Every finding on record at Cedar Healthcare Center

Based on interview and record review, it was determined that the facility failed to ensure that the facility acted upon provider approved recommendations that were identified by the pharmacist during the monthly Pharmacy Medication Regimen Review for 1 of 5 residents reviewed for unnecessary medications in a final sample of 18 residents. (Resident Identifier is #61). Findings include: Review on 6/25/25 of Resident #61's Pharmacy Review dated 3/13/25 revealed a recommendation to the physician/prescriber to Please consider ordering a serum Vitamin D 25-OH level (25-hydroxyvitamin D). Further review revealed that Yes, order a serum Vitamin D 25-OH level was checked in the affirmative and signed/dated by Staff A (Advanced Practice Registered Nurse) on 3/19/25. Review on 6/25/25 of Resident #61's medical record revealed there was no documentation that the above test had been completed. Interview on 6/25/25 at 2:20 p.m. with Staff B (Unit Manager) confirmed the above test was not completed. Interview on 6/25/25 at 2:58 p.m. with Staff A revealed that he/she had agreed to the above pharmacy recommendation and was not aware that it had not been done. Review on 6/25/25 of the facility's policy titled Medication Regimen Review revised on 4/10/25 revealed, . 1. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication . 7 .f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on record review and interview, it was determined that the facility failed to implement smoking policies for 1 of 2 residents reviewed for smoking in a final sample of 22 residents (Resident Identifier #66). Findings include: Review on 5/7/24 of the facility's list of residents who smoke revealed that Resident #66 was identified as a smoker by the facility. Review on 5/7/24 of Resident #66's medical record revealed that Resident #66 was admitted to the facility on [DATE]. Review on 5/7/24 of Resident #66's medical record revealed Resident #66 did not have a smoking assessment to assess for safety of smoking. Further review revealed there was no care plan for smoking. Review on 5/7/24 of the facility's binder titled Vape and Lighter Log revealed that Resident #66 had been signed out to smoke on the following dates: 4/26/24, 4/28/24, 5/1/24, 5/4/24, 5/6/24 and 5/7/24. Interview on 5/7/24 at approximately 11:27 a.m. with Resident #66 revealed that he/she does smoke outside and that staff keep the lighters at the nursing station. Further interview with Resident #66 revealed that cigarettes are kept in his/her room. Interview on 5/7/24 at approximately 11:30 a.m. with Staff A (Unit Manager) confirmed that Resident #66 smokes and that the lighters are kept at the nursing station. Further interview with Staff A confirmed that Resident #66 was not assessed for safety with smoking. Review on 5/8/24 of facility's policy titled Resident Smoking review and revision date 4/30/24, revealed under Policy Explanation and Compliance Guidelines . #7. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment . #8. Residents will smoke in accordance with his/her care plan.

Based on interview and record review, it was determined that the facility failed to ensure their arbitration agreement contained all the necessary elements for 3 of 3 residents reviewed for binding arbitration in a final sample of 22 (Resident Identifiers are #60, #66, and #83). Findings include: Review on 5/8/24 of Resident #60, #66, and #83's signed arbitration agreements revealed that the agreements did not grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing it and did not explicitly state that neither the resident nor his/her representative is required to sign an agreement for binding arbitration as a condition of admission. Interview on 5/8/24 at approximately 12:33 p.m. with Staff B (Regional Director of Operations) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure that the arbitration agreement provided for the selection of a venue that is convenient to both parties for 3 of 3 residents reviewed for binding arbitration in a final sample of 22 residents (Resident Identifiers are #60, #66, and #83). Findings include: Review on 5/8/24 of Resident #60, #66, and #83's signed arbitration agreements revealed that the agreement did not provide for the selection of a venue that is convenient to both parties. Interview on 5/8/24 at approximately 11:18 a.m. with Staff C (Regional Nurse) confirmed the above findings. Interview on 5/8/24 at approximately 12:33 p.m. with Staff B (Regional Director of Operations) confirmed the above findings.

