Every finding on record at Cedar Lake Nursing Center

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation.The facility failed to ensure the ice machine was cleaned and sanitized on a regular basis.These failures could place residents who ate food from the kitchen at risk of foodborne illness.Findings included: During an observation and interview on 09/08/2025 at 10:42 AM the ice machine in the steam table room had visible pink debris and dark brown specks present on the ice chute. A paper towel swipe of the chute, done by the surveyor, returned with pink and brown coloring. The DM said maintenance should be the one that took the machine apart and cleaned it with the chemicals. She said the dietary department wipes down the lid, gasket area, and outside of the machine daily or as needed. She said she had been at the facility a month and to her knowledge no one had broken the machine down to clean it.During an interview on 09/08/2025 at 10:55 AM DA A said maintenance deep cleans the ice machine in the steam table room and the dietary department wipes it down. He thought it had been about a month since it was cleaned about the time the new dietary manager came.During an interview on 09/08/2025 at 1:15 PM the Maintenance Supervisor said he thought dietary was responsible for cleaning the ice machine. He said the facility owned the ice machine and he said he thought he cleaned it maybe once that he knew of probably in December 2024.During an interview on 09/09/2025 at 9:15 AM the administrator said to his knowledge the facility did not have an outside vendor to clean the ice machine. He said the maintenance supervisor should do the maintenance cleaning. He said he had not told the maintenance supervisor he was responsible for deep cleaning the ice machine. He said the maintenance supervisor started working at the facility around January 2024 about a year and a half ago. He said he expected the dietary department to do the day-to-day cleaning of the lid, gasket area, and wiping down the outside of the machine. He said he did not know if he had the manufacturer's user manual but would see if the maintenance supervisor had it. He said the maintenance supervisor should be logging when the cleanings are done.Review of S Model Ice Machine Installation Operation and Maintenance Manual revised 12/2019 indicated under Section 4 Maintenance, Descaling and Sanitizing, General .Descale and sanitize the ice machine every six months for efficient operation.An extremely dirty ice machine must be taken apart for cleaning and sanitizing.Cleaning/Sanitizing Procedure .must be performed a minimum of once every six months. Detailed Descaling/Sanitizing Procedure must be performed a minimum of once every six months.Exterior Cleaning Clean the area around the ice machine as often as necessary to maintain cleanliness and efficient operation.Sponge dust and dirt off the outside of the ice machine with mild soap and water. Wipe dry with a clean, soft cloth.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #24) reviewed for infection control. CNA B failed to don PPE while transferring Resident #24 to the toilet and adjusted her urinary catheter drainage bag.This failure could place residents under their care at risk for the transmission of communicable diseases and infections. Findings included:Record review of a face sheet dated 09/2025 indicated Resident #24 was an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included retention of urine, fracture of 4th lumbar vertebrae, osteoarthritis of left knee, high blood pressure, and chronic pain. Record review of the admission MDS dated [DATE] noted Resident #24 had a BIMS score of 15 which indicated she was cognitively intact. The MDS indicated she required maximum assistance when toileting and was occasionally incontinent of bladder and continent of bowel.Record review of Resident #24's progress notes dated 08/01/2025 at 10:03 PM indicated the resident was unable to urinate and she said she had not urinated since the morning. Upon assessment, the resident's bladder was noted to be distended (overly full) and a new order was received from the nurse practitioner to insert a urinary catheter to check for residual urine. Residual urine was 400 cc of straw-colored urine. An order was given to insert an indwelling urinary catheter.Record review of Resident #24's physician orders, dated 09/08/2025, indicated an order dated 08/01/2025 for an indwelling Foley catheter care every shift, urinary output emptied and recorded every shift, and Foley catheter secured with catheter anchor every shift. A physician order dated 08/04/2025 indicated to the 16 French Foley catheter with 5 cc bulb be changed every month on the first of the month on the night shift starting 09/01/2025.Record review of Resident #24's care plan dated 08/03/2025 indicated she had an indwelling urinary catheter.During an observation and interview on 09/08/2025 at 11:10 AM Resident #24 returned from therapy to use the restroom. The resident said she was hoping to get the catheter removed this afternoon. She said they were hoping she could urinate afterwards so she didn't have to keep it in. CNA B came into the room, washed her hands, put on gloves and assisted the resident to sit on the toilet. The resident was able to transfer herself with some assistance and CNA B helped pull down her pull up. CNA B removed the drainage bag from the wheelchair to reduce tension on the catheter. CNA B did not don proper PPE before assisting Resident #24. CNA B said she was supposed to put on the PPE that was present in the room in the hanging bag when providing direct care to residents with a catheter. A hanging bag was observed attached to the closet door and it contained PPE supplies including gowns and gloves. She said she did not put on the gown only her gloves. During an interview on 09/09/2025 at 9:05 AM the ADON/IP said staff need to put on PPE when doing a transfer on a resident with a urinary catheter. She said Resident #24 had a urinary catheter but was continent of bowel and needed assistance to transfer to the toilet. She said the staff member should have put on a gown in addition to her gloves for the transfer.During an interview on 09/09/2025 at 9:10 AM the DON said EBP should be used according to their facility policy for residents with a urinary catheter, feeding tube, significant wound, etc. She said Resident #24 would require the staff to wear a gown and gloves during a transfer because she had an indwelling urinary catheter. Record review of the facility's undated policy titled Policy and Procedures - Infection Control Enhanced Barrier Precautions indicated the following: .use of gown and gloves during high contact resident care activities that include opportunities for transfer of MDROs to staff hands and clothing. High contact resident care activities include dressing, bathing, transferring, .changing briefs or assisting with toileting.Enhanced Barrier Precautions apply to:.wounds/indwelling medical devices (i.e., central line, urinary catheter, feeding tube tracheostomy/ventilator).

