed to ensure the facility cleaning solution used to disinfect was used in accordance with manufacture directions. This failed practice had the potential to affect more than a limited number of residents. Facility census 60. Findings included: a) Using the facility disinfectant On 10/04/23 at 10:34 AM, Housekeeping Director (HD) #77 was asked about the cleaning agents used to clean resident rooms. On 10/04/23 at 11:08 AM, HD #77 provided a facility document titled Product Specification Document. The Direction for use of this product is as follows: Apply solution with a cloth, sponge, mop, or spray. Allow to air dry. Rinse food contact surfaces with potable water prior to reuse. For Spray applications, spray 6 to 8 inches from the surface. Allow the surface to remain wet for 3 minutes. Allow to air dry or after 3 minutes wipe with mop, cloth, or sponge. During an interview on 10/04/23 at 1:42 PM, Housekeeper (HK) #62 was asked about using the facility cleaning agent, Multi-Purpose Plus Disinfectant Cleaner. HK #62 said she sprays the solution on the surfaces for 20 to 30 seconds. HK #62 was asked if she wiped the over the bedside table that the residents eat on with clean water after it has been on the table for three (3) minutes. HK #62 said no she did not know she needed too. Observation on 10/04/23 at 2:01 PM HK #71 sprayed the tables in the dining room and began wiping the tables off at 2:02 PM. During an interview on 10/04/23 at 2:02 PM, HK #71 was asked how long she should wait before wiping of the cleaning solution. HK #71 said she sprays all of the tables and then goes back and wipes the first one off. She said she figured that was about three (3) minutes. She was informed it was one (1) minute. No further information was provided prior to the close of the survey.

Based on record review, policy review, and staff interview, the facility failed to honor the Resident's rights by not providing a written notice prior for a Residents room change. This is true for two (2) of two (2) Residents reviewed for room change. Resident Identifiers: Resident # 29 and Resident #7. Facility Census: 56. Findings Included: A review of the facility policy titled Resident Room Change Policy read as follows. .Procedure: .2. Notification of Change/Updates a. Social Services will complete Notification of Room Change and New Roommate Notification forms in the Electronic Medical Record (EMR) b. Social Service will document discussions with both residents and residents representatives. a) Resident #29 During a record review on 08/14/23 at 6:30 PM, Resident #29's medical record revealed Resident #29 had room changes on the following dates: -05/23/23 -06/02/23 -06/19/23 -07/05/23 Further record review revealed a Social Services Note for room change dated 6/19/2023 at 12:59 PM(typed as written) Spoke with resident regarding room change. Patient is agreeable to room change with no questions or concerns. Change made 6/19/23. Further record review revealed Social Services Note for room change dated 6/2/2023 at 10:31 AM(typed as written) Spoke with resident regarding need for room change. Patient is agreeable to room change with no questions or concerns. Change made 6/2/23. During an interview on 08/15/23 at 8:55 AM, the Director of Social Services #8 stated the admission director takes care of the room change. I used to do it, but the process is we talk to the family and/or resident if they have capacity. After speaking with them we document our discussions in the Social Services notes. During an interview on 08/15/23 at 9:00 AM, admission Director #12 stated the process of a room transfer is, I speak to the family and/or the Resident if they have capacity. If everyone is in agreement we proceed with the room change. I then document in a progress note under Social Services Note what was discussed and when and where the room change occurred. After a review of Resident #29 medical record, the admission Director acknowledged there was no documentation for the room changes on 05/23/23 and 07/05/23. And no evidence of written notices for any of the room changes per facility policy. b) Resident #7 During a record review on 08/14/23 at 7:30 PM Resident #7 medical record revealed Resident #7 had room changes on the following dates: -06/30/23 -06/28/23 Further review of the records revealed no evidence of documentation for the room changes on 06/30/23 and 06/28/23. After a review of the Resident#7's medical records she acknowledged there was no documentation for the room changes on 06/28/23 and 06/30/23. During an interview on 08/15/23 at 9:00 AM, admission Director #12 stated the process of a room transfer is I speak to the family and/or the Resident if they have capacity. If everyone is in agreement we proceed with the room change. I then document in a progress note under Social Services Note what was discussed and when and where the room change occurred. After a review of Resident #7 medical records, the admission Director acknowledged there was no documentation for the room changes on 06/28/23 and 06/30/23, and no evidence of written notices for any of the room changes per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy, and staff interview the facility failed to provide evidence that a Transfer Notice was sent to the Office of the State Long-Term Care Ombudsman when three (3) residents were transferred to the hospital. This was true for three (3) of three (3) Residents reviewed for hospital transfers. Resident identifiers: #37, #43, and #29. Facility census: 56. Findings Included: A review of the facility policy titled Bed Hold Policy with no initiated or revision date read as follows. .Procedure: 1. In the event a resident returns to the hospital or goes on a leave, the following process will be followed by the facility: a. The nurse or designee will present the Acute Transfer letter at time of transfer with a copy going with the resident and a copy going to the Business Office Manager. Designee will scan to the Ombudsman. a) Resident #37 During a record review on 08/14/23 at 12:45 PM, Resident #37's medical record revealed Resident #37 was transferred to a local hospital on [DATE] with a Hospital transfer notice dated 06/06/23. A record review on 08/14/23 at 12:45 PM, found Resident #37's medical record revealed Resident #37 was transferred to a local hospital on [DATE] with a Hospital transfer notice dated 01/28/23. A further review of the medical record did not reflect any evidence the Notice of Transfer was sent to the Office of the State Long-Term Care Ombudsman for hospital transfers for 06/06/23 and 01/28/23. During an interview on 08/14/23 at 3:26 PM, the Director of Nursing (DON) #7 acknowledged there was no documentation the Notice of Transfer was sent to the Office of the State Long-Term Care Ombudsman. During an interview on 08/15/23 at 8:53 AM, the Executive Director stated she was unable to locate any documentation that the Office of the State Long-Term Care Ombudsman was notified of the Hospital transfers on 06/06/23 and/or 01/28/23. b) Resident #43 During a record review on 08/14/23 at 1:30 PM, Resident #43's medical record revealed Resident #43 was transferred to a local hospital on [DATE] with a hospital transfer notice dated 03/15/23. A further review of the medical record did not reflect any evidence the Notice of Transfer was sent to the Office of the State Long-Term Care Ombudsman for the hospital transfer on 03/15/23. During an interview on 08/14/23 at 3:26 PM, the Director of Nursing (DON) #7 acknowledged there was no documentation of the Notice of Transfer sent to the Office of the State Long-Term Care Ombudsman . During an interview on 08/15/23 at 8:53 AM, the Executive Director stated she was unable to locate any documentation that the Office of the State Long-Term Care Ombudsman was notified of the Hospital transfer on 03/15/23. c) Resident #29 During a record review on 08/14/23 at 3:30 PM, Resident #29's medical record revealed Resident #29 was transferred to a local hospital on [DATE] with a hospital transfer notice dated 03/05/23. Record review found Resident #29 was transferred to the hospital on [DATE]. A further review of the medical record did not reflect any evidence the Notice of Transfer was sent to the Office of the State Long-Term Care Ombudsman for hospital transfers on 03/05/23 and 02/21/23. During an interview on 08/14/23 at 3:26 PM, the Director of Nursing (DON) #7 acknowledged there was no documentation of the Notice of Transfer sent to the Office of the State Long-Term Care Ombudsman. During an interview on 08/15/23 at 8:53 AM, the Executive Director stated she was unable to locate any documentation that the Office of the State Long-Term Care Ombudsman was notified of the hospital transfers on 03/05/23 and 02/21/23.

Based on observation, record review, staff, and resident interview the facility failed to ensure medication used in the treatment of diabetes was available for administration. This failed practice was true for one (1) of three (3) residents reviewed for insulin administration. Resident identifier: #8. Facility census: 56. Findings included: a) Resident #8 Record review showed an order for Trulicity Subcutaneous Solution Pen-injector 0.75 MG/0.5ML (Dulaglutide). Inject 0.75 mg subcutaneously one time a day every Thursday for Type 2 diabetes. Review of the Medication Administration Record (MAR) showed Resident #8 missed 2 doses of Trulicity in July. On 07/13/23 the drug was documented as refused with no other explanation. On 07/20/23, the dose was documented as not given and the MAR stated see nurses note. The nurse's note for that occurrence stated, awaiting delivery from pharmacy. During an interview on 08/14/23 at 3:58 PM, Resident #8 stated that she does not remember refusing any insulin shots. The Resident stated that is one thing she wants to keep up on because she doesn't want her sugar to get too high. Resident stated, I always take my insulin shots. On 08/14/23 at 2:08 PM, the Director of Nursing (DON) stated the Trulicity medication was delivered by pharmacy on 07/21/23 at 9:25 AM. The DON verified the dose ordered on 07/20/23 was not given. Resident #18 has capacity and Brief Interview for Mental Status (BIMS) score of 13 as indicated by the quarterly MDS with ARD date of 07/24/23. Review of Resident's care plan showed no documentation that Resident refuses insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement and follow the specified pain parameters described within the physicians' order when administering pain medication. This was true for one (1) of three (3) Residents reviewed in the care area of pain. Resident identifier: #12. Facility census: 56. Findings included: a) Resident #12 Record review showed an order for Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 6 hours as needed (PRN) for moderate to severe pain. Start date of order 07/14/23. Review of Resident #12's Medication Administration Record (MAR) showed Resident #12 was administered the as needed Percocet Oral Tablet 5-325 MG for 26 occurrences for a pain level of zero (0) in the month of July and August: 07/17/23 at 5:45 PM 07/17/23 at 11:00 PM 07/18/23 at 4:50 AM 07/19/23 at 12:15 PM 07/20/23 at 7:38 AM 07/20/23 at 8:34 PM 07/21/23 at 3:05 AM 07/22/23 at 3:49 AM 07/22/23 at 7:15 PM 07/24/23 at 4:47 PM 07/24/23 at 10:53 PM 07/26/23 at 4:00 AM 07/27/23 at 10:30 PM 07/31/23 at 1:21 AM 07/31/23 at 7:32 PM 08/01/23 at 2:07 AM 08/02/23 at 10:34 PM 08/03/23 at 8:00 PM 08/04/23 at 4:00 AM 08/04/23 at 11:00 AM 08/06/23 at 9:08 PM 08/07/23 at 7:57 PM 08/09/23 at 1:20 AM 08/10/23 at 8:20 PM 08/13/23 at 9:01 PM 08/15/23 at 5:12 AM On 08/15/23 at 10:05 AM, the Director of Nursing (DON) was asked to clarify what moderate to severe pain would be using the 0-10 numeric pain scale. The DON replied, Moderate to severe pain would be anything five or greater. The DON reviewed the documentation and agreed the pain medicine should never have been administered for a pain level of level zero (0). The DON further stated, I don't know why they did that, maybe it's because the Resident is so demanding. Record review of the facility's undated policy titled Pain management and Assessment showed the 1 - 10 pain scale should be used for residents with intact cognition abilities who can and are willing to determine their worst pain ever (10) and no pain (1) range using numbers. Record review indicated the Resident has capacity. The admission MDS dated [DATE] showed a Brief Interview Mental Status (BIMS) score of 15, with 15 being the highest achievable. This indicated the Resident was cognitively intact and capable of accurately reporting the level of pain.