Based on observation, interview, and record review it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards for 1 of 2 residents reviewed for smoking in a final sample of 27 residents (Resident Identifier is #3). Findings include: Review on 5/12/23 of Resident #3's care plan revealed that Resident #3 smokes independently, and has the following interventions in place: 1. Educate and remind to keep smoking materials in a safe place. 3. Educate and remind of center policy and expectations. 4. Re-enforce that no smoking is allowed in the building. Review on 5/12/23 of Resident #3's smoking assessment dated [DATE] revealed that Resident #3 was assessed to smoke independently and is aware of the facility's smoking policy. Review on 5/12/23 of section C of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/14/23 revealed that Resident #3 has a Brief Interview of Mental Status (BIMS) of a 14 indicating that Resident #3 is cognitively intact. Observation on 5/12/23 at approximately 11:50 a.m. of Resident #3's room revealed an electronic cigarette on Resident #3's bedside table. Interview on 5/12/23 at approximately 11:52 a.m. with Resident #3 who stated that he/she keeps a lighter in the bedside table drawer and charges the electronic cigarette on top on the bedside table. Interview on 5/12/23 at approximately 11:55 a.m. with Staff C (Director of Nursing) revealed that residents who were assessed to smoke independently may keep cigarettes in their room but may not keep lighters or electronic cigarettes. Observation on 5/12/23 at approximately 12:00 p.m. with Staff C of Resident #3's bedside table drawer contents revealed a lighter and on top of the bedside table, an electronic cigarette. Review of the facility smoking policy titled Resident Smoking revised on 8/1/21 .Policy Explanation and Compliance Guidelines: Number 4 .Electronic cigarettes will be treated the same as any other smoking product. Interview on 5/12/23 at approximately 1:49 p.m. with Staff D (Front Desk Receptionist) confirmed that resident's smoking materials are supposed to be kept in a lock box behind the reception desk and residents stop and pick up their lighters and smoking materials prior to going outside. Staff D further confirmed that if the receptionist is away from the desk, residents do come back into the facility and go to their rooms with their smoking materials.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure eye medications were labeled with open expiration dates and that expired medications were removed from use on 1 of 3 medication carts and 1 of 2 medication rooms observed (Resident Identifier is #44). Findings include: Observation on 5/10/23 at 8:45 a.m. of the Bay Unit medication room with Staff E (Licensed Practical Nurse) revealed 6 packets of Hydrocortisone 1 percent (%) cream with an expiration date of 11/2022 available for use on Bay Unit. Interview on 5/10/23 at 8:45 a.m. with Staff E confirmed the above finding. 46654 Observation on 5/10/23 at approximately 9:27 a.m. of the Strawberry Cove Medication Cart revealed the following opened eye medications for Resident #44 without an open date or an open expiration date: Latanoprost Ophthalmic Solution 0.005% Interview on 5/10/23 at approximately 9:27 a.m with Staff A (Registered Nurse) and Staff B (Licened Practical Nurse) confirmed the above findings. Record review on 5/11/23 of Resident #44's physican orders revealed the following: Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in right eye at bedtime for eye. Start date 1/30/2023. Review on 5/11/23 of Resident #44's Medication Administration Record for May 2023 revealed the resident had recieved Latanoprost Ophthalmic Solution 0.005% daily. Review on 5/11/23 of the manufactuer's instruction on the Latanoprost Ophthalmic Solution 0.005% label revealed the following: Discard after six weeks. Review on 5/11/23 of the facility policy titled, Labeling of Medication and Biologicals last revised 5/3/2022 states: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate precautions and safe administration of medications .4. Labels for each floor/unit's stock medications must include: c. The expiration date when applicable. 8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed .

Based on observation, interview, and policy review it was determined that the facility failed to clean and disinfect a glucometer after use for 1 out of 2 medication carts observed. Findings include: Observation on 5/10/23 at 9:45 a.m. of the Strawberry Cove medication cart revealed a glucometer in the top right draw with brown dried blood like substance on and around the test strip insertion site. Interview on 5/10/23 at 9:45 a.m. with Staff B (Unit Manger) revealed that the glucometer is to be cleaned after each resident use and confirmed the substance on the meter was a blood-like substance. Review on 5/12/23 of the facilities policy titled Glucometer Disinfection, revised date 08/15/2022, revealed the following: Definition: Disinfection is the process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects .Policy Explanation and Compliance Guidelines: 1. The facility will ensure blood glucometer will be cleaned and disinfected after each use and according to manufacturer's instructions and for multi-resident use . 4. Glucometer's will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Review on 5/12/23 at 2:00 p.m. of the manufacturer's recommendations for the blood glucose meters revealed the following: Cleaning and Disinfecting Guidelines: Healthcare professionals should wear gloves and when cleaning the Assure Platinum meter. Wash Hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Further review revealed that cleaning and disinfection can be done using an EPA-registered disinfectant, germicidal wipe, or bleach solution. Standard: Review on 5/12/23 of the Center for Disease Control and Prevention guidance, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#:~:text=CDC%20is%20alerting%20all%20persons%20who%20assist%20others,never%20be%20used%20for%20more%20than%20one%20person revealed the following: Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.

Based on observation, interview, and record review, it was determined that the facility failed to assess a resident's ability to self-administer medications in 1 of 2 residents reviewed for choices out of a final sample of 26 residents. (Resident identifier is #1.) Findings include: Observation on 5/10/22 at approximately 10:10 a.m. of Resident #1's room revealed Resident #1 was in their recliner chair with their eyes closed. Further observation of Resident #1's room revealed a plastic medicine cup containing 12 pills/capsules on Resident #1's side table positioned accross the room from Resident #1. Interview on 5/10/22 at approximately 10:10 a.m. with Resident #1 revealed that sometimes staff leave Resident #1 their medications so he/she can take them when they get up to eat breakfast. Interview on 5/10/22 at approximately 10:20 a.m. with Staff A (Licensed Practical Nurse) confirmed they had left Resident #1's 9 a.m. medication on the side table for them to take when they woke up. Review on 5/10/22 at approximately 10:30 a.m. if Resident #1's medical record revealed no assessment for self-administration of medication and no order for self-administration of medication. Interview on 5/10/22 at approximately 10:30 a.m. with Staff G (Unit Manager) confirmed Resident #1 has no order or assessment for self-administration of medication. Review on 5/10/22 at approximately 11 a.m. of Resident #1's May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Aspirin 81 mg (milligrams) Circulation vein support 2 capsules [MEDICATION(S)] 30 mg [MEDICATION(S)] 40 mg Losartan 20 mg Potassium Chloride 10 meq (milliequivalent) Vitamin D3 [MEDICATION(S)] Sulfate 325 mg [MEDICATION(S)] 300 mg [MEDICATION(S)] 1000 mg Review on 5/11/22 at approximately 10:00 a.m. of facility policy titled Resident Self-Administration of Medication revised on 8/1/21, revealed .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered .4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical .