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. There were no trash cans at both hand wash sinks. The dish machine was not sanitizing properly and the DW did not report so it could be repaired. Two thickened liquid cartons were not dated when opened. One 32 oz. carton of almond milk was out of date and being used. A drawer under the tea machine had dried brown substance in the bottom. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations and interviews on 08/05/24 of the kitchen the following was noted: *at 09:30 AM no trash can at the handwash sink in the dish room. There was a 55 gallon rolling trash can lined with a plastic bag which had no lid. *at 09:35 AM the dish machine sanitizer was checked by [NAME] A and the test strip came back white instead of purple, indicating the machine was not sanitizing the dishes after washing. [NAME] A looked at the strip and said it was not correct. She was holding the strip next to the sanitizer gauge chart on the strip container. DW B was asked about checking the machine during breakfast and he said the temperatures were all good but the sanitizer was not registering on the test strip. He said he did not tell anyone the test strips were not registering. He said he checked his sanitizing buckets with the test strips from the 3-compartment sink. He said he made a notation on the Temperature/Sanitizing log for the dish machine was sanitizing at 50 ppm when it was not registering. He did not seem to know the difference between the two types of sanitizer. *at 09:43 AM no trash can at the handwash sink adjacent to the 3-compartment sink. There was a 55 gallon rolling barrel adjacent to the 3-compartment sink that had an affixed lid that would need to be opened with previously washed hands, *at 09:50 AM in the Walk-In Cooler: 1-46 oz. Nectar Thick Cranberry Cocktail had no open date. The packaging indicated: After opening, may be kept up to 7 days under refrigeration. 1-46 oz. Nectar Thick Orange Juice had no open date. [NAME] B said they were supposed to put an open date on anything that had been opened. 1- 32 oz. almond milk was marked as being opened on 07/13/24 (23 days). The packaging on the carton indicated: Use within 7-10 days after opening. [NAME] B said the almond milk belonged to a resident who was lactose intolerant and his family member provided it to the facility. He said the kitchen gave him the milk for his cereal in the morning and used it to prepare items that needed milk such as pudding. He discarded the almond milk. *at 10:00 AM the drawer under the tea dispenser had the entire bottom covered with dark brown dried substance. [NAME] B removed the drawer to be washed. *at 10:01 AM [NAME] A had plates that needed to be re-washed and sanitized for lunch at the 3 compartment sink. She said the dish machine vendor had been called and would hopefully be at the facility by lunchtime. *at 11:25 AM no trash cans at either handwash sink. During an interview on 08/07/2024 at 10:37 AM, the DM said staff knew to date all food packaging when they were opened and would need to be stored. She said staff had been trained on dishwashing procedures and checking the sanitizing solutions on the dish machine and the 3-compartment sink. She said she would re-train staff and include information on reporting any discrepancies or issues. Review of an undated facility policy on Dishwashing Procedures indicated .dishwashing machine uses chemical sanitizing, where a chemical such as chlorine is dispensed into the rinse water .the dietary staff must check the rinse water during each dishwashing period to assure at least 50 ppm of sanitizing solution in the rinse water. Review of an undated facility policy on Food Storage indicated .items such as salad dressings, cottage cheese, etc. should be dated as opened.

Based on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 2 of 4 residents (Residents # 24 and 41) reviewed for MDS assessment accuracy. The facility failed to accurately code Resident # 24's and Resident # 41's nutritional status for weight loss on the MDS assessments. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #24's face sheet dated 08/07/2024 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included anorexia (an eating disorder characterized by an abnormally low body weight), debility (physical weakness), and Failure to Thrive (a syndrome that describes a gradual decline in physical and cognitive function that is characterized by weight loss, malnutrition, and debility). A review of Resident #24's weight records indicated she weighed 95.4 pounds on 01/08/2024. Resident # 24's weight on 07/02/2024 was noted to be 84.2 pounds, indicating a weight loss of 11.2 pounds (11.7%) in the last 6 months. A review of a dietary note completed by the RD on 07/12/2024 for Resident #24 indicated Resident #24's July 2024 weight reflected a loss of 11.2 pounds which calculated as a 11.7% weight loss in the last 6 months. A review of Resident #24's Dietary Quarterly Review completed by the facility's DM on 07/24/2024 indicated Resident #24 had no weight loss in the last 6 months. A review of Resident #24's Quarterly MDS assessment (Section K 0300) dated 07/31/2024 indicated Resident #24 had not had a weight loss of 10% in the last 6 months. 2. A review of Resident #41's face sheet dated 08/07/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included dementia, chronic kidney disease, chronic obstructive pulmonary disease (a group of diseases that block airflow making it difficult to breathe), and pneumonia. A review of Resident #41's weight records indicated he weighed 124.8 pounds on 06/05/2024. Resident #41's weight on 06/24/2024 was noted to be 118.2 pounds, indicating a weight loss of 6.6 pounds (5.3%) in the last 30 days. A review of Resident #41's Quarterly/5-day MDS assessment dated [DATE] (Section K 0300) indicated Resident #41 had not had a weight loss of 5% in the last 30 days. During an interview with the MDS Nurse on 08/07/2024 at 10:45 AM/2024, she said the DM completed section K:Swallowing/Nutrition Status of the MDS assessments. During an interview with the DM on 08/07/2024 at 10:55 AM, she said she completed Section K of the MDS assessments. She said she also completed the Dietary Quarterly Reviews. She said she looked at the residents' weight records in the computer to determine if they had any weight loss. The DM said she did not know how to calculate the percentage of weight loss. During an interview on 08/07/2024 at 02:20 PM with the MDS Nurse and the DM, the MDS Nurse said that she and the DM had determined that the DM was not using a computer report that showed calculated weight changes. The DM said she had been using a computer report that listed the residents' weights but did not reflect any weight gains or losses. The MDS Nurse and DM said the MDS assessments completed on Residents # 24 and #41 were incorrect and did not reflect their weight losses. During an interview on 08/07/2024 at 03:15 PM, the MDS Nurse said the facility used the MDS 3.0 RAI Manual as their guide for completing the MDS assessments. She said incorrect coding of the MDS assessments could result in residents not receiving appropriate care and services. During an interview on 08/07/2024 at 03:40 PM the DON said the facility did not have a policy completing MDS assessments. She said the facility used the MDS 3.0 RAI as the guide for completing the MDS. She said incorrect coding of the MDS assessments could result in residents not receiving appropriate care and services. Record review of the MDS RAI 3.0 Manual Chapter 3: Section K: Swallowing/Nutritional Status indicated the following: Intent: The items in this section are intended to assess the many conditions that could affect the resident's ability to maintain adequate nutrition and hydration. This section covers swallowing disorders, height and weight, weight loss, and nutritional approaches. The assessor should collaborate with the dietitian and dietary staff to ensure that items in this section have been assessed and calculated accurately. MDS Section K 0300 indicated this section was to be coded for weight loss if a resident experienced a weight loss of 5% or more in the last month or a loss of 10% or more in the last 6 months.