Based on observation, staff interview, and Resident interviews, the facility failed to provide Residents with evening snacks. This is true for 11 of 23 Residents requiring evening snacks. Resident identifiers: Resident #30, Resident #1, Resident #7, Resident #43, Resident #51, Resident #4, Resident #8, Resident #15, Resident #14, Resident #53 and Resident #37. Facility Census 56. Findings Included: a) Snacks During a tour of the nourishment room on 08/14/23 at 8:55 AM, the refrigerator revealed a tray of snacks dated 08/12 Sat (Saturday) PM for the following residents: -Pudding: Resident #37 Resident #43 -Nectar Thickened Water: Resident #30 -½ Sandwiches: Resident #1 Resident #7 Resident #51 Resident #4 Resident #8 Resident #15 Resident #14 Resident #53 During an interview on 08/14/23 at 9:44 AM, the Director of Nursing (DON) stated the Residents might have eaten something else, I will have to look at the snack documentation record to see what was documented. During an interview on 08/14/23 at 11:43 PM, the Culinary Director (CD) stated we send out the snacks, but the nurses document what they consumed or if the resident refused the snack. Nurses keep up with the weekly percentages of the snacks. I just do the meal percentages, not the snacks. Nursing staff are in charge of passing the snacks to the Residents. During an interview on 08/14/23 at 1:13 PM, the DON stated I am unable to locate snack documentation for 08/12/23. She acknowledged that 11 Residents did not receive the PM snacks on 08/12/23. b) PM Snack list On 08/14/23 at 12:30 PM, the CD provided a snack list that the Kitchen is required to send to the floor for the Nursing staff to distribute to the Residents. A review of the PM Snack list provided by the CD revealed 23 Residents are required to receive a PM snack. c) Residents with a Diabetes Diagnosis 1. Resident #7 During a record review on 08/14/23 at 3:00 PM Resident #7 medical records revealed a diagnosis of type 2 diabetes mellitus without complications dated 05/19/23. 2. Resident #8 During a record review on 08/14/23 at 3:02 PM Resident #8 medical records revealed a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease dated 10/01/21. 3. Resident #14 During a record review on 08/14/23 at 3:04 PM Resident #14 medical records revealed a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease dated 03/15/21. 4. Resident #15 During a record review on 08/14/23 at 3:06 PM Resident #15 medical records revealed a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease dated 05/20/22. 5. Resident #51 During a record review on 08/14/23 at 3:08 PM Resident #51 medical records revealed a diagnosis of type 2 diabetes mellitus without complications dated 05/09/23. 6. Resident #53 During a record review on 08/14/23 at 3:10 PM Resident #53 medical records revealed a diagnosis of type 2 diabetes mellitus with diabetic peripheral angioplasty without gangrene dated 11/10/22. During an interview on 08/14/23 at 3:35 PM, the DON acknowledged that six (6) of the eleven (11) residents were diabetics and needed to receive a snack before bed.

. Based on observation, resident and staff interview, and record review, the facility failed to provide an extra over-the-bed table for meals to prevent further injury due to spilled tray which cause a second (2nd) degree burn on right foot. Resident identifier: #2. Facility census: 57. Findings included: a) Resident #2 An interview and observation with Resident #2, on 10/17/22 at 1:53 PM, found the resident in bed with the right foot wrapped in a cling dressing. Resident #2 stated that she had suffered a burn from coffee on 10/10/22. She stated her tray fell off because she keeps her personal items close to be able to reach them throughout the day and her tray doesn't fit on the table very well. Review of Resident #2's incident report dated 10/10/22 at 3:30 PM, which reads: Resident requested her Unna Boot ( is a compressive dressing used in the treatment of venous stasis ulcers) to be removed due to her tray had spilled and coffee had went into her Unna boot on the right foot and it was burning. When the boot was removed, it was noted to have a blister measuring 2 centimeters (cm) in length and 3 cm in width on the outer aspect of the right heel. The blister had ruptured due to the resident stating that she was rubbing the foot back and forth on the sheet when it felt like it was burning. An area of light pink erythema was noted. Factors: Resident has her bedside table full of personal items and leaves little room for resident's meal set-up. A review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/22, found the Brief Interview for Mental Status (BIMS) was 15, which indicates cognitively intact. Resident #2 has capacity to make her own medical decisions. She rarely gets out of bed due to edema and neuropathy in the lower extremities. She likes to have her personal items close on the overbed table. She has limited range of motion in both shoulders. An interview with the Director of Nursing (DON) on 10/19/22 at 11:00 AM when asked if the resident could have an over the bed table for eating to prevent the resident from further injury without moving her personal items which she uses frequently stated, she can have an over the bed table for eating. The DON agreed the staff should have offered an over the bed table for eating to accommodate the resident's needs. .

. Based record review and staff interview, the facility failed to ensure a Physicians Orders for Scope of Treatment (POST) form was completed by the appropriate designee for one (1) of two (2) residents reviewed for advance directives. This failed practice had the potential to affect only a limited number of residents. Resident identifier: #35. Facility census: 57. Findings included: a) Resident #35 Record review showed Resident #35's POST form was completed and signed by the Resident's Health Care Surrogate (HCS) on 02/26/20. Further record review showed a physician's determination of capacity that was completed on 11/01/21 indicating at that time the Resident demonstrated incapacity to make medical decisions. During an interview on 10/19/22 at 12:46 PM, the Director of Nursing (DON) verified the POST form was completed by the Resident's HCS prior to the Resident being incapacitated. The DON confirmed the Resident should have been the one to complete and sign the form at that time. .

. Based on observation, medical record review and staff interview, the facility failed to follow the physician orders for Resident #109 with a order for Lidocaine patches without a dosage and Resident #2's orders for treatment of a second degree burn on the right foot. These failed practices had the potential to affect a limited number of residents. Resident identifiers: #109 and #2. Facility census: 57. Findings included: a) Resident #109 During medication pass on 10/18/22 at 8:15 AM Resident #109 had an order for a Lidocaine patch to be applied to the left hip topically daily for eleven (11) days for pain. The order on the electronic Medication Administration Record (MAR) did not have a dosage. Further review found the physician had ordered a Lidocaine patch 4%. In an interview with the Director of Nursing (DON) on 10/18/22 at 1:15 PM confirmed the order failed to have the dosage and the order was updated immediately. b) Resident #2 Review of Resident #2's incident report dated 10/10/22 at 3:30 PM, which reads: Resident requested her Unna Boot (is a compressive dressing used in the treatment of venous stasis ulcers) to be removed due to her tray had spilled and coffee had gone into her Unna boot on the right foot, and it was burning. When boot was removed, it was noted to have a blister measuring 2 centimeters (cm) in length and 3 cm in width on the outer aspect of the right heel. The blister had ruptured due to the resident stating that she was rubbing the foot back and forth on the sheet when it felt like it was burning. Area with light pink erythema noted. The incident report noted the following: Factors: Resident has her bedside table full of personal items and leaves little room for resident's meal set-up. Review of Resident #2's physician orders found the following orders: --Effective 06/30/22- Cleanse bilateral lower extremities with soap and water, pat dry and apply Unna boots every Monday and Thursday for vascular disease. Discontinued on 10/19/22 (9 days after the incident). --Effective 10/12/22-Silvadene cream to right lateral malleolus (ankle) topically every day for 14 days. (2 days after incident). --Effective 10/20/22- Cleanse left lower extremity with soap and water, pat dry and apply Unna boot every Monday and Thursday. (10 days after the incident.) In an interview with the DON on 10/19/22 at 2:00 PM acknowledged the residents' orders were not updated when the incident occurred, and the physician orders were not followed. .

. Based on observation and staff interview, the facility failed to ensure the resident's environment was as free of accident hazards as possible. Unit 3/4 medication cart was left unlocked and unattended. This was a random opportunity for discovery. Facility census: 57. Findings included: On 10/18/22 at 3:11 PM, the Unit 3/4 medication cart was observed to be unlocked and unattended. The Director of Nursing was notified immediately. A list of residents who wanders was requested. The list of wandering residents contained the following residents: #47, #28, #15, #49, #52, #41, #55 and #53. No further information was provided. .

. Based on medical record review, staff interview and resident interview, the facility failed to ensure a complete and accurate medical record. The facility failed to document Resident #6's bathing task and Resident #51's weights in the electronic medical record. This was a random opportunity of discovery. Resident identifiers: Resident #6 and Resident #51. Facility Census: 57 Findings Included: a) Resident #6 During an interview on 10/17/22 at 2:03 PM, Resident # 6 stated that I get a shower most of the time, they skip a few, don't get as many as I should, I think I am scheduled two (2) times a week. During a medical record review on 10/18/22 revealed Resident #6's bathing documentation as follows: Bed bath: -09/20/22 at 2:29 PM -09/22/22 at 11:58 AM -09/25/22 at 11:41 AM Showers: 09/24/22 at 12:48 AM No evidence of the bathing task was in the electronic medical record since 09/25/22. During an interview on 10/18/22 at 10:55 AM, the Director of Nursing (DON) stated that Resident #6 had showers scheduled on Wednesday and Saturday. She received her showers. The showers were documented on the shower sheet. During an interview on 10/18/22 at 12:25 PM the DON verified Resident #6's bathing/showers were not documented in the electronic medical record since 09/25/22. b) Resident #51 During a review of Resident #51's medical record on 10/18/22 at 7:58 PM revealed physician orders dated 05/09/22 weekly weights. Further review of Resident #51's electronic medical record on 10/18/22 at 8:00 PM revealed the following weights: -10/05/22 174.2 pounds (lbs) -09/15/22 170.8 lbs -09/06/22 170 lbs -08/30/22 170 lbs -08/30/22 170 lbs wheelchair During an interview on 10/19/22 at 9:35 AM the DON stated weekly weights were done, the weights are kept in a book at the nurses station. A review of the weight book at the nursing station on 10/19/22 revealed Resident # 51 weight record as followed: -08/30/22 170.0 lbs -09/16/22 169.4 lbs -09/13/22 170.8 lbs -09/20/22 176.6 lbs -10/06/22 174.2 lbs -10/10/22 182.4 lbs -10/17/22 182.8 lbs During an interview on 10/19/22 at 11:28 AM, the DON verified the weights were not recorded in the electronic medical record. The DON stated the weight are usually done by the same staff member and wrote in the weekly weight book. We have a person that is supposed to put the weights in the computer but the position is open, and has been for months. I have been trying to put them in or Dietary tries to put the weights in the computer. Resident #51 name has had a gain of eight (8) pounds since 10/05/22, and we did not know because it was not put in the computer. No other information was provided by the end of the survey. .