Based on interview, record review, and policy review, it was determined that the facility failed to follow physician's orders 1 of 1 resident reviewed for hydration (Resident identifier is #39) and 2 of 8 residents reviewed for nutrition (Resident identifiers are #53 and #73) in a final sample of 26 residents. Findings include: Standard Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #39 Review on 5/11/22 of Resident #39's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)], onset 5/11/21 Dependence on Renal [CONDITION(S)], onset 6/2/21 Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or [CONDITION(S)], onset 6/2/21 Review on 5/11/22 of Resident #39's April 2022 and May 2022 MARs (Medication Administration Records) revealed the following physician's order: 1500 cc (cubic centimeters)/day Fluid Restriction. May have 300 cc with each meal and 200 cc Free fluids (Nursing) per shift total of 1500 cc's. every shift, order date 8/31/22 and dc (discontinue) date of 5/9/22. Further review of the MARs revealed the following entries on the MARs with no documented fluid intakes: April 2022 Day 5th, 6th, 8th, 13th, 20th, and 22nd Eve (evening) 28th Noc (night) 1st, 20th, 27th, and 28th May 2022 Day 2nd, 4th, 6th, 7th, and 8th. Review of the MARs also revealed that on shifts that Resident #39 had no fluid intake were documented as 0. Review on 5/11/22 of the facility policy titled, Fluid Restriction, Revised on 8/31/21 revealed: .Policy: It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders. . Compliance Guidelines: 1. The nurse will obtain and verify the physician's order for the fluid restriction and an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 5/11/22 at approximately 12:45 p.m. with Staff A (Licensed Practical Nurse) revealed that the fluid intakes for Resident #39 would be documented in the MAR and not documented anywhere else. Resident #53 Review on 5/11/22 of Resident #53's physician's orders revealed the following physician's order: Daily weight. Notify MD (Medical Doctor) if weight gain > (greater than) 3 pounds in 24 hours. Every day shift for CHF ([CONDITION(S)]), order date 4/13/22. Review on 5/11/22 of Resident #53's Weights and Vitals Summary revealed the following dates had no weights recorded: April (2022) 14th, 16th, 17th, 18th, 25th, and 30th. May (2022) 1st, 5th and 8th. Interview on 5/11/22 1:00 p.m. with Staff A confirmed that weights were not obtained on the dates listed above for Resident #53. Resident #73 Review on 5/11/22 of Resident #73's April and May MARs revealed the following physician's order: Weigh every day shift every 1 month(s) starting on the 1st for 10 day(s), start date 1/1/22. Further review of the April 2022 and May 2022 MARs revealed the following dates there were no weights obtained: April 1st, 3rd, 5th, and 10th. May 2nd, 3rd, 4th, 5th, 6th and 8th. Interview on 5/12/22 at approximately 8:30 a.m. with Staff F (Licensed Practical Nurse) confirmed that the dates above had no documented weights for Resident #73.

Based on interview, record review, and policy review, it was determined that the facility failed to ensure that the attending physician document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it in regards to resident's allergies for 1 out of 7 residents reviewed for drug regimen reviews. (Resident identifier is #278.) Findings include: Review on 5/12/22 of Resident #278's medical record revealed that he/she was admitted on [DATE]. Review on 5/12/22 of Resident #278's May 2022 MAR (Medication Administration Record) revealed that listed under allergies was Acetaminophen. Further review of the May 2022 MAR revealed the following physician orders: 1. Acetaminophen Tablet 325 mg (milligram) Give 1 tablet by mouth every 4 hours as needed for mild pain, Start Date 4/28/22. 2. Acetaminophen Tablet 325 mg Give 2 tablets by mouth every 4 hours as needed for moderate pain, Start Date 4/28/22. Review on 5/12/22 of Resident #278's monthly pharmacy drug regimen review, dated 4/29/22 revealed the following pharmacy recommendation had not been addressed the physician: .Medication: The resident has an order of Tylenol (acetaminophen). Recommendation: Please consider a discontinuation of the Tylenol (acetaminophen) order since the resident has a listed allergy to the medication or remove the allergy from their profile if they are not having an adverse reaction to the order. Reason: The resident has a listed medication allergy to Tylenol (acetaminophen) . Interview on 5/12/22 at approximately 10:30 a.m. with Staff H (Director of Nursing) confirmed the above findings. Staff H stated that the facility has 30 days to address pharmacy recommendations and that allergies should be addressed right away. Review on 5/12/22 of the facility policy titled, Medication Regimen Review, Revised date 8/1/21 revealed: . 1. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. . E. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen reviews.