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 4 Residents (Residents #'s 24 and 41) reviewed for medical records accuracy. The facility failed to ensure the Dietary Manager accurately documented weight losses in the Dietary Quarterly Reviews for Resident #24 and Resident #31. These deficient practices could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: 1. A review of Resident 24's face sheet dated 08/07/2024 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included anorexia (an eating disorder characterized by an abnormally low body weight), debility (physical weakness), and Failure to Thrive (a syndrome that describes a gradual decline in physical and cognitive function that is characterized by weight loss, malnutrition, and debility). A review of Resident #24's weight records indicated she weighed 95.4 pounds on 01/08/2024. Resident # 24's weight on 07/02/2024 was noted to be 84.2 pounds, indicating a weight loss of 11.2 pounds (11.7%) in the last 6 months. A review of a dietary note completed by the RD on 07/12/2024 for Resident #24 indicated Resident #24's July 2024 weight reflected a loss of 11.2 pounds which calculated as a 11.7% weight loss in the last 6 months. A review of Resident #24's Dietary Quarterly Review completed by the facility's DM on 07/24/2024 indicated Resident #24 had no weight loss in the last 6 months. 2. A review of Resident #41's face sheet dated 08/07/2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included dementia, chronic kidney disease, chronic obstructive pulmonary disease (a group of diseases that block airflow making it difficult to breathe), and pneumonia. A review of Resident #41's weight records indicated he weighed 124.8 pounds on 06/05/2024. Resident #31's weight on 06/24/2024 was noted to be 118.2 pounds, indicating a weight loss of 6.6 pounds (5.3%) in the last 30 days. Resident #41's weight on 07/01/2024 was noted to be 118.0 pounds, indicating a weight loss of 6.8 pounds (5.4%) in the last 30 days. A review of medical records indicated a progress note dated 07/04/2024 wherein the DON noted Resident #41 had a 5% weight loss in the last month. A review of a the RD's Dietician Comprehensive Review dated 07/12/2024 indicated Resident #41's July 2024 weight showed a 6.8 pounds (5.4%) weight loss in the last 1 month. A review of Resident #41's Dietary Quarterly Reviews completed by the facility's DM on 07/24/2024 and 07/29/2024 indicated Resident #41 had no weight loss in the last 30 days. During an interview with the DM on 08/07/2024 at 10:55 AM, she said she completed the Dietary Quarterly Reviews. She said she looked at the residents' weight records in the computer to determine if they had any weight loss. The DM said she did not know how to calculate percentage of weight loss. She said she had not asked anyone how to calculate the percentage of weight loss. She said she used the information documented on the Dietary Quarterly Reviews to complete MDS assessments. She said incorrect Dietary Quarterly reviews could place residents at risk for incorrect MDS assessments. During interviews with the MDS Nurse and the DON on 08/07/2024 at 03:15 PM and 03:40 PM respectively, they said incorrect assessment data on the Dietary Quarterly Reviews could place residents at risk for having incorrect MDS assessments and not receiving appropriate care and services. During an interview on 08/07/2024 at 03:40 PM the DON said the facility did not have a policy on Dietary Reviews nor a policy on documentation/charting accuracy.

Based on interview, the facility failed to ensure the residents received mail for 3 of 3 residents reviewed for rights to forms of communication. The facility did not implement a system for delivering mail on Saturday. Resident #s 12, 24 and 35 said the mail is not delivered on Saturday. This failure could place residents who received mail at risk of not receiving mail in a timely manner and a diminished quality of life. Findings included: During interviews on 07/11/2023 at 9:30 a.m., in a resident council meeting, Resident #s 12, 24 and 35 said they received their mail during the week, but they do not receive their mail on Saturdays. They said they believe they receive it on Monday. During an interview on 07/11/2023 at 10:45 a.m., the Activity Director said this was her second day with the facility and she was not sure how the mail was handled on Saturday. During an interview on 07/11/2023 at 11:05 a.m., the Business Office Assistant said she believed mail delivered on the weekend was held over until Monday, but she was not sure. During an interview on 07/11/2023 at 11:13 a.m., the Administrator said he handles the weekend mail. He said when he comes in on Monday, he sorts the mail that came in over the weekend. He said he keeps the business mail for the facility, and he gives the resident mail to the transportation aide to distribute to the residents . When asked, the Administrator said they did not have a policy on mail.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meals (lunch meal) reviewed for menus and nutritional adequacy. Dietary staff did not serve bread during the noon meal on 07/10/23 to any residents eating food provided by the dietary department. This failure could place residents who eat food from the kitchen at risk of not having their nutritional needs met. Findings included: The planned menu dated 07/10/23 for the noon meal was herb roasted chicken, creamy noodles, garlic green beans,1 slice of bread, and banana pudding for dessert. The diet spreadsheet for the noon meal indicated residents were to receive Herb Roasted Chicken 3 oz., Creamy Noodles 4 oz., Garlic Green Beans 4 oz., Banana Pudding, #8 dip (3.75 oz. or 1/2 cup), 1 slice Bread/Margarine 1 tsp. Residents on pureed diets were to receive Pureed Herb Roasted Chicken #8 dip (3.75 oz. or 1/2 cup; Pureed Creamy Noodles #12 dip (2.875 oz. or 1/3 cup); Pureed Garlic Green Beans #12 dip (2.875 oz. or 1/3 cup); ; Pureed Banana Pudding #8 dip (3.75 oz. or 1/2 cup); Pureed Bread # 20 dip (1.875 oz. or 3.5 tablespoons) During an observation of the dietary department on 07/10/22 at 11:45 AM the dietary carts contained trays for each resident receiving food from the kitchen. Each tray had silverware/napkin, dietary slip, banana pudding, a single serving container of margarine, and a beverage of the resident's choice. There was no sliced bread or pureed bread on the trays. During an observation on 07/10/23 at 12:28 PM, tray line service began and continued until 01:04 PM and the following was observed: *At 12:40 PM the dining room cart left the kitchen and no sliced bread or pureed bread were placed on any trays. *At 12:53 PM the hall 100 cart left the kitchen and no sliced bread or pureed bread were placed on any trays. *At 01:02 PM the hall 200 cart left the kitchen and no sliced bread or pureed bread were placed on any trays. *At 01:04 PM the hall300/400 cart left the kitchen and no sliced bread were placed on any trays. There were no residents on these halls receiving a pureed diet. During an interview on 07/10/23 at 01:07 PM Cook A said he was responsible for preparing the pureed bread and he did not prepare any. During an interview on 07/10/23 at 01:08 PM, the DM said the cook was responsible to put the bread on the trays whether it was sliced bread, rolls, cornbread, or pureed breads. She said she expects bread to be served to residents if it was part of the menu or if a resident requested bread. Review of a facility Diet Roster dated 07/10/2023 indicated there were 50 residents receiving food from the kitchen. Review of a facility menu policy dated 10/2017 indicated Menus are developed ad prepared to meet established national guidelines for nutritional adequacy. And .1. Menus meet the nutritional needs of the residents in accordance with the recommended dietary allowances . and .9. If a food group is missing from a resident's diet, the resident is provided an alternate means of meeting his or her nutritional needs