. Based on record review, resident council meeting, resident interview and staff interviews, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. The facility failed to implement evening activities of interest for the residents. This was a random opportunity for discovery. Facility census: 57. Findings Included: a) Resident Council During the Resident Council Meeting held on 10/18/22 at 2:43 PM the Residents as a group were asked the question, How are the activities? The following concerns were voiced. -Could be more activities, -We need evening activities, we do nothing but sit in our rooms after dinner. -It's so boring in the evenings, We need more to do in the evening. -We need someone to help us set out the games and stuff but some of the others need help participating in the games that are available. -The last activity is at 2:00 PM and then nothing. A review of previous Resident Council minutes revealed a Resident Council Meeting held on 03/08/22 revealed the following Residents were asked about PM activities, several residents said they would like to have some. b) Monthly Activity Calendars A review of the monthly activity calendars revealed evening activities on the following months and days: -On 04/04/22 Bowling at 6:00 PM -On 04/11/22 Outdoor Time Weather Permitting or Yahtzee at 6:00 PM -On 04/18/22 Outdoor Time Weather Permitting or Board Game at 6:00 PM -On 04/25/22 Outdoor Time Name that Tune Music Hour at 6:00 PM -On 05/02/22 Outdoor Time with Music at 6:00 PM -On 05/09/22 Let's Play Yahtzee at 6:00 PM -On 05/16/22 Wii Games Chip and Dip at 6:00 PM -On 05/23/22 AN Evening Outdoors at 6:00 PM -On 05/30/22 Outdoor Time at 6:00 PM -From 06/22 to 10/22 every Thursday Evening Worship with (a local pastor's name) at 6:45 PM c) Interviews During an interview on 10/19/22 at 9:18 AM, the Activity Director (AD) stated that we play board and card games during the day and I leave them out so they can continue them in the evening when we are not here. We were staying till 6:00 PM in April and May but no one was attending or wanting to come outside to the activities and dinner was not over till sometimes 5:45 PM. The Nursing staff were taking the residents outside for the evening activity when I (AD) was not able to stay. A local pastor volunteered to do Thursday evenings. The local pastor visits all the residents in their rooms, sometimes bringing cookies, and watched the WVU game last week with them. I encourage the Resident to be independent and do activities themselves and get the games and cards themselves and bring themselves to the activities. I have a limited amount of staff, and all of my staff including myself are Nurse Aides. The Activity staff were pulled to work the floor and which interferes with the activity schedule and the activities are not being done. During the exit interview process on 10/19/22 at 4:00 the Administrator stated that yes we do pull the Activity staff to the floor. They are all certified nurses aides. I will use them when I need to. I have been pulling them to the floor. We are still supposed to schedule two (2) evening activities a week. .

. Based on medical record review and staff interview, the facility failed to have two (2) licensed nurses to sign off at the beginning and ending of the shift to verify the control substances were accurate and accounted for as directed. This failed practice had the potential to affect more than a limited number of residents. This was discovered during the medication pass on 10/18/22. Facility census: 57. Findings included: Review of Unit 1/2 medication cart found the following days the narcotic book was only signed by one (1) licensed nurse: 10/02/22-not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 10/06/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 10/10/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 10/15/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 10/16/22-not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-10/18/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am Review of Unit 1/2 medication cart found the following days the narcotic book was only signed by one (1) licensed nurse: 07/28/22-10:30 pm -6am- not signed by the off going nurse 07/31/22-not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 08/01/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 08/05/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 08/18/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 08/30/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 08/31/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 09/11/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 09/12/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 09/22/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am 10/08/22- not signed by oncoming nurse on the 6a-6p shift and the off going nurse on the 6p-6 am An interview with the Director of Nursing (DON) on 10/18/22 at 11:00 AM, the DON verified only one (1) licensed nurse signed off the narcotic count on the above dates. In addition, the DON also verified two (2) licensed nurses are to sign off the narcotic count at the beginning and end of the shift. .

. Based on medical record review and staff interview, the consultant pharmacist failed to complete a medication regimen review every thirty (30) days. This was true for Residents #13, #29, #16 and #36. Additionally, the facility failed to timely complete a gradual dose reduction (GDR) as approved by the physician. Resident identifiers: #13, #29, #16 and #36. Facility census: 57. Findings included: a) Policy A review of the policy titled Medication Regimen Review (MRR) Time Frame with an implemented date of 11/27/17 and a review date of 05/03/21 was as follows: The medication regimen of each patient is reviewed at least once a month by a licensed Consultant Pharmacist. b) Resident #13 A review of Resident #13's MRR completed by the consultant pharmacist monthly for the last year revealed on 03/28/22, the consultant pharmacist stated this date was done on 03/28/22 for the period of 02/01/22 through 02/28/22. There was not an MRR completed for February 2022. c) Resident #29 A review of Resident #29's MRR completed by the consultant pharmacist monthly for the last year revealed on 03/28/22, the consultant pharmacist stated this date was done on 03/28/22 for the period of 02/01/22 through 02/28/22. There was not an MRR completed for February 2022. d) Resident #16 A review of Resident #16's MRR completed by the consultant pharmacist monthly for the last year revealed on 03/28/22, the consultant pharmacist stated this date was done on 03/28/22 for the period of 02/01/22 through 02/28/22. No MRR completed for February 2022. e) Interview An interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 10/19/22 at 9:00 AM verified the Consultant Pharmacist did not complete a MRR for Residents #13, #29, #16 and #36 for the month of February 2022. f) Resident #36 A record review of the consultant pharmacist medication regimen review for September 2021 showed a dose reduction was suggested for was Zoloft (used to treat depression anxiety and mood) 25 mg (milligrams) daily to be decreased to 12.5 mg daily. The suggested dose reduction was approved and ordered by the provider to be decreased on 09/13/21. A review Resident #36's Medication Administration Record (MAR) for September and October of 2021 showed the Zoloft 25 mg dose was continued and administered until 10/25/21. The reduced dose that was ordered on 09/13/21 was not initiated until 10/26/21. During an interview on 10/19/22 at 12:44 PM the DON verified the order to decrease the Zoloft from 25 mg to 12.5 mg was done on 09/13/21 and should have been done that day without being delayed until 10/26/21. .

. Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 57 Findings Included: A facility policy titled labeling and dating with a date of 2017 stated the following. .Guidelines for Labeling and Dating .Food labels must include: -The food name -The date of preparation/receipt/removal from freezer -The use by date . Use By Dating Guidelines -The manufacturer's expiration date, when, available is the use by for unopened items a) Walk-in Refrigerator A facility policy titled food storage and retention guide with a date of 2017 stated the following. .Shelf Stable Foods . Condiments after opening in refrigerator less than 41 degrees Fahrenheit -Pickles: one (1) to two (2) weeks -Salad dressing: three (3) months -Vinegar: two (2) weeks An initial tour of the kitchen with the Food Service Director (FSD) beginning on 10/17/22 at 10:40 AM, the walk-in refrigerator the following items were found: -an opened gallon of Thousand Island Dressing with an open date 07/02/22 -an opened gallon of Vinegar with an open date 09/13/22 -an opened gallon of Red Wine Vinegar with an open date 06/13/22 -an open gallon of relish with an open date 06/20/22 . The FSD acknowledged the failure to label food items with a Use by Date. Also indicated the items needed to be discarded because they were out of date or not dated. b) Walk-in Freezer An initial tour of the kitchen with the FSD beginning on 10/17/22 at 10:40 AM, the walk-in freezer the following items were found: -an opened bag of tater tots with no open date and/or use by date The FSD acknowledged the failure to label food items with an open date and/or Use by Date. Also indicated the item needed to be discarded because they were not dated. c) Kitchen Pantry An initial tour of the kitchen with the FSD beginning on 10/17/22 at 10:40 AM, the pantry the following items were found: -A storage container with a lid with a label sugar with no open date and/or Use by Date. -A storage container with a lid with a label thickener with no open date and/or Use by Date. The FSD stated I poured the sugar in the barrel on Thursday, it was empty. I have never labeled these barrels with an open or use by date in 20 years and no one has ever said anything to me. d) Spice Rack in Pantry A facility policy titled food storage and retention guide with a date of 2017 stated the following. .Shelf Stable Foods . -Spices 12 months . An initial tour of the kitchen with the FDS beginning on 10/17/22 at 10:40 AM, the pantry the following items were found: The FSD stated we usually don't date the spices when we open them we go by the delivery date. She stated spices are good for one (1) year. -An opened bottle of Bay Leaves with a delivery date of 06/18/22, no open date or use by date -An opened bottle of Ground Basil with a delivery date of 09/23/21, no open date or use by date -An opened bottle of Zesty Seasoning with a delivery date of 11/12/20, no open date or use by date -An opened bottle of Ground Ginger with a delivery date of 11/06/19, no open date or use by date -An opened bottle of Dill Weed with a delivery date of 08/01/19, no open date or use by date -An opened bottle of Lemon Pepper with a delivery date of 02/04/19, no open date or use by date -An opened bottle of Ground Oregano with a delivery date of 09/30/21, no open date or use by date -An opened bottle of Spice Nutmeg with a delivery date of 11/21/20, no open date or use by date -An opened bottle of Tarragon Leaf with a delivery date of 08/12/21, no open date or use by date -An opened bottle of Ground Cloves with a delivery date of 11/27/20, no open date or use by date -An opened bottle of [NAME] Pepper with a delivery date of 08/08/20, no open date or use by date -An opened bottle of Vegetable Seasoning with a delivery date of 05/21/21, no open date or use by date -An opened bottle of Ground Cumin with a delivery date of 01/30/20, no open date or use by date The FSD acknowledged the failure to label food items with an open date and/or Use by Date. Also indicated the item needed to be discarded because they were out of date. .

. Based on observation and staff interview, the facility failed to ensure Resident #27 was treated with respect and dignity during wound care. This was a random opportunity for discovery. Resident Identifier: #27. Facility Census: 55. Findings Included: a) Resident #27 During an observation of Resident #27's wound care treatment to the wound on her left buttock, on 06/29/21 at 1:10 PM, Licensed Practical Nurse (LPN) #49 failed to pull the privacy curtain, between Resident #27 and her roommate, to ensure Resident #27's privacy. At the conclusion of the observation, LPN #49 confirmed she should have pulled the privacy curtain between the two (2) residents before providing the wound care. .

. Based on resident observation, resident interview, staff interviews and review of Resident Assessment Instrument (RAI), the facility failed to assure a resident received an accurate assessment of oral status at the time of the admission Minimum Data Set (MDS). This was true for one (1) of one (1) residents reviewed for oral/dental status during the annual survey. Resident identifier: #30. Facility census: 55. Findings included: a) Resident #30 During an interview with Resident #30 on 06/28/21 at 11:31 AM, the resident stated that a tooth was lose and needed to be seen by a dentist. An observation of Resident #30's teeth found upper and lower missing teeth. Resident #30 stated that two (2) teeth had been lost when in the hospital during intubation. A review of the admission MDS with an Assessment Reference Date (ARD) of 05/24/21 found in Section L0200 Oral/Dental had not been coded for missing teeth. A review of the medical record revealed Resident #30 had been transferred to another facility on 06/29/21. The discharge assessment noted the resident had missing teeth. An interview conducted with the Registered Nurse (RN) Unit Manager on 06/29/21 at 1:50 PM revealed she had completed the discharge assessment and confirmed Resident #30 had missing teeth. The MDS Coordinator on 06/29/21 at 1:53 PM, stated that Resident #30 had capacity and when asked if she had an dental pain, Resident #30 stated No. When asked if the MDS Coordinator had made an observation of resident's oral cavity, she stated :No. The Resident Assessment Instrument (RAI) stated Steps for Assessment 1. Ask the resident about the presence of chewing problems or mouth or facial pain/discomfort. 2. Ask the resident, family, or significant other whether the resident has or recently had dentures or partials. (If resident or family/significant other reports that the resident recently had dentures or partials, but they do not have them at the facility, ask for a reason.) 3. If the resident has dentures or partials, examine for loose fit. Ask him or her to remove, and examine for chips, cracks, and cleanliness. Removal of dentures and/or partials is necessary for adequate assessment. 4. Conduct exam of the resident's lips and oral cavity with dentures or partials removed, if applicable. Use a light source that is adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth. 5. If the resident is unable to self-report, then observe him or her while eating with dentures or partials, if indicated, to determine if chewing problems or mouth pain are present. 6. Oral examination of residents who are uncooperative and do not allow for a thorough oral exam may result in medical conditions being missed. Referral for dental evaluation should be considered for these residents and any resident who exhibits dental or oral issues. .