Based on interview and record review, it was determined that the facility failed to ensure that PRN (as needed) [CONDITION(S)] medication did not extend beyond 14 days without a documented physician rationale for 2 out of 10 residents reviewed for unnecessary medications in a final sample size of 26 residents. (Resident identifiers are #38 and #63) Findings include: Resident #38 Review on 5/12/22 of Resident #38's current physician's orders revealed the following physician order: [MEDICATION(S)] Tablet 0.25 MG (milligram) ([MEDICATION(S)]) .Give 0.25 mg by mouth as needed for Pain two times per day .Start date 12/3/2021 .End date Indefinite . Interview on 5/12/22 at approximately 11:29 a.m. with Staff F (Registered Nurse) confirmed there was no end date on the above mentioned PRN [MEDICATION(S)] order. Review on 5/12/22 of Resident #38's progress notes revealed no evidence that the attending physician documented a rationale for extending the [CONDITION(S)] medication longer than 14 days. Resident # 63 Review on 5/12/22 of Resident # 63's current physician's orders revealed the following physician order: [MEDICATION(S)] Tablet 0.5 mg ([MEDICATION(S)]) .Give 0.5 mg by mouth every 4 hours as needed for anxiety .Start date 10/14/2021 .End date Indefinite . Interview on 5/12/22 at approximately 12:06 p.m. with Staff J (Medication Nursing Assistant) confirmed there was no stop date on the above mentioned PRN [MEDICATION(S)] order. Interview on 5/12/22 at approximately 12:09 p.m. with Staff G (Registered Nurse) confirmed the [MEDICATION(S)] PRN order should have an end date. Review on 5/12/22 of Resident #63's progress notes revealed no evidence that the attending physician documented a rational for extending the [CONDITION(S)] medication longer than 14 days.

Based on observation, interview, record review, and policy review, it was determined that the facility failed to ensure medication error rates were less than 5% (percent) during medication administration observation with 33 medication opportunities. Resident identifiers are #44, #61 and #41.) Standard of Practice. (Follow MD (Doctor of Medicine) order) The Potter-Perry, 2009, Fundamentals of Nursing 7th Edition, St. Louis, Missouri: Mosby, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Findings include: New Castle Unit Resident #44 Observation on 5/11/22 at approximately 7:35 a.m. of medication administration with Staff D (Registered Nurse) revealed Staff D was preparing Resident #44's medications and was going to administer a tablet of multivitamin with minerals. Review on 5/11/22 of Resident #44's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Multivitamin Tablet (Multiple Vitamin), Give 1 tablet by mouth one time a day for Supplement, order date 11/27/20. Interview on 5/11/22 at approximately 7:35 a.m. with Staff D confirmed that he/she administered the multivitamin with minerals to Resident #44. Staff D stated that Staff D had been administering the multivitamin with minerals to Resident #44 since Staff D had been at the facility (approximatley 6 months). Nubble Unit Resident #61 Observation on 5/11/22 at approximately 7:50 a.m. of medication administration with Staff E (Medication Nurse Assistant) revealed Staff E was preparing Resident #61's medications and was going to administer a tablet of chewable Aspirin 81 mg (milligrams) . Review on 5/11/22 of Resident #61's physicians orders revealed the following order: Aspirin EC ([MEDICATION(S)] Coated) Tablet Delayed Release 81 mg (Aspirin) Give 1 tablet by mouth one time a day for anticoag (anticoagulation), order date 7/15/21. Interview on 5/11/22 at approximately 7:50 a.m. with Staff E confirmed that he/she was going to administer the a tablet of chewable Aspirin 81 mg. Resident #41 Observation on 5/11/22 at approximately 8:00 a.m. during medication administration with Staff E revealed Staff E handed Resident #41 the [MEDICATION(S)] Suspension 50 MCG (micrograms)/ACT to self administer. Resident #41 administered 2 sprays in each nostril. Review on 5/11/22 of Resident #41's physicians orders revealed the following order: [MEDICATION(S)] Suspension 50 MCG/ACT ([MEDICATION(S)]) 1 spray in both nostrils one time a day for seasonal allergies, 1 spray to each nare daily, order date 5/3/22. Order specifies: Administered by Clinician. Interview on 5/11/22 at approximately 8:00 a.m. with Staff E confirmed that Resident #41 did administer 2 sprays to each nostril. Review on 5/11/22 of the facility policy titled, Medication Administration, Revised on 8/1/21 revealed: .Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . There were 3 medication errors out of a total 33 medication opportunities resulting in 9.09% medication error rate.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that medications and biologicals were secured on 1 out of 4 units observed (Bay Unit) and failed to discard wasted medication in a proper receptacle on 2 out of 4 units observed (Bay and Nubble Units). findings include: Bay Unit Observation on 5/10/22 at approximately 11:00 a.m. to 11:15 a.m. on the Bay Unit revealed the treatment cart was unlocked and without staff present. Further observation revealed the following medications/expired treatments in the treatment cart unlocked: Medications 1 enema 101 [MEDICATION(S)] 5% (percent) patches [pronoun omitted] cough drops Expired Treatments 1 hydrocortisone 1% cream expiration date 4/22 1 sterile water 100 mls (milliliters), expiration date 11/11/21 2 silver alginate dressing x2 expiration date 4/27/22 26 puracol ultra powder collagen (biological) wound dressing expiration date 2/25/22 1 suction catheter kit 14 french expiration date 5/31/20 1 [MEDICATION(S)] packing strip expiration date 5/22 1 Resident #70's [MEDICATION(S)] 12% lotion exp 05/21 Interview on 5/10/22 at approximately 11:15 a.m. with Staff F (Licensed Practical Nurse) confirmed that the treatment cart had been unlocked with medications in the cart and expired medications and treatments. Review on 5/11/22 of the facility policy titled, Medication Storage, revised on 8/1/21 revealed: . Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biological's [sic] will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. . Nubble Unit Observation on 5/11/22 at approximately 7:50 a.m. during medication administration revealed Staff E (Medication Nursing Assistant) wasted an 81 mg (milligram) Aspirin tablet in the sharps container and another 81 mg Aspirin tablet in the open garbage attached to the medication cart. Resident #14 was sitting within 3 feet of the open garbage. Interview on 5/11/22 at approximately 7:50 a.m. with Staff E revealed that the his/hers normal practice is to waste medications in the toilet and that is their facility. Review on 5/11/22 of Resident #14's latest BIMS (Brief Interview for Mental Status) dated 2/11/22 , revealed a score of 3. A score of 3 indicates that 0-7 severe cognitive impact. Review on 5/11/22 of the facility policy titled, Destruction of Unused Drugs, Revised on 8/1/21 revealed: . Policy Explanation and Compliance Guidelines: 1. Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. . 3. Prescription drugs may not be flushed down the toilet in accordance to EPA (Environmental Protection Agency) regulations. .