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. Baking sheets had thick, black burned on substances that were greasy and transferred grease when wiped with paper toweling. Cook A and DA B did not wear a beard restraint when in the kitchen or while serving food and preparing food trays. Mechanically altered chicken removed from the steam table by Cook A and placed on a insulated cover was returned to the pan on the steam table. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 07/10/23 of the kitchen the following was noted: *At 10:07 AM at the pan rack by the stove: 5 full size baking sheets were encrusted with thick, black burned substances. They were stacked together and were greasy to touch and when wiped with a paper towel transferred a greasy brown substance. There were 4 half-size baking sheets with a slight build-up of burned on substances, they were stacked together and greasy to the touch, and when wiped with a paper towel transferred a greasy brown substance. *At 10:15 AM DA B had a full facial beard and moustache. He was not wearing a beard restraint to contain facial hair and was preparing food trays for residents. During an observation on 07/10/23 at 11:45 AM Cook A had a full facial beard and moustache and was not wearing a beard restraint to contain his facial hair. He was cooking food and placing food on the steam table. DA B was not wearing a beard restraint to cover his beard and moustache and was placing items on residents' meal trays. During an observation on 07/10/23 at 12:55 PM Cook A scooped a serving of mechanically altered chicken from the steam table pan and placed it on an insulated plate holder instead of a plate. He dumped the chicken back into the steam table pan from the plate holder. He continued to serve the mechanical chicken to halls 200, 300 and 400. During an interview on 07/10/23 at 01:05 PM Cook A said he should not have put the chicken back into the steam table pan from the insulated holder. He said he realized it when he did it. He said he should have removed that chicken from the steam table and prepared fresh chicken to serve to the residents. During an interview on 07/10/23 at 01:08 PM the DM said when the cook contaminated the mechanical chicken he should have prepared more fresh chicken. She said she did not have any beard guards for the men to wear. She said they were not wearing them when she came to work at the facility last year and she asked them if they wore them and they told her they did not. She said she did not get any for them to wear. She said the baking sheets were fairly thick with burned on substances and she was not sure if she could get it all off so she said she would order new baking sheets. Review of a facility Food and Nutrition Services Staff Policy dated 10/2017 indicated 1. The food and nutrition services staff under the supervision of the dietitian and/or the food and nutrition services manager, will safely and effectively carry out the functions of the food and nutrition services department. Review of a facility Food Preparation and Service Policy dated 04/2019 indicated .7. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. Review of a facility Preventing Foodborne Illness Policy dated 10/2017 indicated 1. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness .12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens . Review of a facility Sanitation Policy dated 10/2008 indicated .3. All equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .

Based on, interview, and record review, the facility failed to report an allegation of abuse for 1 of 3 residents reviewed for abuse. (Resident #219) The facility did not report an allegation of abuse by Resident #219 to administrative staff. The hospice social worker reported to the DON the resident's behavior of allegation of abuse by facility staff and it was not reported to the administrator or called in to the state. This failure could place residents at risk of abuse. Findings included: The most recent physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS dated [DATE] indicated Resident #219 sometimes understood others and had severely impaired cognition. The MDS indicated Resident #219 required extensive to total two persons assist with all ADLs. A care plan dated 03/17/22 indicated Resident #219 experienced behaviors of false allegations pertaining to staff and family. An untimed daily skilled nurse's note dated 03/17/22 by LVN F indicated Resident #219 had no skin concerns but had delusional thinking at this time believes people are trying to hurt him. A nurse's note dated 03/17/22 at 12:35 p.m. by the DON indicated the hospice social worker came to discuss a behavior issue of (Resident #219) .he (the hospice social worker) stated (Resident #219) tells the family that he is getting beat up by the staff and he is going to call the police. The family told (the hospice social worker) that (Resident #210) always accused people and wanted to fight and threatens to call the cops. (The DON) spoke with (Resident #219's responsible parties) and they stated that he always says stuff like that, and they know we are providing great care and are very attentive to (Resident #219). (The DON) spoke to (Resident #219) and asked him if he felt safe here, he stated that he did and asked him if he was being care for, he said yes. (The DON) also asked him if he had any concerns and he stated no. (Resident #219's wife) stated that since he has been sick, he has been accusatory towards care givers and family members. (Resident #219's wife) stated that she wanted us to know this to protect the facility, they assured (the DON) that all staff were providing great care to the resident. During an interview on 05/25/22 at 9:16 a.m., The DON said the hospice social worker reported on 03/17/22 Resident #219 made allegations he was mistreated, and she conducted an investigation that included a physical assessment and Resident #219 had no skin concerns or injuries. The DON said she spoke with Resident 219's family who stayed at his bedside and thought the allegations were a behavior and care planned it as a behavior and did not notify the administrator or report it to the state. During an interview on 05/25/22 at 9:20 a.m. the administrator said she was the abuse coordinator and was unaware of any allegations by Resident #219. The administrator said, an allegation is an allegation of abuse and must and should have been reported and she should have been notified. The administrator said she had to report the allegation as required since she was now aware of the incident. During an interview on 05/25/22 at 1:45 p.m., The DON said she was only ever told by the hospice social worker that Resident #219 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 05/25/22 at 2:01 p.m., LVN F said she was the charge nurse that cared for Resident #219 on 03/17/22. LVN F confirmed she made a nurse's note entry regarding Resident #219 repeatedly alleged staff hurt him but there were no signs of abuse upon assessment and Resident #219's daughters were at his bedside and said he always said this even against them and she did not report the allegations because she did not think it was founded. During an interview on 05/25/22 at 2:21 p.m., the hospice social worker said Resident #219 had a great deal of paranoia and Resident #219's daughter told him he made allegations the facility staff beat him up, and said, those statements were a safety blanket behavior triggered by Resident #219's panic. The hospice social worker said Resident #219's daughter reported to him that the facility staff abused him that day and he notified the DON and his hospice supervisor because he was required to report any allegations of abuse. The hospice social worker said he did not recall if he told the DON if Resident #219's allegation was a behavior or just an allegation. The abuse policy effective 11/19 and reviewed 03/05/21 indicated the following: .it is the policy of the facility to respond to all abuse, neglect, misappropriation of property of residents, and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . It is also the policy of the facility to report all reportable incidents as identified by State and Federal guidelines.