Based on observation and staff interview, the facility failed to make staffing information readily available in a readable format to residents and visitors at all times. This practice had the potential to affect a limited number of residents. This was a random opportunity for discovery. Facility Census: 55 Findings Included: On a random opportunity for observation, on 6/29/21 at 3:15 PM, this surveyor noted that the daily nurse staffing form was not completed for the 2:30 PM to 10:30 PM shift. An interview, on 06/29/21 at 3:16 PM, with Licensed Practical Nurse (LPN) # 74, confirmed the staffing sheet was not filled in for the 2:30 PM to 10:30 PM shifts. LPN # 74 corrected the staffing sheet at this time. .

. Based on observation, staff interview and anonymous resident interview, the facility failed to serve food that was palatable and at an acceptable temperature. The failed practice had the potential to affect a limited number of residents. Facility census 55. Findings included: Anonymous Resident Interview #1 on 06/28/21 found the following when asked how the food was, Need to improve presentation of food, they just 'plop' it on the plate and slop it up that kills it. No one wants to eat that. Anonymous Resident Interview #2 on 06/28/21 found the following when asked how the food was, The food is terrible, they don't know how to cook. Doesn't taste good. Most of the time its cold. On 06/29/21 at 8:16 AM, temperatures were obtained on the breakfast meal tray for Resident #47 at the time of service. The following temperatures were obtained by the Certified Dietary Manager (CDM) using her thermometer: -- Sausage and gravy 117 degrees Fahrenheit (F). -- Pureed Egg and Cheese Omelet: 116 degrees F. -- Sweet Tea : 55 degrees F. -- Water: 51 degrees F. On 06/29/21 at 12:15 PM, 5 state surveyors tasted the noon time meal, for palatability. The parslied cauliflower was tasteless, and not palatable. On 06/29/21 at 12:35 PM, the CDM provided the recipe for cauliflower parsalied which was as follows: recipe ingredients were cauliflower, margarine and parsley flakes, the surveyors did not taste or observe the margarine. .

. Based on observation and staff interview the facility failed to store food in a safe and sanitary manner to prevent the spread of food-borne illness. This failed practice had the potential to affect a limited number of residents currently residing in the facility. Facility census 55. Findings included: An initial tour of the kitchen with the Certified Dietary Manager (CDM) beginning on 06/28/21 at 11:15 AM, found in the walk-in refrigerator 23-Activa yogurts with a manufacture stamped expiration date of 06/14/21. The CDM indicated the yogurts needed to be discarded because the were out of date. .

. Based on resident interview and staff interview, the facility failed to ensure recommendations, concerning issues of resident care and life in the facility, discovered during the the resident council meetings were resolved. This has the potential to affect more than a limited number of residents. Facility census: 55. Findings included: a) Resident council meeting During the resident council meeting held on 06/29/21 at 10:33 AM, seven (7) residents in attendance were asked question (#12) from the long - term care Resident Council facility task, Do you get snacks at bedtime? Four (4) of the seven (7) residents in attendance stated they did get snacks, but they had asked for healthier snacks such as fruits and vegetables when the facility can get them. Residents said the usual snacks provided are ice cream, chips, lunch cakes, and sandwiches. One (1) of the seven (7) attendees at the meeting was asleep and did not participate in the meeting. According to the activity director, the facility started holding group meetings in April 2021. (Group meetings were not held for several months due to COVID - 19.) Review of the minutes for meetings held on 04/06/21, 05/04/21, and 06/08/21 found the following: On 04/06/21, under the heading of old business, a resident had asked for a, better variety of snacks on the cart. The printed form used to document the council minutes has a heading for each facility department, including Dietary. No documentation was present under the heading of Dietary. Review of the 05/04/21 minutes found the following documentation under the heading of Old Business, Several residents asked for a new variety of snacks offered on the snack cart. Again, under the heading of Dietary no documentation was present to substantiate the Dietary Manager had been involved in resolving the issue. A third meeting was held on 06/08/21. There was no information in the minutes of the June meeting indicating the concern was resolved. The activity director and the facility social worker attended the resident council meeting on 06/29/21, per the resident's request. During the meeting, the activity director said she just forgot to document on the June minutes the residents were satisfied with the snacks. However, the residents in attendance at the meeting expressed they were not satisfied with the items available on the snack cart. At 10:42 AM on 06/29/21, the resident pantry was toured with the Dietary Manager (DM) and two (2) surveyors. The following snacks were available for resident consumption: Cereal - four (4) bowls, no milk, two (2) cans of soup, a loaf of bread (no ingredients: meat, cheese, peanut butter, etc. to make a sandwich) ice cream, and soda. On 06/29/21 at 2:24 PM, the Dietary Manager said she had no formal documentation regarding the resident council's concern about having healthy snacks on the snack cart and the steps taken to resolve the issue. She said the activity director did inform her of the resident's concerns and she had made changes. On 06/30/21 at 8:47 AM, the administrator said the issues were resolved, but the problem was with the documentation. .