Based on observation, interview, and policy review, it was determined that the facility failed to follow professional standard for labeling and storage of frozen healthshakes in 3 out of 4 kitchenette. Findings include: Observation on 5/10/22 at 9:12 a.m. with Staff K (Food Service Director) in the kitchen revealed a box of healthshakes in the refrigerator. Further observation of the healthshake revealed a manufacturer's instructions indicating good for 14 days once thawed. Interview on 5/10/22 at 9:12 a.m. with Staff K confirmed above findings. Bay unit kitchenette Observation on 5/10/22 at 9:38 a.m. with Staff K revealed 2 healthshake carton in the unit refrigerator with no thaw date, open date or open expiration date. Interview on 5/10/22 at 10:02 a.m. with Staff K confirmed above findings. Staff K stated that they do not label the healthshake carton with thaw dates. Interview also stated that the healthshakes in the kitchenettes were thawed 5/3/22. Nubble unit kitchenette Observation on 5/10/22 at 9:40 a.m. with Staff K revealed a container of healthshakes with no thaw date, open date or open expiration date on the container or the healthshake cartons in the unit refrigerator. Interview on 5/10/22 at 9:40 a.m. with Staff K above findings at the Nubble unit kitchenette. Strawberry unit kitchenette Observation on 5/10/22 at 9:41 a.m. with Staff K revealed a container of healthshakes with no thaw date, open date or open expiration date on the container or the healthshake cartons in the unit refrigerator. Interview on 5/10/22 at 9:41 a.m. with Staff K above findings at the Strawberry unit kitchenette. Review on 5/11/22 of the facility's policy on Use By Dating Guidelines with revision date of 12/01/15 revealed The following is a guide to use when establishing a use by date for food items. The manufacturer's expiration date, when available, is the use by for unopened items . Day of preparation or opening is considered Day 1 in the use by date . Item Frozen shakes .Use by date of 14 days once thawed- use label for individual items when removed from the carton .

Based on interview and record review, it was determined that the facility failed to offer pneumococcal vaccine for 2 out of 5 residents reviewed for immunizations. (Resident identifiers are #9 and #279.) Findings include: Review on 5/10/22 of the facility's policy titled, Pneumococcal Vaccine (Series) dated 8/01/21, revealed .1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional effort to obtain information shall be documented, including efforts to determined date of immunization or type of vaccine required. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident had already be immunized . 4. The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record . Resident #9 Review on 5/10/22 of Resident #9's electronic immunization record revealed [MEDICATION(S)] dose 1 required consent. Further review revealed no documentation of refusal or history of pneumococcal vaccinations. Review on 5/10/22 of Resident #9's paper medical record revealed no pneumococcal vaccination consent form. Review on 5/10/22 of Resident #9's progress notes revealed no documentation that Resident #9's representative was offered the pneumococcal vaccine for Resident #9. Interview on 5/11/22 at approximately 10:00 a.m. with Staff I (Registered Nurse) confirmed above findings. Resident #279 Review on 5/12/22 of Resident #279's electronic health record revealed that Resident #279 was admitted on [DATE]. Review on 5/12/22 of Resident #279's BIMS (Brief Interview for Mental Status) score dated 5/10/22 revealed a score of 13 indicating intact cognitive response. Review on 5/12/22 of Resident #279's electronic immunization record revealed no documentation of Resident #279's refusal or history of pneumococcal vaccinations. Review on 5/12/22 of Resident #279 medical record revealed a pneumococcal vaccine informed consent form was blank. Interview on 5/12/22 at 11:15 a.m. with Staff F (Licensed Practical Nurse) confirmed above findings on Resident #279's pneumococcal consent form. Staff F stated that if the form was not filled out signed by the resident the pneumococcal vaccine was not offered. Review on 5/12/22 of Resident #279 progress notes revealed no documentation that Resident #279's was offered the pneumococcal vaccine. Interview on 5/12/22 at approximately 1:50 p.m. with Resident #279 revealed that he/she does not recall being offered the pneumococcal vaccine. Resident #279 stated what is a pneumococcal vaccine.