Based on observation, interview, and record review the facility failed to ensure an accurate MDS assessment to reflect the resident's status for 1 (Resident #3) of 15 residents reviewed for assessments in that: -The facility did not ensure Resident #3's MDS accurately reflected the resident's oxygen use under Section O: Special Treatments. This failure could place residents needing oxygen care at risk of not receiving proper care, treatments, and interventions. Findings included: Resident #3 Record review of Resident #3's face sheet revealed an [AGE] year-old female who was admitted on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's comprehensive MDS dated [DATE] revealed the resident had a BIMS of 13 indicating the resident was cognitively intact. The MDS indicated the resident was not coded for oxygen use under Section O: Special Treatments. The resident required limited assistance with one person assist for bed mobility, transfer, walk in the room, walk in the corridor, dressing, toilet use, and personal hygiene. She required supervision with setup help for eating. Record review of Resident #3's care plan dated 3/2/22 read in part . Care Plan Description: I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care Plan Goal: I will maintain a respiratory rate within normal limits over the next 90 days. Start date 2/27/22. Interventions: Assess and monitor respirations and breath sound as needed, noting rate and sounds-Notify MD of concerns. Assist patient to assume position of comfort (elevate head of bed, have patient lean on overbed table or sit on edge of bed). Administer my medications as per orders. Provide respiratory treatments as per orders . Record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's daily skilled nurse notes from 2/26/22- 3/15/22 read in part . oxygen therapy 2LPM @ HS with oxygen saturation readings . Record review of the facility's admission report, New Admit Information Report Form revised on, (2/25/22) read in part . Oxygen: PRN at night 2 LPM . Observation and interview on 05/23/22 at 10:30 AM with Resident #3, revealed the resident was sitting on the side of her bed. The oxygen therapy concentrator was operating at a rate of 1.5 LPM. She said she was on continuous oxygen prior to admission, and she required continuous oxygen. She said when she first arrived, she told them she had to have oxygen, but no one followed through. She said on the second day of her arrival, she escalated her concern for oxygen. She said they finally provided her with oxygen due to her demanding it. During an interview on 05/24/22 at 3:10 PM with CMA/CNA A, she said she had worked at the facility for almost 4 years. She said she was recently away on leave for 1 month. She said she bathed Resident #3, brought her meal trays, and put away the resident's groceries. She said Resident #3 stayed in bed all day. She said she knew the resident was on continuous oxygen because she always had the oxygen concentrator on. During an interview on 05/24/22 at 3:55 PM with the MDS Coordinator, she said she played a role with admissions and discharges. She said she had been at the facility since 3/20/22. She pulled up the resident's quarterly MDS dated [DATE] on her computer. She acknowledged and confirmed that the MDS on 3/2/22 did not trigger oxygen under Section O Special treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 05/24/22 at 4:05 PM with the DON, she said she had been at the facility for 2 years. She said she started as DON in 11/22. She said she was familiar with Resident #3. She said Resident #3 was on oxygen since her admission due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She looked at the resident's clinical records. She confirmed there was no order in place for Resident #3 upon admission . She said she revised Resident #3's care plan when she noticed she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she should have brought it to the attention of the MDS Coordinator so she could update Resident #3's MDS. She said the failure occurred becauseshe got caught up doing other things and it slipped her mind. She said an inaccurate MDS assessment for residents on oxygen could place residents at risk of not having their needs met which could lead to [CONDITION(S)] or even death. She said nurses should report any changes of condition so residents can be reassessed. She could not recall the last time her nursing staff had been in-serviced. She said, they will all be in-serviced as soon as tomorrow. Record review of the facility's policy titled, CLNH-Comprehensive Assessments and the Care Delivery Process (07/17) revised on, (5-2017) read in part . a. Assess the individual. (1) Gather relevant information from multiple sources, including: (a) Observation: (b) Physical assessment (c) Symptom or condition-related assessments (d) Resident and family interview . Record review of the facility's policy titled, CLNH-Comprehensive Assessments and the Care Delivery Process (07/17) revised on, (5-2017) read in part . (1) Identify potential causes or contributing factors of problems and symptoms, including: (a) Medical . Record review of the facility's policy titled, Critical Care Therapy and Respiratory Care Section revised on, (02-02) read in part .3.1 Check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's policy titled, Physician Order/Order Entry Information Policy, not dated, read in part . 1. Written Orders: Written orders must include the following information: e) detailed order that includes medication name, dose to be administered, quantity to be given, route of administration, frequency of administration. F) Appropriate Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to ensure a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences, and for residents reviewed for oxygen therapy care for 1 of 1 resident (Resident #3) reviewed for oxygen therapy in that: -Resident #3's oxygen tubing was not bagged while not in use. -Resident #3 who was on continuous oxygen had no oxygen sign posted on her door. -Resident #3's oxygen concentrator had not been serviced since 2/2020. -Resident #3's had no physician orders in place from admission on 2/25/22 to 4/5/22 for oxygen therapy. These deficient practices could affect residents on oxygen therapy care and place them at risk of infection Findings included: Resident # 3 Record review of Resident #3's face sheet revealed an [AGE] year-old female who was admitted on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's comprehensive MDS dated [DATE] revealed the resident had a BIMS of 13 indicating the resident was cognitively intact. The MDS indicated the resident was not coded for oxygen use under Section O: Special Treatments. The resident required limited assistance with one person assist for bed mobility, transfer, walk in the room, walk in the corridor, dressing, toilet use, and personal hygiene. She required supervision with setup help for eating. Record review of Resident #3's care plan dated 3/2/22 read in part . Care Plan Description: I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care Plan Goal: I will maintain a respiratory rate within normal limits over the next 90 days. Start date 2/27/22. Interventions: Assess and monitor respirations and breath sound as needed, noting rate and sounds-Notify MD of concerns. Assist patient to assume position of comfort (elevate head of bed, have patient lean on overbed table or sit on edge of bed). Administer my medications as per orders. Provide respiratory treatments as per orders . Record review of Physician Orders revealed no orders in place for oxygen therapy from the time of admission (2/25/22) until 4/5/22. Record review of Physician Orders dated 4/6/22 indicated orders for OXYGEN VIA NC AT 1-2 LPM QSHIFT. Record review of Resident #3's daily skilled nurse notes from 2/26/22- 3/15/22 read in part . oxygen therapy is documented 2LMP @ HS with oxygen saturation readings . Observation and interview on 05/23/22 at 10:30 AM with Resident #3, revealed the resident was sitting on the side of her bed. There was no oxygen posting on the resident's door indicating oxygen in use. The oxygen therapy concentrator was operating at a rate of 1.5 LPM while the resident's nasal canula dated 5/20/22 was lying on her pillow not bagged while not in use. The oxygen concentrator was dispersing an unusual amount of heat as you stood by it. The