. Based on record review and staff interview the facility failed to administer medications and perform treatments in accordance with the physicians orders. This was true for four (4) of 14 sampled residents. Resident identifiers: #27, #32, #47 and #51. Facility Census: 55. Findings included: a) Resident #47 A review of Resident #47's medical record found a physicians order for Lantus Solution 100 unit/ml (milliliters) inject 27 units subcutaneous one time a day related to Type II diabetes mellitus without complications. This medication was scheduled to be administered at 7:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 9:45 AM this was 2 hours and 45 minutes past the scheduled administration time. -- 06/06/21 at 10:12 AM this was 3 hours and 12 minutes past the scheduled administration time. -- 06/08/21 at 8:54 AM this was 1 hour and 54 minutes past the scheduled administration time. -- 06/11/21 at 8:48 AM this was 1 hour and 48 minutes past the scheduled administration time. -- 06/18/21 at 9:52 AM this was 2 hours and 52 minutes past the scheduled administration time. -- 06/19/21 at 9:44 AM this was 2 hours and 44 minutes past the scheduled administration time -- 06/20/21 at 9:47 AM this was 2 hours and 47 minutes past the scheduled administration time. -- 06/22/21 at 9:55 AM this was 2 hours and 55 minutes past the scheduled administration time. -- 06/24/21 at 9:37 AM this was 2 hours and 37 minutes past the scheduled administration time. Resident #47 Medical record contained an order for Prilosec capsule delayed release 40 milligrams, give one capsule one time a day for GERD (Gastroesphogial Reflux Disease). This medication was scheduled to be administered at 9:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/06/21 at 10:12am this was 1 hour and 12 minutes past the scheduled administration time. -- 06/13/21 at 10:32am this was 1 hour and 32 minutes past the scheduled administration time. -- 06/16/21 at 10:37am this was 1 hour and 37 minutes past the scheduled administration time. Resident #47 Medical record contained an order for Flonase suspension 50 mcg/act 1 spray in each nostril two times a day for allergies. This medication was scheduled to be administered at 6:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/11/21 - dose documented as administered on 6/29/21 at 10:22am this was 18 days after it was scheduled to be administered. -- 06/15/21 - dose documented as administered on 6/29/21 at 10:23am this was 14 days after it was scheduled to be administered. Resident #47 Medical record contained an order for Lamictal 150 mg by mouth two times a day related to unspecified psychosis. This medication was scheduled to be administered at 6:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/11/21 - dose documented as administered on 6/29/21 at 10:22am this was 18 days after it was scheduled to be administered. -- 06/15/21 - dose documented as administered on 6/29/21 at 10:23am this was 14 days after it was scheduled to be administered. Resident #47 Medical record contained an order for Lamictal 25 mg by mouth two times a day related to unspecified psychosis. This medication was scheduled to be administered at 6:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/11/21 - dose documented as administered on 6/29/21 at 10:22 AM this was 18 days after it was scheduled to be administered. -- 06/15/21 - dose documented as administered on 6/29/21 at 10:23 AM this was 14 days after it was scheduled to be administered. Resident #47 Medical record contained an order for Norco tablet 7.5/325 mg one tablet by mouth every 6 hours for pain. This medication was scheduled to be administered at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 - at 3:56 AM this was 3 hours and 56 minutes past the scheduled administration time. -- 06/02/21 - at 2:46 AM this was 2 hours and 46 minutes past the scheduled administration time. -- 06/03/21 - at 5:26 AM this was 5 hours and 26 minutes past the scheduled administration time. -- 06/04/21 - at 2:24 AM this was 2 hours and 24 minutes past the scheduled administration time. -- 06/06/21 - at 1:50 AM this was 1 hour and 50 minutes past the scheduled administration time. -- 06/11/21 - at 5:07 AM this was 5 hours and 7 minutes past the scheduled administration time. -- 06/11/21 - dose documented as administered on 6/29/21 at 10:22 AM this was 18 days after it was scheduled to be administered. -- 06/15/21 - dose documented as administered on 6/29/21 at 10:23 AM this was 14 days after it was scheduled to be administered. -- 06/16/21 - at 6:01 AM this was 6 hours and 1 minutes past the scheduled administration time. -- 06/19/21 - at 1:39 AM this was 1 hour and 39 minutes past the scheduled administration time. -- 06/21/21 - at 5:14 AM this was 5 hours and 14 minutes past the scheduled administration time. -- 06/22/21 - at 1:44 PM this was 1 hour and 44 minutes past the scheduled administration time. On 06/03/21, 06/11/21, 06/16/21 and 06/21/21 Resident #47 received her 12:00 AM dose of Norco within one hour of receiving her 6:00 AM dose of Norco. Resident #47 Medical record contained an order for Zyprexa give 10mg by mouth at bedtime related to major depressive disorder, severe with psychotic symptoms. This medication was scheduled to be administered at 8:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 - at 9:26 PM this was 1 hour and 26 minutes past the scheduled administration time. -- 06/03/21 - at 9:28 PM this was 1 hour and 28 minutes past the scheduled administration time. -- 06/05/21 - at 9:29 PM this was 1 hour and 29 minutes past the scheduled administration time. -- 06/06/21 - at 9:38 PM this was 1 hour and 38 minutes past the scheduled administration time. -- 06/07/21 - at 10:02 PM this was 2 hours and 2 minutes past the scheduled administration time. -- 06/08/21 - at 10:45 PM this was 2 hours and 45 minutes past the scheduled administration time. -- 06/09/21 - was administered on 06/10/21 at 12:22 AM that was 4 hours and 22 minutes past the scheduled administration time. -- 06/10/21 - at 10:06 PM this was 2 hours and 6 minutes past the scheduled administration time. -- 06/14/21 - at 9:48 PM this was 1 hour and 48 minutes past the scheduled administration time. -- 06/16/21 - at 10:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/17/21 - at 9:30 PM this was 1 hour and 30 minutes past the scheduled administration time. -- 06/18/21 - was administered on 06/19/21 at 1:39 AM this was 5 hours and 39 minutes past the scheduled administration time. -- 06/19/21 - at 11:15 PM this was 3 hours and 15 minutes past the scheduled administration time. -- 06/20/21 - at 9:52 PM this was 1 hour and 52 minutes past the scheduled administration time. -- 06/21/21 - at 9:27 PM this was 1 hour and 27 minutes past the scheduled administration time. -- 06/23/21 - at 10:23 PM this was 2 hours and 23 minutes past the scheduled administration time. -- 06/24/21 - at 9:30 PM this was 1 hour and 30 minutes past the scheduled administration time. Resident #47 Medical record contained an order for Trazadone give 50 mg by mouth at bedtime related to major depressive disorder, severe with psychotic symptoms. This medication was scheduled to be administered at 8:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 - at 9:26 PM this was 1 hour and 26 minutes past the scheduled administration time. -- 06/03/21 - at 9:54 PM this was 1 hour and 54 minutes past the scheduled administration time. -- 06/05/21 - at 9:29 PM this was 1 hour and 29 minutes past the scheduled administration time. -- 06/06/21 - at 9:38 PM this was 1 hour and 38 minutes past the scheduled administration time. -- 06/07/21 - at 10:04 PM this was 2 hours and 4 minutes past the scheduled administration time. -- 06/08/21 - at 10:46 PM this was 2 hours and 46 minutes past the scheduled administration time. -- 06/09/21 - was administered on 06/10/21 at 12:22 AM that was 4 hours and 22 minutes past the scheduled administration time. -- 06/10/21 - at 10:06 PM this was 2 hours and 6 minutes past the scheduled administration time. -- 06/14/21 - at 9:58 PM this was 1 hour and 58 minutes past the scheduled administration time. -- 06/16/21 - at 10:17 PM this was 2 hours and 17 minutes past the scheduled administration time. -- 06/17/21 - at 9:30 PM this was 1 hour and 30 minutes past the scheduled administration time. -- 06/18/21 - was administered on 06/19/21 at 1:39 AM this was 5 hours and 39 minutes past the scheduled administration time. -- 06/19/21 - at 11:14 PM this was 3 hours and 14 minutes past the scheduled administration time. -- 06/20/21 - at 9:53 PM this was 1 hour and 53 minutes past the scheduled administration time. -- 06/21/21 - at 9:28 PM this was 1 hour and 28 minutes past the scheduled administration time. -- 06/22/21 - at 9:12 PM this was 1 hour and 12 minutes past the scheduled administration time. -- 06/23/21 - at 10:24 PM this was 2 hours and 24 minutes past the scheduled administration time. -- 06/24/21 - at 9:30 PM this was 1 hour and 30 minutes past the scheduled administration time. -- 06/28/21 - at 9:17 PM this was 1 hour and 17 minutes past the scheduled administration time. Resident #47 Medical record contained an order for Lantus solution inject 14 units subcutaneous at bedtime related to Type II diabetes mellitus without complications. This medication was scheduled to be administered at 8:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 - at 9:25 PM this was 1 hour and 25 minutes past the scheduled administration time. -- 06/03/21 - at 9:28 PM this was 1 hour and 28 minutes past the scheduled administration time. -- 06/05/21 - at 9:28 PM this was 1 hour and 28 minutes past the scheduled administration time. -- 06/06/21 - at 9:38 PM this was 1 hour and 38 minutes past the scheduled administration time. -- 06/07/21 - at 10:03 PM this was 2 hours and 3 minutes past the scheduled administration time. -- 06/08/21 - was administered on 06/09/21 at 1:23 AM that was 5 hours and 23 minutes past the scheduled administration time -- 06/09/21 - was administered on 06/10/21 at 12:22 AM that was 4 hours and 22 minutes past the scheduled administration time. -- 06/10/21 - at 10:13 PM this was 2 hours and 13 minutes past the scheduled administration time. -- 06/15/21 - at 10:06 PM this was 2 hours and 6 minutes past the scheduled administration time. -- 06/16/21 - at 10:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/18/21 - was administered on 06/19/21 at 1:39 AM this was 5 hours and 39 minutes past the scheduled administration time. -- 06/19/21 - at 11:15 PM this was 3 hours and 15 minutes past the scheduled administration time. -- 06/20/21 - at 9:52 PM this was 1 hour and 52 minutes past the scheduled administration time. -- 06/21/21 - at 9:27 PM this was 1 hour and 27 minutes past the scheduled administration time. -- 06/22/21 - at 9:11 PM this was 1 hour and 11 minutes past the scheduled administration time. -- 06/23/21 - at 10:24 PM this was 2 hours and 24 minutes past the scheduled administration time. -- 06/24/21 - at 9:31 PM this was 1 hour and 31 minutes past the scheduled administration time. -- 06/28/21 - at 9:16 PM this was 1 hour and 16 minutes past the scheduled administration time. Resident #47 Medical record contained an order for Remeron tablet 15 milligrams by mouth one time a day related to major depressive disorder, recurrent severe psychotic symptoms. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/08/21 at 10:46 PM this was 1 hour and 46 minutes past the scheduled administration time. -- 06/09/21 was administered on 06/10/21 at 12:22 AM which was 3 hours and 22 minutes passed the scheduled administered time. -- 06/19/21 at 11:14 PM this was 2 hours and 14 minutes past the scheduled administration time. -- 06/23/21 at 10:24 PM this was 1 hour and 24 minutes past the scheduled administration time. An interview with the Director of Nursing (DON) (48) at 3:00 PM on 06/29/21 confirmed the above medications were administered late. She stated, when my managers help out they don't have a routine and are late administering the medications. b) Resident #32 Resident #32 Medical record contained an order for Novolog FlexPen solution Pen-injector 100 units/ml 20 units subcutaneous before meals for diabetes mellitus. This medication was scheduled to be administered at 8:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/02/21 at 9:48 AM this was 1 hour and 48 minutes past the scheduled administration time. -- 06/03/21 at 9:43 AM this was 1 hour and 43 minutes past the scheduled administration time. -- 06/04/21 at 12:33 PM this was 4 hours and 33 minutes past the scheduled administration time. -- 06/05/21 at 9:54 AM this was 1 hour and 54 minutes past the scheduled administration time. -- 06/06/21 at 10:10 AM this was 2 hours and 10 minutes past the scheduled administration time. -- 06/08/21 at 9:31 AM this was 1 hour and 31 minutes past the scheduled administration time. -- 06/09/21 at 9:25 AM this was 1 hour and 25 minutes past the scheduled administration time. -- 06/10/21 at 10:33 AM this was 2 hours and 33 minutes past the scheduled administration time. -- 06/13/21 at 10:21 AM this was 2 hours and 21 minutes past the scheduled administration time. -- 06/14/21 at 10:26 AM this was 2 hours and 26 minutes past the scheduled administration time. -- 06/16/21 at 10:19 AM this was 2 hours and 19 minutes past the scheduled administration time. -- 06/22/21 at 9:15 AM this was 1 hour and 15 minutes past the scheduled administration time. -- 06/26/21 at 10:33 AM this was 2 hours and 33 minutes past the scheduled administration time. -- 06/27/21 at 9:34 AM this was 1 hour and 34 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Novolog FlexPen solution Pen-injector 100 units/ml 20 units subcutaneous before meals for diabetes mellitus without complications. This medication was scheduled to be administered at 11:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 4 hours and 33 minutes past the scheduled administration time. -- 06/05/21 at 12:29 PM this was 1 hour and 30 minutes past the scheduled administration time. -- 06/10/21 at 1::49 PM this was 2 hours and 49 minutes past the scheduled administration time. -- 06/11/21 at 13:33 PM this was 2 hours and 33 minutes past the scheduled administration time. --06/12/21 at 12:32 PM this was 1 hour and 32 minutes past the scheduled administration time. -- 06/13/21 at 12:52 PM this was 1 hour and 52 minutes past the scheduled administration time. -- 06/14/21 at 1:27 PM this was 2 hours and 27 minutes past the scheduled administration time -- 06/16/21 at 2:29 PM this was 3 hours and 29 minutes past the scheduled administration time. -- 06/26/21 at 4:11 PM this was 5 hours and 11 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Novolog FlexPen solution Pen-injector 100 units/ml 20 units subcutaneous before meals for diabetes mellitus without complications. This medication was scheduled to be administered at 4:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 5:20 PM this was 1 hour and 20 minutes past the scheduled administration time. -- 06/10/21 at 5:42 PM this was 1 hour and 42 minutes past the scheduled administration time. -- 06/20/21 at 6:10 PM this was 2 hours and 10 minutes past the scheduled administration time. -- 06/23/21 at 6:40 PM this was 2 hours and 40 minutes past the scheduled administration time. -- 06/25/21 at 6:13 PM this was 2 hours and 13 minutes past the scheduled administration time. -- 06/28/21 at 6:02 PM this was 2 hours and 2 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Novolog FlexPen solution Pen-injector 100 units/ml 20 units subcutaneous at bedtime for diabetes mellitus without complications. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Proventil HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA) 2 puffs inhale orally two times a day for shortness of breath. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/13/21 at 10:35 AM this was 1 hour and 35 minutes past the scheduled administration time. -- 06/14/21 at 10:27 AM this was 1 hour and 27 minutes past the scheduled administration time. -- 06/16/21 at 10:20 AM this was 1 hours and 20 minutes past the scheduled administration time. -- 06/19/21 at 1:14 PM this was 4 hours and 14 minutes past the scheduled administration time. -- 06/26/21 at 10:34 AM this was 1 hours and 34 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Proventil HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA) 2 puffs inhale orally two times a day for shortness of breath. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time. -- 06/09/21 at 10:23 PM this was 1 hour and 23 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Depakote Tablet Delayed Release 250 mg by mouth two times a day related to other specified disorders of Brain Target behaviors, increased anxiety, withdraw, tearfulness, refusal of care. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 AM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/11/21 at 10:15 AM this was 1 hour and 15 minutes past the scheduled administration time. -- 06/13/21 at 10:40 AM this was 1 hour and 40 minutes past the scheduled administration time. -- 06/14/21 at 10:27 AM this was 1 hour and 27 minutes past the scheduled administration time. -- 06/16/21 at 10:19 AM this was 1 hour and 19 minutes past the scheduled administration time. -- 06/19/21 at 1:09 PM this was 4 hours and 9 minutes past the scheduled administration time. -- 06/26/21 at 10:33 AM this was 1 hour and 33 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Depakote Tablet Delayed Release 250 mg by mouth two times a day related to other specified disorders of Brain Target behaviors, increased anxiety, withdraw, tearfulness, refusal of care. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time. -- 06/09/21 at 10:23 PM this was 1 hour and 23 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Levemir Flex Touch Solution Pen-injector 100 units/ml Inject 43 units subcutaneous one time a day related to Type II diabetes mellitus without complications. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 PM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/26/21 at 10:33 PM this was 1 hour and 33 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Levemir Flex Touch Solution Pen-injector 100 units/ml Inject 71 units subcutaneous at bedtime for diabetes mellitus. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time. -- 06/09/21 at 10:23 PM this was 1 hour and 23 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for Prophylaxis. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/13/21 at 10:40 AM this was 1 hour and 40 minutes past the scheduled administration time. -- 06/14/21 at 10:27 AM this was 1 hour and 27 minutes past the scheduled administration time. -- 06/19/21 at 1:09 PM this was 4 hours and 9 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Dulera Aerosol 100-5 MCG/ACT 2 puffs inhale orally every 12 hours for COPD rinse mouth with water after use. No not swallow. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/4/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/13/21 at 10:40 AM this was 1 hour and 40 minutes past the scheduled administration time. -- 06/19/21 at 1:09 PM this was 3 hours and 9 minutes past the scheduled administration time. -- 06/26/21 at 10:33 AM this was 1 hour and 33 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Dulera Aerosol 100-5 MCG/ACT 2 puffs inhale orally every 12 hours for COPD rinse mouth with water after use. No not swallow. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Dexamethasone Tablet Give 4 mg by mouth one time a day related to other specified disorders of the brain. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/13/21 at 10:40 AM this was 1 hours and 40 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Omeprazole 20 MG capsule delayed release Give 1 capsule by mouth one time a day for GERD. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time -- 06/13/21 at 1:03 PM this was 4 hours and 3 minutes past the scheduled administration time -- 06/19/21 at 1:14 PM this was 4 hours and 14 minutes past the scheduled administration time Resident #32 Medical record contained an order for Ferrous Sulfate Tablet 325 MG Give 1 Tablet by mouth three times a day for anemia. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time -- 06/13/21 at 10:40 AM this was 1 hour and 40 minutes past the scheduled administration time -- 06/19/21 at 1:09 PM this was 4 hours and 9 minutes past the scheduled administration time -- 06/26/21 at 10:33 AM this was 1 hour and 33 minutes past the scheduled administration time Resident #32 Medical record contained an order for Ferrous Sulfate Tablet 325 MG Give 1 Tablet by mouth three times a day for anemia. This medication was scheduled to be administered at 2:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: --- 06/25/21 at 6:12 PM this was 4 hours and 12 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Ferrous Sulfate Tablet 325 MG Give 1 Tablet by mouth three times a day for anemia. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time Resident #32 Medical record contained an order for Methimazole Tablet 5 MG Give 1 tablet by mouth two times a day for Thyroid. This medication was scheduled to be administered at 9:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 16 minutes past the scheduled administration time -- 06/10/21 at 10:34 AM this was 1 hours and 34 minutes past the scheduled administration time -- 06/13/21 at 11:03 AM this was 2 hours and 3 minutes past the scheduled administration time -- 06/19/21 at 1:14 PM this was 4 hours and 14 minutes past the scheduled administration time Resident #32 Medical record contained an order for Methimazole Tablet 5 MG Give 1 tablet by mouth two times a day for Thyroid. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time -- 06/03/21 at 11:15 PM this was 2 hours and 15 minutes past the scheduled administration time -- 06/09/21 at 10:23 PM this was 1 hour and 23 minutes past the scheduled administration time Resident #32 Medical record contained an order for Lisinopril Tablet 20 MG Give 1 tablet by mouth one time a day for Hypertension This medication was scheduled to be administered at 9:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. --06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. --06/13/21 at 11:03 AM this was 2 hours and 3 minutes past the scheduled administration time. --06/14/21 at 10:27 AM this was 1 hour and 27 minutes past the scheduled administration time. --06/19/21 at 1:14 PM this was 4 hours and 14 minutes past the scheduled administration time. --06/26/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Levetiracetam Solution 100 mg/ml Give 5 ml by mouth two times a day for seizures. This medication was scheduled to be administered at 9:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. --06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. --06/13/21 at 11:03 AM this was 2 hours and 3 minutes past the scheduled administration time. --06/14/21 at 10:27 AM this was 1 hour and 27 minutes past the scheduled administration time. --06/19/21 at 1:14 PM this was 4 hours and 14 minutes past the scheduled administration time. --06/26/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Lipitor Tablet 40 MG Give 1 Tablet by mouth one time a day for Hyperlipidemia. This medication was scheduled to be administered at 9:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. --06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. --06/13/21 at 10:40 AM this was 2 hours and 40 minutes past the scheduled admi[TRUNCATED]