Based on observation, interview and record review, the facility failed to ensure that a [CONDITION(S)] (Continuous Positive Air Pressure) was maintained per the manufacturer's instructions for 1 of 1 residents reviewed for [CONDITION(S)] use in a final sample of 26 residents. (Resident identifier is # 58.) Findings include: Observation on 5/10/22 at approximately 10:15 a.m. of Resident #58's room revealed an [CONDITION(S)] machine on the nightstand. Further observation of the [CONDITION(S)] machine revealed debris on the inside of the mask and a pink discoloration at the bottom of water chamber. Interview on 5/10/22 at approximately 10:15 a.m. with Resident #58 revealed that do remember staff cleaning their [CONDITION(S)] machine. Review on 5/11/22 at approximately 11:00 a.m. of Resident #58's current physician orders revealed an order dated 1/29/21 that read: [CONDITION(S)] on at HS (hour of sleep) off in AM. Review on 5/11/21 of facility policy titled [CONDITION(S)]/[CONDITION(S)] (Bilevel Positive Airway Pressure) Cleaning revised 8/1/22, revealed .clean [CONDITION(S)]/[CONDITION(S)] equipment in accordance with . manufacturer recommendations in order to prevent the occurrence or spread of infection . Review on 5/11/21 of [CONDITION(S)] machine manufacturer's instructions revealed .Cleaning 1. Wash the water tub and air tubing in warm water using a mild detergent .2. Rinse the water tub and air tubing thoroughly and allow to dry out of direct sunlight and/or heat .

Based on interview and record review, it was determined that the facility failed to consult with the resident's physician of a resident's change of condition for 1 resident out of 2 residents reviewed for falls. (Resident identifier is #1.) Findings include: Review on 3/10/22 of Resident #1's nurse's note by Staff E (Licensed Practical Nurse), dated 2/27/22 time 10:02 p.m., revealed that Resident #1 stayed in his/her room the whole day, sleepy and fatigued. Further review of the Resident #1's progress note dated 2/27/22 time 10:02 p.m. revealed that Resident #1's afternoon and evening medications were held due to lethargy. Review also revealed that Resident #1 had few sips of water and juice and had no solid food intake. Review of Resident #1's progress note dated 2/27/22 time 10:02 p.m. also revealed no documentation that Resident #1's provider was notified that medications were held as Resident #1 was lethargic. Review on 3/10/22 of Resident #1's February 2022 EMAR (Electronic Medication Administration Record) revealed the following medications were not administered on 2/27/22: [MEDICATION(S)] (antihyperlipidemic) 5 mg (milligram) - 1 dose (7:00 p.m.) [MEDICATION(S)] (antipsychotic) 12.5 mg - 1 dose (4:00 p.m.) [MEDICATION(S)] Sprinkles (anticonvulsant) 250 mg - 2 doses (2:00 p.m. and 8:00 p.m.) [MEDICATION(S)] 300 mg (anticonvulsant) - 2 doses (2:00 p.m. and 7:00 p.m.). Further review of Resident #1's February 2022 EMAR revealed that medications were coded as 7 which indicated resident was sleeping. Review on 3/10/22 of Resident #1's current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 3/10/22 of Staff E's written statement with a date of incident of 2/27/22 revealed the following: 9:30 a.m. - Resident [Resident #1] was sleeping in bed, Staff E woke Resident [Resident #1] to administer morning medications. 11:30 a.m. - Resident [Resident #1] was sleeping 1:00 p.m. - Resident [Resident #1] was sleeping, afternoon medications and lunch were held. 4:30 p.m.- Staff E called the supervisor (Staff I (Nurse Supervisor)) to check the resident [Resident #1] because of lethargy. 5:30 p.m. - Resident [Resident #1] sleeping and evening medications were held. 8:00 p.m. - Resident [Resident #1] sleeping and bedtime medications were held. Further review of Staff E's written statement as mentioned above revealed no documentation that Staff E notified Resident #1's provider that Resident #1's afternoon, evening and bedtime medications were held due to lethargy. Interview on 3/10/22 at 11:11 a.m. with Staff F (Patient Care Assistant) revealed on 2/27/22 Resident #1 was in bed the whole day. Interview also revealed that Resident #1 did not react or respond when he/she and Staff H (Licensed Nursing Assistant) provided morning care (personal hygiene), which Staff F stated that he/she reported this to Staff E. Staff F also stated that Resident #1 did not eat lunch and only took half of a nutritional supplement for dinner then went back to sleep and that this was not Resident #1's baseline as Resident #1's baseline was wandering the hallways, independently ambulating, restless, and chanting. Interview on 3/10/22 at approximately 12:00 p.m. with Staff H revealed that he/she along with Staff F provided morning care to Resident #1 on 2/27/22. Staff H stated that Resident #1 did not react or respond when they were providing care to Resident #1, which was not baseline for Resident #1. Staff H also stated that he/she reported this to Staff E and that Resident #1 baseline was wandering the hallways, independently ambulating, constant chanting nonsensical words. Staff H also stated that the Staff I came to assess Resident #1. Interview on 3/10/22 at approximately 12:15 p.m. with Staff I revealed that at approximately 4:00 p.m. on 2/27/22 Staff I was called by Staff E. Staff E reported to Staff I that Resident #1 was lethargic, not at baseline and had a recent increase in medications with a possible decline. Staff I assessed Resident #1 and recommended Staff E hold medications and call the provider. Interview on 3/10/22 at 1:00 p.m. with Staff J (Advance Practice Registered Nurse) revealed he/she was Resident #1's provider and oversees Resident #1's care. Staff J stated that he/she nor Staff J's on-call provider group was notified that Resident #1's medications, as mentioned above (Resident #1's February EMAR), were held and that Resident #1 had lethargy on 2/27/22. Interview with Staff J confirmed that Resident #1's baseline was wandering all day and ambulating independently. Staff J stated that he/she expected that nursing staff should have notified him/her or Staff J's on-call provider group on 2/27/22 instead of 2/28/22. Review on 3/10/22 of the facilities's policy titled, Notification of Changes, reviewed/revised date 11/23/21 revealed: . Definitions: Life Threatening Conditions: Examples - [CONDITION(S)] or Stroke. Clinical Complications Examples - Development of stage 2 pressure injury, recurrent episodes of [CONDITION(S)], recurrent UTIs or onset of depression. Need to alter treatment significantly means to stop a form of treatment because of adverse consequences (such as adverse drug reaction), or commence a new form of treatment to deal with a problem (for example, the use of any medical procedure, or therapy that has been used on that resident before) Compliance Guidelines: . The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification . 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii Acute condition. iii. Exacerbation of a chronic condition