oxygen concentrator had service preventive maintenance dates 2/12/19 and 2/2020 indicating the last time the concentrator was serviced. There was a plastic bag dated 5/20/22 by the resident's bedside table where the nasal cannula should have been stored while not in use. Resident #3 said she put on and took off her nasal cannula. She said the nursing staff had not educated her on putting the nasal cannula in the plastic bag. She said she would do it if they had told her she had to do it. She said she was on continuous oxygen prior to admission. Observation on 05/23/22 at 11:00 AM with Resident #3 revealed her sitting on the side of her bed applying makeup. There was no oxygen posting on the resident's door indicating oxygen in use. The oxygen therapy concentrator was operating at a rate of 1.5 LPM while the resident's nasal canula dated 5/20/22 was lying on her pillow not bagged while not in use. The oxygen concentrator was dispersing an unusual amount of heat as you stood by it. The oxygen concentrator had service preventive maintenance dates 2/12/19 and 2/2020 indicating the last time the concentrator was serviced. There was a plastic bag dated 5/20/22 by the resident's bedside table where the nasal cannula should have been stored while not in use. Observation on 05/23/22 at 12:20 PM with Resident #3, she was sitting on the side of her bed eating lunch. There was no oxygen posting on the resident's door indicating oxygen in use. The oxygen therapy concentrator was operating at a rate of 1.5 LPM while the resident's nasal canula dated 5/20/22 was lying on her pillow not bagged while not in use. The oxygen concentrator was dispersing an unusual amount of heat as you stood by it. The oxygen concentrator had service preventive maintenance dates 2/12/19 and 2/2020 indicating the last time the concentrator was serviced. There was a plastic bag dated 5/20/22 by the resident's bedside table where the nasal cannula should have been stored while not in use. Observation on 05/23/22 at 3:23 PM with Resident #3 revealed the resident was not in her room. There was no oxygen posting on the resident's door indicating oxygen in use. The oxygen therapy concentrator was operating at a rate of 1.5 LPM while the resident's nasal canula dated 5/20/22 was lying on her pillow not bagged while not in use. The oxygen concentrator was dispersing an unusual amount of heat as you stood by it. The oxygen concentrator had service preventive maintenance dates 2/12/19 and 2/2020 indicating the last time the concentrator was serviced. There was a plastic bag dated 5/20/22 by the resident's bedside table where the nasal cannula should have been stored while not in use. Observation on 05/24/22 at 11:24 AM with Resident #3 revealed the resident was sitting on the side of her bed. There was no oxygen posting on the resident's door indicating oxygen in use. The oxygen therapy concentrator was operating at a rate of 1.5 LPM while the resident's nasal canula dated 5/20/22 was lying on her pillow not bagged while not in use. The oxygen concentrator was dispersing an unusual amount of heat as you stood by it. The oxygen concentrator had service preventive maintenance dates 2/12/19 and 2/2020 indicating the last time the concentrator was serviced. There was a plastic bag dated 5/20/22 by the resident's bedside table where the nasal cannula should have been stored while not in use. Observation on 05/24/22 at 3:06 PM revealed CMA/CNA A assisting resident to her bed. There was no oxygen posting on the resident's door indicating oxygen in use. The oxygen therapy concentrator was operating at a rate of 1.5 LPM while the resident's nasal canula dated 5/20/22 was lying on her pillow not bagged while not in use. The oxygen concentrator was dispersing an unusual amount of heat as you stood by it. The oxygen concentrator had service preventive maintenance dates 2/12/19 and 2/2020 indicating the last time the concentrator was serviced. There was a plastic bag dated 5/20/22 by the resident's bedside table where the nasal cannula should have been stored while not in use. During an interview on 05/24/22 at 3:10 PM with CMA/CNA A, she said she had worked at the facility for almost 4 years. She said she was recently away on leave for 1 month. She said she bathed Resident #3, brought her meal trays, and put away the resident's groceries. She said Resident #3 stayed in bed all day. She said she knew the resident was on continuous oxygen because she always had the oxygen concentrator on. She said the resident refused to use oxygen when she was showering. She said she knew the nasal cannula should be bagged while not in use to prevent cross-contamination that could lead to infection. She said no one had educated the resident about leaving the nasal cannula exposed to cross-contamination. She said anything related to oxygen care was outside her scope of responsibilities. She had been instructed to not touch oxygen or tubing, and she was supposed to report it to the charge nurse. She said she had never been trained on what to do with tubing while not in use. She said that there was no sign posted on the door for oxygen use. She said staff may have overlooked posting an oxygen sign when Resident #3 moved from one hall to another about 1-2 months ago. During an interview on 05/24/22 at 3:18 PM LVN B, she said she worked for a nursing agency. She said she had been working at the facility for about 8 weeks. She said she was the nurse assigned to hall one. She said she used the nurse's MAR and relied on CNAs and CMAs to verify that she had the correct resident. She said she checked on Resident #3 in the morning, but she was asleep. She said she took her groceries into the room. She said she did not notice if the resident was getting an oxygen infusion while she was in her room. She said that there was no oxygen sign posted on the resident's door. She said the resident's oxygen tubing should have been stored in a bag while not in use. She said any CNA or CMA should place oxygen tubing's in bags because it didn't take a nurse to do it. She said she did not know how often the tubing was replaced. She said the purpose of the bag was to store the oxygen tubing while not in use to prevent infections. She said she got her trainings/CEU's online. She said she also attended in-services at the facility. She said the facility should have care planned and educated staff on the resident's behavior of taking her oxygen nasal cannula off on her own. She said physician orders were required for residents to receive continuous oxygen. She said if orders for oxygen were not present when reconciliation of medications occurred during admissions, the nurse should verify with the physician that orders needed to be continued because the resident could de-saturate causing a lot of problems. She confirmed the resident had been receiving oxygen therapy at 2.0 LPM. During an interview on 05/24/22 at 3:55 PM with the MDS Coordinator, she said she played a role with admissions and discharges. She said she was an LVN as well. She said she had been at the facility since 3/20/22. She said that the MDS on 3/2/22 did not trigger oxygen. She said order reconciliation should occur at admission. She said the nurse should have noticed that she was using oxygen and did not have an order. She said the physician should have been notified to prevent [CONDITION(S)] and death. She said she could not explain why the failure occurred because the event occurred prior to her hired date. During an interview on 05/24/22 at 4:05 PM with the DON, she said she had been at the facility for 2 years. She said she started as DON in 11/21. She said there should be an oxygen sign posted outside the doors of resident who use oxygen. She said oxygen nasal cannula tubing's should be bagged while not in use. She said the nurses should be assessing if residents took their oxygen nasal cannula off on their own. She said CNAs had been told not to mess with anything related to oxygen care. She said they were supposed to report it to the charge nurse. She said if a resident was cognitively intact, then the nurse should educate the resident on taking off their nasal cannula. She said the tubing should be changed when not bagged while not in use. The DON pulled up Resident #3's physician orders and she said the oxygen order was not clear or well written. She said, it could be continuous or