b) Resident #5 An observation on 06/23/21 at 2:10PM, found Resident #5's oxygen flow rate was set at 3 liters per minute (L/m) via nasal cannula (NC). A review of the residents record found a physicians order for oxygen to be running at 2L/m via nasal cannula. The latest change out for respiratory tubing was performed 06/23/21 by restorative Certified Nursing Assistant (CNA) #27. She changed the respiratory tubing and dated it appropriately on 06/23/21 but failed to change the humidified water bottle. The humidified water bottle was dated 06/16/21 and initialed by restorative CNA #59 from the last respiratory change out. An interview with the Director of Nursing (DON) #48 on 06/23/21 at 2:20PM , confirmed the oxygen was running at continuous 3L/m NC rather than the ordered continuous 2L/m as well as the discrepancy of the dates on the tubing and humified water bottle. c) Resident #9 An observation on 06/28/21 at 12:00 PM found Resident #9's oxygen flow rate was set at 2 liters via the nasal cannula (L/NC) An observation of Resident #9's flow meter on 06/28/21 at 12:35 PM with Licensed Practical Nurse ( LPN) #72 found the oxygen flow rate was set at 2L/NC. LPN #72 stated, oxygen should be at 3 Liters. LPN # 72 turned the oxygen up to 3L/NC at this time. A record review found a physician order dated 01/29/21 at 6:30 AM which read as follows, O2 at 3 LPM (Liters Per Minute) via NC continuous every shift. An interview on 06/29/21 at 1:55 PM with the Director of Nursing (DON) inquiring why Resident #9's oxygen was found on 2L/NC instead of 3L/NC as per order. The DON had no reason why it would be on a different flow rate. Based on observation, record review and staff interview the facility failed to maintain respiratory equipment within proper working order and administer oxygen at the correct liter flow rate setting as ordered for three (3) of three (3) residents reviewed for respiratory care. Residents #16, #5 and #9 were receiving Oxygen at an incorrect liter flow rate, oxygen concentrators were not properly maintained for Residents #16 and #5. Resident identifiers: #16, #5, #9. Facility census: 55. Findings included: a) Resident #16 During initial tour of the long-term care facility on 06/28/21 at 12:30 PM, Resident #16 was observed resting in bed, utilizing supplemental Oxygen (O2) via Nasal Cannula (NC) at 3 liters/minute (l/m). The oxygen concentrator was noted to be missing the knob that adjusted the liter flow. Resident stated she always used oxygen at 2 l/m. On 06/28/21 01:02 PM, Licensed Practical Nurse (LPN) #74 verified the O2 concentrator was on 3 l/m and should be 2 l/m via nasal canula. LPN #74 also confirmed the O2 Concentrator was missing the control knob used to adjust liter flow and stated the resident may have turned it (liter flow adjustment knob) herself and tore it off. LPN #74 stated he would switch out the concentrator immediately and ensure the correct liter flow was implemented. Record review indicated an active order with effective date of 5/12/21 for continuous Oxygen to be administered at 2 l/m via nasal canula. .