Based on observation and interview the facility failed to assure that all staff wore appropriate PPE per policy and CDC recommendations. One staff member was observed feeding a resident while improperly wearing eye protection. This lapse in PPE use has the potential to facilitate the spread of COVID-19 and other pathogens to all residents in the facility. Evidence includes: On June 2, 2021 at approximately 12:30 PM the surveyor observed Licensed Nurse Aid #1 (LNA#1) assisting a resident with dinning. This observation occurred on the Bay Unit which the facility was using as the quarantine unit for residents whose COVID-19 status was not determined. At the time of the survey, the unit housed 3 residents whose COVID-19 Status was not determined. These residents were isolated in their rooms. LNA #1 was observed for several minutes wearing protective goggles on top of the head, not covering the eyes. During the observation LNA#1 became aware of the presence of surveyors and correctly placed the goggles over the eyes. Prior to this observation, at approximately 12:15 PM in an interview with surveyors, The facilities acting Infection Control Nurse stated the facilities expectation that all staff providing direct care to residents when splashing or other material transmission could occur should wear full PPE including eye protection. Facility Infection Control Policy and Procedures for Contact Precautions effictive 02/15/01 and reviewed on 11/15/20 states Wear eye protection if splashing of infectious material is likely. Current CDC Guidance for Health Care Providers states Eye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions In an interview at approximately 3:30 PM LNA#1 acknowledged not wearing eye protection properly while providing dining assistance. In an interview at 3:45 PM the facilities acting Infection Control Nurse acknowledged an LNA providing dining assistance to residents would be expected to be fully protected by PPE including properly worn eye protection.