PRN. She said when oxygen orders were not clear the nurses should confirm the orders with physician. She confirmed there was no order in place for Resident #3 upon admission. She said the admitting nurse LVN C should have called the physician to request physician orders for Resident #3's oxygen use. She said she revised Resident #3's care plan when she noticed the had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she should have called the physician for oxygen orders. She said she should have care planned the resident's request to not use a humidifier on the oxygen concentrator. She said Resident #3 had been on oxygen since admission according to the nurses' notes. She said if an order is not reconciled correctly it could cause injury to the resident. She said she could not recall the last time staff had not been in-serviced on oxygen therapy care. Observation on 05/25/22 at 9:23 AM revealed oxygen in use sign posted on Resident #3's door after surveyor intervention on 5/24/22. During an interview on 05/25/22 at 9:42 AM with CMA D, said she had worked at the facility for forty years. She said she worked on Unit 2 Hall. She said the nurses were responsible for setting up the oxygen equipment. She said the nurses did all troubleshooting related to oxygen therapy care. She said the facility policy was that no one was to touch anything related to oxygen care other than nurses. She said if she encountered a problem, then she had to contact the nurse. She said she was familiar with Resident #3. She said Resident #3 had been on her hall for about one month. She said she would check on Resident #3 twice a day. She said she noticed Resident #3 took off her nasal cannula on her own. She said she had to remind her that she needed to have it on. She said she knew she had to notify the charge nurse when she saw Resident #3 taking off her oxygen nasal canula. She said she never noticed the tubing lying on the bed. She said infection control was a concern with tubing lying on a resident's bed. She said it should have been bagged while not in use. She said the risk to the resident was infection. She said it had been a long time since she received training on oxygen because she no longer handled oxygen care. Observation and interview on 05/25/22 at 9:51 AM with Resident #3 The oxygen therapy concentrator was operating at a rate of 1.5 LPM while the resident's nasal canula dated 5/20/22 was lying on her pillow not bagged while not in use. The oxygen concentrator was dispersing an unusual amount of heat as you stood by it. The oxygen concentrator had service preventive maintenance dates 2/12/19 and 2/2020 indicating the last time the concentrator was serviced. There was a plastic bag dated 5/20/22 by the resident's bedside table where the nasal cannula should have been stored while not in use. She said the oxygen concentrator dispersed a lot of heat. She said she keeps a fan running in her room to help keep the room cooler. She said the concentrator had not been serviced since she had been using it. The resident said she came to the facility using oxygen at admission. She said the nursing staff did not put the nasal canula on her because she did it herself. She said that she was having to use her oxygen more frequently. She said she had not mentioned it to the nursing staff but, indicated that she would let them know. She said that around the time she was admitted to the facility the nursing staff was not checking her oxygen saturation levels on a regular basis until she said something to them. She said the facility did not have a respiratory therapist. She said that she has refused to use the humidifier since water went up through tubing even with a spacer. During an interview on 05/25/22 at 10:02 AM with CNA/CMA D she said that a nurse should check orders and call physician to verify orders if a resident is needing oxygen and does not have orders. She said she checked on residents every 1-2 hours and made sure they were stabled and that there were no dangers in the room. She said when a resident needs oxygen she takes a concentrator out of the allocated room. She said if she felt the concentrator giving off too much heat, she would remove the concentrator from the room and replace with another machine. She said that she is trained on infection control every couple of months. She said concentrators are to be cleaned weekly by staff. She said that the CNAs notify nurses about anything involving oxygen. She said if she saw a resident's oxygen tubing that was not inside of a bag when not in use, she would replace tubing. She said that the behavior of taking off nasal canula should be care planned. She would notify physician and family that resident takes off the nasal canula on her own frequently. She said the resident should be checked on more frequently because she takes off nasal canula. During an interview on 05/25/22 2:15 PM with the DON, she said she was responsible for ensuring that nurses assessed oxygen concentrator equipment to ensure they were working properly. She said residents were not educated on storing tubing while oxygen was not in use. She said staff had not been in-serviced for oxygen hazard training. She said staff did not accomplish daily safety hazard checks on a routine basis. She said Resident #3 could report her needs to staff. She said Resident #3 did not tell her that her room was hot. She said Resident #3 brought a fan from home on admission for increased air circulation. She said an oxygen concentrator could increase the temperature in a room. She said nurses were responsible for making sure the concentrators worked properly. She said if a concentrator was not working properly, it was tagged for repair and placed in a separate location. She said unused oxygen concentrators that work properly were bagged and then stored in an allocated room by a nurse. She said if a resident needed oxygen a nurse would take a bagged concentrator from the allocated room to the resident in need. She said a maintenance company did repairs as needed. She said the facility did not conduct routine maintenance on their oxygen concentrators. She said the facility did not have a policy that addressed routine maintenance of oxygen concentrators. In a follow-up interview on 05/25/22 03:03 PM the DON said she checked the temperature of concentrators in the building. Resident #3's concentrator read 4 degrees warmer than other concentrators in the building that had been running. She said she replaced the concentrator in Resident #3's room and tagged it for repair. In a follow-up interview on 05/25/22 at 03:45 PM with the DON, she said the facility did not have a policy in place to address oxygen hazards, oxygen concentrator equipment maintenance, oxygen in use postings, and a policy or protocol for ensuring oxygen nasal cannulas are not left exposed to cross-contamination.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 4 residents reviewed for Quality of Care. (Resident #1) LVN B identified a skin shear/abrasion on Resident #1's left gluteal fold on 12/10/21. She did not notify the physician nor obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] This failure could place residents at risk for impaired skin integrity and untreated wounds. Findings included: Record review of Resident #1's Face Sheet, dated 1/26/22, indicated Resident #1, admitted [DATE], was a [AGE] year old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS, dated [DATE], indicated she was able to understand others, make herself understood, and was cognitively intact. Resident #1 required supervision only for transfers, locomotion, dressing, and eating. She required limited assistance of one staff for toileting and personal hygiene. Resident #1 had no impairment in range of motion in upper extremities and impaired range of motion in both lower extremities. Resident #1 was continent of bowel but required intermittent catheterization of bladder. The MDS indicated Resident #1 had three stage 4 pressure ulcers, all of which were present on admission. Record review of Resident #1's care plan, dated 12/20/21, indicated: *11/14/21 noncompliance with medical treatment - Resident turns air overlay off and refuses to use low air loss mattress *6/21/21 resident refuses showers *6/17/21 Resident has pressure injury to right heel, left heel, and sacrum - resident refused Prostat (protein supplement for wound