. Based on observation, record review and staff interview, the facility failed to ensure nursing staff were competent to administer medications timely and safely. This practice had the potential to affect more than an isolated number of residents. Resident Identifiers: #47, #33, #51, and #32. Facility Census: 55. Findings included: a) Resident #47- Late Medication Administration A review of Resident #47's medical record found a physicians order for Lantus Solution 100 unit/ml (milliliters) inject 27 units subcutaneous one time a day related to Type II diabetes mellitus without complications. This medication was scheduled to be administered at 7:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 9:45 AM this was 2 hours and 45 minutes past the scheduled administration time. -- 06/06/21 at 10:12 AM this was 3 hours and 12 minutes past the scheduled administration time. -- 06/08/21 at 8:54 AM this was 1 hour and 54 minutes past the scheduled administration time. -- 06/11/21 at 8:48 AM this was 1 hour and 48 minutes past the scheduled administration time. -- 06/18/21 at 9:52 AM this was 2 hours and 52 minutes past the scheduled administration time. -- 06/19/21 at 9:44 AM this was 2 hours and 44 minutes past the scheduled administration time -- 06/20/21 at 9:47 AM this was 2 hours and 47 minutes past the scheduled administration time. -- 06/22/21 at 9:55 AM this was 2 hours and 55 minutes past the scheduled administration time. -- 06/24/21 at 9:37 AM this was 2 hours and 37 minutes past the scheduled administration time. Resident #47 Medical record contained an order for Prilosec capsule delayed release 40 milligrams, give one capsule one time a day for GERD (Gastroesphogial Reflux Disease). This medication was scheduled to be administered at 9:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/06/21 at 10:12am this was 1 hour and 12 minutes past the scheduled administration time. -- 06/13/21 at 10:32am this was 1 hour and 32 minutes past the scheduled administration time. -- 06/16/21 at 10:37am this was 1 hour and 37 minutes past the scheduled administration time. Resident #47 Medical record contained an order for Flonase suspension 50 mcg/act 1 spray in each nostril two times a day for allergies. This medication was scheduled to be administered at 6:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/11/21 - dose documented as administered on 6/29/21 at 10:22am this was 18 days after it was scheduled to be administered. -- 06/15/21 - dose documented as administered on 6/29/21 at 10:23am this was 14 days after it was scheduled to be administered. Resident #47 Medical record contained an order for Lamictal 150 mg by mouth two times a day related to unspecified psychosis. This medication was scheduled to be administered at 6:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/11/21 - dose documented as administered on 6/29/21 at 10:22am this was 18 days after it was scheduled to be administered. -- 06/15/21 - dose documented as administered on 6/29/21 at 10:23am this was 14 days after it was scheduled to be administered. Resident #47 Medical record contained an order for Lamictal 25 mg by mouth two times a day related to unspecified psychosis. This medication was scheduled to be administered at 6:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/11/21 - dose documented as administered on 6/29/21 at 10:22 AM this was 18 days after it was scheduled to be administered. -- 06/15/21 - dose documented as administered on 6/29/21 at 10:23 AM this was 14 days after it was scheduled to be administered. Resident #47 Medical record contained an order for Norco tablet 7.5/325 mg one tablet by mouth every 6 hours for pain. This medication was scheduled to be administered at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 - at 3:56 AM this was 3 hours and 56 minutes past the scheduled administration time. -- 06/02/21 - at 2:46 AM this was 2 hours and 46 minutes past the scheduled administration time. -- 06/03/21 - at 5:26 AM this was 5 hours and 26 minutes past the scheduled administration time. -- 06/04/21 - at 2:24 AM this was 2 hours and 24 minutes past the scheduled administration time. -- 06/06/21 - at 1:50 AM this was 1 hour and 50 minutes past the scheduled administration time. -- 06/11/21 - at 5:07 AM this was 5 hours and 7 minutes past the scheduled administration time. -- 06/11/21 - dose documented as administered on 6/29/21 at 10:22 AM this was 18 days after it was scheduled to be administered. -- 06/15/21 - dose documented as administered on 6/29/21 at 10:23 AM this was 14 days after it was scheduled to be administered. -- 06/16/21 - at 6:01 AM this was 6 hours and 1 minutes past the scheduled administration time. -- 06/19/21 - at 1:39 AM this was 1 hour and 39 minutes past the scheduled administration time. -- 06/21/21 - at 5:14 AM this was 5 hours and 14 minutes past the scheduled administration time. -- 06/22/21 - at 1:44 PM this was 1 hour and 44 minutes past the scheduled administration time. On 06/03/21, 06/11/21, 06/16/21 and 06/21/21 Resident #47 received her 12:00 AM dose of Norco within one hour of receiving her 6:00 AM dose of Norco. Resident #47 Medical record contained an order for Zyprexa give 10mg by mouth at bedtime related to major depressive disorder, severe with psychotic symptoms. This medication was scheduled to be administered at 8:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 - at 9:26 PM this was 1 hour and 26 minutes past the scheduled administration time. -- 06/03/21 - at 9:28 PM this was 1 hour and 28 minutes past the scheduled administration time. -- 06/05/21 - at 9:29 PM this was 1 hour and 29 minutes past the scheduled administration time. -- 06/06/21 - at 9:38 PM this was 1 hour and 38 minutes past the scheduled administration time. -- 06/07/21 - at 10:02 PM this was 2 hours and 2 minutes past the scheduled administration time. -- 06/08/21 - at 10:45 PM this was 2 hours and 45 minutes past the scheduled administration time. -- 06/09/21 - was administered on 06/10/21 at 12:22 AM that was 4 hours and 22 minutes past the scheduled administration time. -- 06/10/21 - at 10:06 PM this was 2 hours and 6 minutes past the scheduled administration time. -- 06/14/21 - at 9:48 PM this was 1 hour and 48 minutes past the scheduled administration time. -- 06/16/21 - at 10:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/17/21 - at 9:30 PM this was 1 hour and 30 minutes past the scheduled administration time. -- 06/18/21 - was administered on 06/19/21 at 1:39 AM this was 5 hours and 39 minutes past the scheduled administration time. -- 06/19/21 - at 11:15 PM this was 3 hours and 15 minutes past the scheduled administration time. -- 06/20/21 - at 9:52 PM this was 1 hour and 52 minutes past the scheduled administration time. -- 06/21/21 - at 9:27 PM this was 1 hour and 27 minutes past the scheduled administration time. -- 06/23/21 - at 10:23 PM this was 2 hours and 23 minutes past the scheduled administration time. -- 06/24/21 - at 9:30 PM this was 1 hour and 30 minutes past the scheduled administration time. Resident #47 Medical record contained an order for Trazadone give 50 mg by mouth at bedtime related to major depressive disorder, severe with psychotic symptoms. This medication was scheduled to be administered at 8:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 - at 9:26 PM this was 1 hour and 26 minutes past the scheduled administration time. -- 06/03/21 - at 9:54 PM this was 1 hour and 54 minutes past the scheduled administration time. -- 06/05/21 - at 9:29 PM this was 1 hour and 29 minutes past the scheduled administration time. -- 06/06/21 - at 9:38 PM this was 1 hour and 38 minutes past the scheduled administration time. -- 06/07/21 - at 10:04 PM this was 2 hours and 4 minutes past the scheduled administration time. -- 06/08/21 - at 10:46 PM this was 2 hours and 46 minutes past the scheduled administration time. -- 06/09/21 - was administered on 06/10/21 at 12:22 AM that was 4 hours and 22 minutes past the scheduled administration time. -- 06/10/21 - at 10:06 PM this was 2 hours and 6 minutes past the scheduled administration time. -- 06/14/21 - at 9:58 PM this was 1 hour and 58 minutes past the scheduled administration time. -- 06/16/21 - at 10:17 PM this was 2 hours and 17 minutes past the scheduled administration time. -- 06/17/21 - at 9:30 PM this was 1 hour and 30 minutes past the scheduled administration time. -- 06/18/21 - was administered on 06/19/21 at 1:39 AM this was 5 hours and 39 minutes past the scheduled administration time. -- 06/19/21 - at 11:14 PM this was 3 hours and 14 minutes past the scheduled administration time. -- 06/20/21 - at 9:53 PM this was 1 hour and 53 minutes past the scheduled administration time. -- 06/21/21 - at 9:28 PM this was 1 hour and 28 minutes past the scheduled administration time. -- 06/22/21 - at 9:12 PM this was 1 hour and 12 minutes past the scheduled administration time. -- 06/23/21 - at 10:24 PM this was 2 hours and 24 minutes past the scheduled administration time. -- 06/24/21 - at 9:30 PM this was 1 hour and 30 minutes past the scheduled administration time. -- 06/28/21 - at 9:17 PM this was 1 hour and 17 minutes past the scheduled administration time. Resident #47 Medical record contained an order for Lantus solution inject 14 units subcutaneous at bedtime related to Type II diabetes mellitus without complications. This medication was scheduled to be administered at 8:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 - at 9:25 PM this was 1 hour and 25 minutes past the scheduled administration time. -- 06/03/21 - at 9:28 PM this was 1 hour and 28 minutes past the scheduled administration time. -- 06/05/21 - at 9:28 PM this was 1 hour and 28 minutes past the scheduled administration time. -- 06/06/21 - at 9:38 PM this was 1 hour and 38 minutes past the scheduled administration time. -- 06/07/21 - at 10:03 PM this was 2 hours and 3 minutes past the scheduled administration time. -- 06/08/21 - was administered on 06/09/21 at 1:23 AM that was 5 hours and 23 minutes past the scheduled administration time -- 06/09/21 - was administered on 06/10/21 at 12:22 AM that was 4 hours and 22 minutes past the scheduled administration time. -- 06/10/21 - at 10:13 PM this was 2 hours and 13 minutes past the scheduled administration time. -- 06/15/21 - at 10:06 PM this was 2 hours and 6 minutes past the scheduled administration time. -- 06/16/21 - at 10:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/18/21 - was administered on 06/19/21 at 1:39 AM this was 5 hours and 39 minutes past the scheduled administration time. -- 06/19/21 - at 11:15 PM this was 3 hours and 15 minutes past the scheduled administration time. -- 06/20/21 - at 9:52 PM this was 1 hour and 52 minutes past the scheduled administration time. -- 06/21/21 - at 9:27 PM this was 1 hour and 27 minutes past the scheduled administration time. -- 06/22/21 - at 9:11 PM this was 1 hour and 11 minutes past the scheduled administration time. -- 06/23/21 - at 10:24 PM this was 2 hours and 24 minutes past the scheduled administration time. -- 06/24/21 - at 9:31 PM this was 1 hour and 31 minutes past the scheduled administration time. -- 06/28/21 - at 9:16 PM this was 1 hour and 16 minutes past the scheduled administration time. Resident #47 Medical record contained an order for Remeron tablet 15 milligrams by mouth one time a day related to major depressive disorder, recurrent severe psychotic symptoms. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/08/21 at 10:46 PM this was 1 hour and 46 minutes past the scheduled administration time. -- 06/09/21 was administered on 06/10/21 at 12:22 AM which was 3 hours and 22 minutes passed the scheduled administered time. -- 06/19/21 at 11:14 PM this was 2 hours and 14 minutes past the scheduled administration time. -- 06/23/21 at 10:24 PM this was 1 hour and 24 minutes past the scheduled administration time. An interview with the Director of Nursing (DON) (48) at 3:00 PM on 06/29/21 confirmed the above medications were administered late. She stated, when my managers help out they don't have a routine and are late administering the medications. b) Resident #32 Resident #32 Medical record contained an order for Novolog FlexPen solution Pen-injector 100 units/ml 20 units subcutaneous before meals for diabetes mellitus. This medication was scheduled to be administered at 8:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/02/21 at 9:48 AM this was 1 hour and 48 minutes past the scheduled administration time. -- 06/03/21 at 9:43 AM this was 1 hour and 43 minutes past the scheduled administration time. -- 06/04/21 at 12:33 PM this was 4 hours and 33 minutes past the scheduled administration time. -- 06/05/21 at 9:54 AM this was 1 hour and 54 minutes past the scheduled administration time. -- 06/06/21 at 10:10 AM this was 2 hours and 10 minutes past the scheduled administration time. -- 06/08/21 at 9:31 AM this was 1 hour and 31 minutes past the scheduled administration time. -- 06/09/21 at 9:25 AM this was 1 hour and 25 minutes past the scheduled administration time. -- 06/10/21 at 10:33 AM this was 2 hours and 33 minutes past the scheduled administration time. -- 06/13/21 at 10:21 AM this was 2 hours and 21 minutes past the scheduled administration time. -- 06/14/21 at 10:26 AM this was 2 hours and 26 minutes past the scheduled administration time. -- 06/16/21 at 10:19 AM this was 2 hours and 19 minutes past the scheduled administration time. -- 06/22/21 at 9:15 AM this was 1 hour and 15 minutes past the scheduled administration time. -- 06/26/21 at 10:33 AM this was 2 hours and 33 minutes past the scheduled administration time. -- 06/27/21 at 9:34 AM this was 1 hour and 34 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Novolog FlexPen solution Pen-injector 100 units/ml 20 units subcutaneous before meals for diabetes mellitus without complications. This medication was scheduled to be administered at 11:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 4 hours and 33 minutes past the scheduled administration time. -- 06/05/21 at 12:29 PM this was 1 hour and 30 minutes past the scheduled administration time. -- 06/10/21 at 1::49 PM this was 2 hours and 49 minutes past the scheduled administration time. -- 06/11/21 at 13:33 PM this was 2 hours and 33 minutes past the scheduled administration time. --06/12/21 at 12:32 PM this was 1 hour and 32 minutes past the scheduled administration time. -- 06/13/21 at 12:52 PM this was 1 hour and 52 minutes past the scheduled administration time. -- 06/14/21 at 1:27 PM this was 2 hours and 27 minutes past the scheduled administration time -- 06/16/21 at 2:29 PM this was 3 hours and 29 minutes past the scheduled administration time. -- 06/26/21 at 4:11 PM this was 5 hours and 11 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Novolog FlexPen solution Pen-injector 100 units/ml 20 units subcutaneous before meals for diabetes mellitus without complications. This medication was scheduled to be administered at 4:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 5:20 PM this was 1 hour and 20 minutes past the scheduled administration time. -- 06/10/21 at 5:42 PM this was 1 hour and 42 minutes past the scheduled administration time. -- 06/20/21 at 6:10 PM this was 2 hours and 10 minutes past the scheduled administration time. -- 06/23/21 at 6:40 PM this was 2 hours and 40 minutes past the scheduled administration time. -- 06/25/21 at 6:13 PM this was 2 hours and 13 minutes past the scheduled administration time. -- 06/28/21 at 6:02 PM this was 2 hours and 2 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Novolog FlexPen solution Pen-injector 100 units/ml 20 units subcutaneous at bedtime for diabetes mellitus without complications. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Proventil HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA) 2 puffs inhale orally two times a day for shortness of breath. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/13/21 at 10:35 AM this was 1 hour and 35 minutes past the scheduled administration time. -- 06/14/21 at 10:27 AM this was 1 hour and 27 minutes past the scheduled administration time. -- 06/16/21 at 10:20 AM this was 1 hours and 20 minutes past the scheduled administration time. -- 06/19/21 at 1:14 PM this was 4 hours and 14 minutes past the scheduled administration time. -- 06/26/21 at 10:34 AM this was 1 hours and 34 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Proventil HFA Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate HFA) 2 puffs inhale orally two times a day for shortness of breath. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time. -- 06/09/21 at 10:23 PM this was 1 hour and 23 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Depakote Tablet Delayed Release 250 mg by mouth two times a day related to other specified disorders of Brain Target behaviors, increased anxiety, withdraw, tearfulness, refusal of care. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 AM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/11/21 at 10:15 AM this was 1 hour and 15 minutes past the scheduled administration time. -- 06/13/21 at 10:40 AM this was 1 hour and 40 minutes past the scheduled administration time. -- 06/14/21 at 10:27 AM this was 1 hour and 27 minutes past the scheduled administration time. -- 06/16/21 at 10:19 AM this was 1 hour and 19 minutes past the scheduled administration time. -- 06/19/21 at 1:09 PM this was 4 hours and 9 minutes past the scheduled administration time. -- 06/26/21 at 10:33 AM this was 1 hour and 33 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Depakote Tablet Delayed Release 250 mg by mouth two times a day related to other specified disorders of Brain Target behaviors, increased anxiety, withdraw, tearfulness, refusal of care. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time. -- 06/09/21 at 10:23 PM this was 1 hour and 23 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Levemir Flex Touch Solution Pen-injector 100 units/ml Inject 43 units subcutaneous one time a day related to Type II diabetes mellitus without complications. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 PM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/26/21 at 10:33 PM this was 1 hour and 33 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Levemir Flex Touch Solution Pen-injector 100 units/ml Inject 71 units subcutaneous at bedtime for diabetes mellitus. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time. -- 06/09/21 at 10:23 PM this was 1 hour and 23 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for Prophylaxis. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/13/21 at 10:40 AM this was 1 hour and 40 minutes past the scheduled administration time. -- 06/14/21 at 10:27 AM this was 1 hour and 27 minutes past the scheduled administration time. -- 06/19/21 at 1:09 PM this was 4 hours and 9 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Dulera Aerosol 100-5 MCG/ACT 2 puffs inhale orally every 12 hours for COPD rinse mouth with water after use. No not swallow. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/4/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/13/21 at 10:40 AM this was 1 hour and 40 minutes past the scheduled administration time. -- 06/19/21 at 1:09 PM this was 3 hours and 9 minutes past the scheduled administration time. -- 06/26/21 at 10:33 AM this was 1 hour and 33 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Dulera Aerosol 100-5 MCG/ACT 2 puffs inhale orally every 12 hours for COPD rinse mouth with water after use. No not swallow. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time. -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Dexamethasone Tablet Give 4 mg by mouth one time a day related to other specified disorders of the brain. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. -- 06/13/21 at 10:40 AM this was 1 hours and 40 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Omeprazole 20 MG capsule delayed release Give 1 capsule by mouth one time a day for GERD. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time -- 06/13/21 at 1:03 PM this was 4 hours and 3 minutes past the scheduled administration time -- 06/19/21 at 1:14 PM this was 4 hours and 14 minutes past the scheduled administration time Resident #32 Medical record contained an order for Ferrous Sulfate Tablet 325 MG Give 1 Tablet by mouth three times a day for anemia. This medication was scheduled to be administered at 9:00AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. -- 06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time -- 06/13/21 at 10:40 AM this was 1 hour and 40 minutes past the scheduled administration time -- 06/19/21 at 1:09 PM this was 4 hours and 9 minutes past the scheduled administration time -- 06/26/21 at 10:33 AM this was 1 hour and 33 minutes past the scheduled administration time Resident #32 Medical record contained an order for Ferrous Sulfate Tablet 325 MG Give 1 Tablet by mouth three times a day for anemia. This medication was scheduled to be administered at 2:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: --- 06/25/21 at 6:12 PM this was 4 hours and 12 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Ferrous Sulfate Tablet 325 MG Give 1 Tablet by mouth three times a day for anemia. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time -- 06/03/21 at 11:25 PM this was 2 hours and 25 minutes past the scheduled administration time Resident #32 Medical record contained an order for Methimazole Tablet 5 MG Give 1 tablet by mouth two times a day for Thyroid. This medication was scheduled to be administered at 9:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 16 minutes past the scheduled administration time -- 06/10/21 at 10:34 AM this was 1 hours and 34 minutes past the scheduled administration time -- 06/13/21 at 11:03 AM this was 2 hours and 3 minutes past the scheduled administration time -- 06/19/21 at 1:14 PM this was 4 hours and 14 minutes past the scheduled administration time Resident #32 Medical record contained an order for Methimazole Tablet 5 MG Give 1 tablet by mouth two times a day for Thyroid. This medication was scheduled to be administered at 9:00 PM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/01/21 at 11:16 PM this was 2 hours and 16 minutes past the scheduled administration time -- 06/03/21 at 11:15 PM this was 2 hours and 15 minutes past the scheduled administration time -- 06/09/21 at 10:23 PM this was 1 hour and 23 minutes past the scheduled administration time Resident #32 Medical record contained an order for Lisinopril Tablet 20 MG Give 1 tablet by mouth one time a day for Hypertension This medication was scheduled to be administered at 9:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. --06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. --06/13/21 at 11:03 AM this was 2 hours and 3 minutes past the scheduled administration time. --06/14/21 at 10:27 AM this was 1 hour and 27 minutes past the scheduled administration time. --06/19/21 at 1:14 PM this was 4 hours and 14 minutes past the scheduled administration time. --06/26/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Levetiracetam Solution 100 mg/ml Give 5 ml by mouth two times a day for seizures. This medication was scheduled to be administered at 9:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. --06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. --06/13/21 at 11:03 AM this was 2 hours and 3 minutes past the scheduled administration time. --06/14/21 at 10:27 AM this was 1 hour and 27 minutes past the scheduled administration time. --06/19/21 at 1:14 PM this was 4 hours and 14 minutes past the scheduled administration time. --06/26/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. Resident #32 Medical record contained an order for Lipitor Tablet 40 MG Give 1 Tablet by mouth one time a day for Hyperlipidemia. This medication was scheduled to be administered at 9:00 AM daily. A review of the Medication Administration Audit Report found this medication was administered late on the following occasions: -- 06/04/21 at 12:33 PM this was 3 hours and 33 minutes past the scheduled administration time. --06/10/21 at 10:34 AM this was 1 hour and 34 minutes past the scheduled administration time. --0[TRUNCATED]