Based on observation, interview, medical record review and policy review, it was determined that the facility failed to ensure proper storage of expired medications and medication needing refrigeration for 1 out 1 medication room observed and 3 out of 3 medication carts observed. (Resident identifiers are #36, #38, #53 and #61.) Findings include: Nubble unit medication room Observation on 5/5/21 at 8:13 a.m. with Staff C (Licensed Practical Nurse (LPN)) at the nubble unit medication room refrigerator revealed an used [MEDICATION(S)] vial with a labeled date of 1/19/21 on the container. Further observation revealed that the storage instruction on the container indicated that entered vials are to be discarded after 30 days. Review on 5/5/21 of the [MEDICATION(S)] manufacturer's instruction revealed that vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Interview on 5/5/21 at 8:13 a.m. with Staff C confirmed the above findings at the nubble unit medication room. Staff C stated that the vial should have been discarded after 30 days on the labeled date on the [MEDICATION(S)] container. Staff C also stated that he/she will discard the [MEDICATION(S)] vial immediately. Strawberry unit medication cart Observation on 5/5/21 at 8:30 a.m. with Staff E (LPN) revealed 4 packets of bleach with an expiration date of 11/2018 were with the unexpired packets of bleach in the medication cart. Observation on 5/5/21 at 8:31 a.m. with Staff E revealed an opened acidophilus (probiotic) bottle. The storage instruction on the acidophilus bottle indicated to refrigerate after opening. Observation on 5/5/21 at 8:32 a.m. with Staff E revealed 1 bingo card with 7 tablets of Resident #53's [MEDICATION(S)] 20 meq (milliequivalent) with an expiration date of 12/31/20, which was found with Resident #53's unexpired medications. Observation on 5/5/21 at 8:33 a.m. with Staff E revealed 1 bingo card with 7 tablets of Resident #38's [MEDICATION(S)]-s (stool softener) 8.6 mg-50 mg (milligram) with an expiration date of 1/31/21, which was found with Resident #38's unexpired medications. Observation on 5/5/21 at 8:34 a.m. with Staff E revealed 3 bingo cards with 56 tablets of Resident #36's [MEDICATION(S)] (analgesia) 7.5 mg with an expiration date 8/31/20, which was found with Resident #36's unexpired overflow medications. Observation on 5/5/21 at 8:35 a.m. with Staff E revealed an opened bottle of nonaspirin (histamine-1 receptor antagonist) with an expiration date of 02/2021, which was found with the unexpired Over-The-Counter medications. Observation on 5/5/21 at 8:36 a.m. with Staff E revealed 1 bingo card with 14 tablets of Resident #61's [MEDICATION(S)] (vasodilator) 10 mg with an expiration date of 1/30/21 and 1 bingo card with 24 tablets of Resident #61's [MEDICATION(S)] (antihypertensive) 25 mg with an expiration date of 8/31/20 which was found with Resident #61's unexpired medications. Interview on 5/5/21 at 8:36 a.m. with Staff E confirmed the above findings at the strawberry unit medication cart. Staff E stated that the medication as mentioned above for Resident #36, #38, #53 and #61 were expired. Staff E stated that the expired medications should be stored at the medication room in a return to pharmacy bag. Staff C also stated that he/she did not know that the acidophilus was to be refrigerated after opening. Nubble unit medication cart Observation on 5/5/21 at 9:25 a.m. with Staff F (LPN) revealed an opened acidophilus bottle with a storage instruction on the bottle to refrigerate after opening. Interview on 5/5/21 at 9:25 a.m. with Staff F confirmed the above findings at the nubble unit medication cart. Staff F stated that he/she did not know that the acidophilus was to be refrigerated after opening. Bay unit medication cart Observation on 5/5/21 at 10:37 a.m. with Staff A (LPN unit manager) revealed an opened acidophilus bottle with a storage instruction on bottle to refrigerate after opening. Interview on 5/5/21 at 10:37 a.m. with Staff A confirmed the above findings at the bay unit medication cart. Staff A stated that he/she did not know that the acidophilus was to be refrigerated after opening. Review on 5/5/21 of the facility's medication report for current list of residents on acidophilus revealed that no residents were taking acidophilus at the nubble, strawberry and bay units. Review on 5/5/21 of the facility's medication report for current list of residents on non aspirin revealed no residents were taking non aspirin at the facility. Review on 5/5/21 of Resident #38's active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 5/5/21 of Resident #36's active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 5/5/21 of Resident #53's active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 5/5/21 of Resident #61's active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 5/6/21 at approximately 8:00 a.m. with Staff G (Interim Administrator) confirmed above findings on medical record review for Resident #36, #38, #53, #61 and medication reports. Review on 5/6/21 of facility's policy titled, disposal medication waste, dated 11/01/19, revealed .Medications for disposal include: Medications which are not taken with the patient upon discharge; Discontinued, expired, or contaminated medication not returned to the pharmacy .Practice Standards 1. Return discontinued medications to pharmacy .medications that cannot be return to the pharmacy, discharge with patient, or donated will be placed in medication disposal bins .Waste bins will be stored in the medication room or other secure medication storage area not accessible to patients .solid dosage form medications (e.g. pills, capsules) are to be removed from their original container before disposal .

Based on interview and medical record review, it was determined that the facility failed to accurately document a resident's right to request for emergency life support, including CPR (cardiopulmonary resuscitation) for 1 resident of 22 residents reviewed for advanced directives in a final survey sample of 22 residents. (Resident identifier is Resident #29.) Findings include: Review on [DATE] of Resident #29's medical record revealed the following: Resident #29's paper chart had a pink portable DNR (do not resuscitate) form, dated [DATE]. Resident #29's EHR (electronic health record) had a physicians order for Full Code, dated [DATE]. Interview on [DATE] at approximately 11:15 a.m. with Staff A (Unit Manager) revealed that he/she would look for a resident's code status in either/or the resident's paper chart or EHR. Staff A stated that she did know that Resident #29 wished to be a Full Code, I know that [pronoun omitted] changed .code status to Full Code when [they] came here and the pink portable DNR should have been removed from the chart. Interview on [DATE] at approximately 12:30 p.m. with Resident #29 revealed that his/her wishes was to be a Full Code. Review on [DATE] of the facility policy and procedure titled, Emergency: Medical Response, revision date, [DATE] revealed: . 1. Respond to identified emergency. 1.1 A licensed nurse assumes responsibility as Emergency Leader. 1.1.1. Identify patient's code status. . 1.2.2. Initiate appropriate medical intervention (CPR, .) . Review on [DATE] of the facility policy and procedure titled, OPS117 Health Care Decision Making, Revision Date [DATE] revealed: .Policy .Establish mechanisms for documenting and communicating the patient's choices to the interprofessional team and staff responsible for the patient's care Practice Standards . 1. Upon admission, determine whether the patient has an advance directive and/or portable medical orders such as POLST, MOLST, etc 2. Throughout the stay, advance care planning conversations will be conducted as part of the care plan process and with significant change in condition to identify, clarify, and review existing advance directives and or/portable medical orders and determine whether the patient wishes to change or continue with these instructions.