Based on record review and staff interview, the facility failed to follow procedures to ensure the accurate administration and documentation of medications per physicians orders. Additionally, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and to determine that drug records are in order and an account of all controlled drugs is maintained and periodically reconciled. This was true for three (3) of 14 sampled Residents, and had the potential to affect more than an isolated number of residents. Resident Identifiers: #51, #33 and #47. Resident Census 55. Findings included: a) Resident #51 A review of Resident #51 medical record on 06/30/21 at 9:15 AM found an order for Norco 5-325 mg give 1 tablet by mouth every six hours as needed for pain. Review of the controlled substance log for the Norco for the month of 06/2021 and the medication administration record (MAR) for the month of 06/2021 found on the following dates and times Resident #51's Norco was signed out on the controlled substance log but not documented as administered on the MAR: -- 06/02/21 at 9:00 PM -- 06/04/21 at 9:00 PM --06/07/21 at 9:00 PM --06/09/21 at 9:00 PM -- 06/10/21 at 9:00 PM -- 06/13/21 at 9:00 PM -- 06/14/21 at 9:00 PM -- 06/16/21 at 10:00 PM -- 06/17/21 at 9:00 PM -- 06/21/21 at 9:00 PM An interview with the Director of Nursing (DON) at 9:41 AM on 06/30/21 confirmed the above doses of Norco was signed out on the controlled substance log but was not documented on the MAR. She indicated the proper procedure was for them to sign both the controlled substance log and the MAR. b) Resident #33 A review of Resident #33 medical record on 06/30/21 at 9:15 AM found an order for Oxycodone IR Tab 5 mg 1 tablet by mouth every eight hours as needed for pain. Review of the controlled substance log for the Oxycodone for the month of 06/2021 and the medication administration record (MAR) for the month of 06/2021 found on the following dates and times Resident #33's Oxycodone was signed out on the controlled substance log but not documented as administered on the MAR: --06/07/21 at 9:30 PM --06/08/21 at 9:00 PM --06/11/21 at 9:00 PM --06/19/21 at 8:00 PM --06/20/21 at 8:30 PM --06/21/21 at 4:14 PM --06/25/21 at 9:00 PM --06/27/21 at 11:00 AM An interview with the Director of Nursing (DON) at 9:41 AM on 06/30/21 confirmed the above doses of Norco was signed out on the controlled substance log but was not documented on the MAR. She indicated the proper procedure was for them to sign both the controlled substance log and the MAR. c) Resident #47 A record review of Resident #47's medical record in the morning of 06/29/21 found on the medication administration record on 06/11/21 and 06/15/21 there were multiple medications which the nurse did not initial as being administered. A copy of the MAR was requested from the administration staff in the afternoon of 06/29/21. When the staff provided the MAR the previous blanks were initialed to indicate the medication was given. The initials on those dates belonged to Licensed Practical Nurse (LPN) #49. A review of the Medication Administration Audit Report found LPN #49 documented the following medications which were scheduled to be administered on 06/11/21 and 06/15/21 respectively were documented as administered on 06/29/21 between the times of 10:22 AM and 10:23 AM: --Senna Plus scheduled at 6:00 PM on 06/11/21 and 06/15/21 --Flonase Suspension scheduled at 6:00 PM on 06/11/21 and 06/15/21 --Norco Tablet scheduled at 6:00 PM on 06/11/21 and 06/15/21 --Lamictal Tablet scheduled at 6:00 PM on 06/11/21 and 06/15/21 During an interview with LPN #49 on 06/29/21 at 2:20 PM when asked if she administered the aforementioned medications she stated, we were working together and I initialed the MARs for the medications while another nurse prepared and administered the medications. When asked how she knew the other nurse administered the medications LPN #49 stated, she goes down the hall with the medications in a cup and when she comes back, the cup is empty. During an interview with the DON on 06/29/21 at 2:10 PM when asked how long after medication administration can a nurse document the administration on the MAR she stated, they have up to 30 days. A review of the facilities policy title Medication Administration: Policy 5.3 General Guidelines for Medication Administration found the following in regards to medication administration. . 14. Return to the medication cart and document medication administration with initials on the Medication Administration Record (MAR) immediately after administering medication to each resident d) Narcotic Count An observation, on 06/29/21 at 12:10 PM, of the Narcotic Count Sheets, for 04/6/21 through 04/22/21 and 05/05/21 through 05/23/21, revealed that on the following dates the sheets were not signed by two (2) licensed nurses: -- 04/10/21 for the 6 AM-6 PM shift. -- 04/14/21 for the 6 AM-6 PM shift and the 6 PM-6 AM shift. -- 04/15/21 for the 6 AM-6 PM shift and the 6 PM-6 AM shift. -- 04/16/21 for the 6 AM-6 PM shift and the 6 PM-6 AM shift. -- 05/19/21 for the 6 AM-6 PM shift. -- 05/23/21 for the 6 AM-6 PM shift. There was an entry on the sheet appearing under the 05/23/21 entry which was not dated nor signed by two (2) licensed nurses. On 06/29/21 at 12:15 PM, Licensed Practical Nurse (LPN) # 45 stated during an interview it is the facility's policy for two nurses to sign off at the end of each shift on the Narcotic Count Sheets. LPN # 45 verified the Narcotic Count sheets showed several days with out two (2) nurses signatures at the end of each shift. A facility policy, titled Controlled Substance Administration and Accountability, implemented on 11/27/17 and reviewed/revised on 09/09/20, under Section 7.a., Inventory Verification, reads: Two licensed nurses account for all controlled substances and access keys at the end of each shift. An interview, on 06/29/21 at 12:40 PM, with the Director of Nursing (DON), confirmed there were several times the Narcotic Count Sheets were not double signed per the facility policy. The DON stated as nurses, you wouldn't give the keys to the next nurse unless the narcotics were counted. The DON had no other process to verify or show the narcotic count was correct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to provide record keeping; monitoring for medication expiration dates; and steps for replenishing used medications. This had the potential to affect a limited number of residents living at the facility. Facility Census: 55 Findings Included: a) Medication Storage and Labeling An observation with Registered Nurse (RN) #11 and RN #69, on [DATE] at 10:35 AM, of the medication refrigerator in the locked medication room showed the Purified Protein Derivative (PPD) bag, holding the PPD vials, marked with an opened date of [DATE]. The two (2) individual vials contained in the bag were opened and not dated. CMS GUIDANCE, §483.45(g), Labeling of Drugs and Biologicals, and §483.45(h), Storage of Drugs and Biologicals, states: If a multi-dose vial has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Further observation of the locked medication room showed, per the label on the vial, the narcan in the locked emergency box expired on 11/2020. There was no process in place to indicate when the medications would expire or what medications had been used within the locked emergency medication box. RN #11 and RN #69 were unable to identify facility policies or processes regarding identification and/or monitoring of expiring medications. An interview with the Director of Nursing (DON), on [DATE] at 11:31 AM, regarding the process for monitoring expiring medications in the emergency medication box and the medication refrigerator, confirmed the pharmacy goes through and makes sure everything is dated and not expired. When asked what process was in place to ensure that pharmacy was doing this, the DON had no answer. .