healing) and [MEDICATION(S)] (nutritional supplement for wound healing). *6/17/21 Resident has cognitive impairment and short-term memory problems *5/7/21 Resident requires the use of an air matters to decrease pressure to current wounds - Resident refuses to use an air mattress, she agrees to an overlay but is noncompliant with use of overlay. *5/6/21 Resident will receive treatments per orders - assess and document skin weekly per protocol and PRN with a new skin area noted. Administer wound treatments per orders. *5/2/21 Resident displays manipulative behaviors - Resident denies care was provided, and reports that dressing had been provided, when in fact they had. Resident also insinuates certain care or medications are not being given to her at this facility, but when questioned states she meant the other facility she came from. (The care plan did not list Resident #1's left gluteal wound as a problem, nor indicate goals and interventions for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's nursing notes dated 12/10/21 at 7:43 p.m., by LVN B indicated a new skin shear to resident #1's left gluteal fold measuring 2.5 cm (length) x 3.5 cm (width) with no depth. The note indicated LVN B cleansed the area with normal saline and patted dry, applied collagen (treatment to promote wound healing) and a dry dressing. The note indicated LVN B notified the wound care nurse of the skin shear and treatment. The note did not indicate the physician was notified, that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of facility 24-hour reports indicated: *12/10/21 10p-6a shift, Resident #1 new area to inner left buttock crease. 2.5 cm L x 3 cm W skin shear. Cleansed, applied collagen and dry dressing. *12/11/21 10p-6a shift, Resident #1 new open area to inner left buttock crease. 2.5 cm L x 3 cm W skin shear. Cleansed, applied collagen and dry dressing. *12/12/21 10p-6a shift, Resident #1 new open area to inner left buttock crease. 2.5 cm L x 3 cm W skin shear. Cleansed, applied collagen and dry dressing. There was no indication the physician had been notified of the new wound. Record review of Resident #1's weekly skin assessments dated 12/9/21 and 12/16/21 indicated Resident #1 had existing skin problems. The assessments contained no other information. Record review of Resident #1's wound assessment dated [DATE] indicated a new wound described as an abrasion on Resident #1's left buttock (left gluteal fold), measuring 3.5 cm L x 3.5 cm W x 0.1 cm depth. The left gluteal wound was not included in any prior wound assessments. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no previous order for wound care of left gluteal fold. Record review of Resident #1's TAR for December 2021 included a treatment which indicated cleanse abrasion to left trochanter (left gluteal fold) with normal saline, pat dry, apply collagen to wound bed and cover with [MEDICATION(S)] dressing every 5 days and as needed. The treatment had been administered as ordered. There was no previous treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 1/25/22 at 3:58 p.m., the DON said skin assessments are supposed to occur every week, and that there was a separate assessment for wounds. She said an abrasion should be charted in the nurse's notes, while other wounds should be charted on the wound assessment. During an interview on 1/27/22 at 9:15 a.m., LVN B said she found the wound on Resident #1's left gluteal fold on 12/10/21 when she was doing the treatments for Resident #1's other wounds. LVN B said the area looked like an abrasion or skin shear, and that the top layer of skin was missing. LVN B said Resident #1 was not aware of the wound, and that Resident #1 did not have sensation in her lower extremities. LVN B said after consulting with the treatment nurse she applied collagen and a dressing. LVN B said it would have been her responsibility to call the doctor and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN B said she did not get an order, nor complete a wound assessment. LVN B said she did not put the treatment on the TAR, and that she thought the treatment nurse would have followed up on the wound after being notified of it. During an interview on 1/26/22 at 12:30 p.m., the DON said the wound located on Resident #1's left gluteal fold was described by many different anatomical terms in the record including thigh, inner thigh, upper thigh, upper leg, ischial, left buttock, and trochanter. The DON said all of the terms were referring to the same wound, and the correct anatomical description for that location was left gluteal fold. The DON said the wound was initially identified as a skin shear but was later referred to as an abrasion. During an interview on 1/26/22 at 4:46 p.m., The treatment nurse said she was working as a charge nurse on 12/10/21 when LVN B notified her of the new wound on Resident #1's left gluteal fold. The treatment nurse said she probably told LVN B how to treat the wound, and there was no order for that treatment. The treatment nurse said she did not know what happened after that until she obtained on order for wound care for the left gluteal fold on 12/17/21. The treatment nurse said there should be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/27/22 at 8:35 a.m., NP H said she was first made aware of Resident #1's left gluteal wound on 1/24/22. NP H said there was an on-call physician for weekend call. NP H said the on-call physician would not necessarily communicate with her to inform her of an issue if they received a call from the facility on a weekend. NP H said it would have been appropriate for the facility to notify the physician of a new wound when it was identified. During an interview on 1/27/22 at 12:00 p.m., the administrator said she had reviewed all available documentation, and there was no evidence that the physician was notified of Resident #1's new skin issue (left gluteal fold) on 12/10/21. During an interview on 1/27/22 at 2:30 p.m., Resident #1 said she received help when needed. Resident #1 said she had no idea how or when the wound on her left gluteal fold occurred. Record Review of a Performance Improvement Plan (PIP), dated 1/24/22, indicated wound assessments were not updated by the treatment nurse when assessments were completed. The plan indicated the goal was documentation of assessments and treatments in a timely manner. Record Review of a facility policy titled Weekly Skin Assessments, dated 12/4/12, indicated weekly skin assessments will be done by the wound care nurse. The policy indicated each skin problem should be listed, including skin tears, bruises, rashes, reddened area, any [CONDITION(S)] type areas, calluses, and any abnormality and any condition that requires treatment. Document the treatment order, put on the treatment sheet and initiate treatment. Make proper weekly skin sheets. Reassess and document weekly.

Based on observation , interview and record review, the facility failed to submit a complete and accurate request for Nursing Facility Specialized Services in the LTC Online Portal within 20 business days after the date of the IDT for one of three residents reviewed for PASRR services. (Resident#1) Facility failed to provide a specialized service for a PASRR positive resident as agreed to during Resident #1's IDT meeting; CMWC was initially recommended 3/20/20, however CMWC assessment was not completed until June 2020. This failure could affect the residents with intellectual and developmental disabilities by placing them at risk of not receiving specialized services that would enhance their highest level of functioning. Findings included: Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of revised care plan printed on 1/6/22 indicated effective 2/19/20 Resident #1 had been identified as PASRR positive status due to an intellectual disability. Goal: Resident #1 will maintain highest level of practicable wellbeing. Interventions: follow up with agency representative to ensure recommendations are fully implemented. Record review of admission MDS dated [DATE] indicated Resident #1 was PASRR positive and had an Intellectual disability . Also indicated he had a BIMS score of 12 indicating Resident #1 had moderate impairment. He required extensive assistance with locomotion on and off unit and limited assistance with transfers. Mobility device used was wheelchair. Record review of PASRR Level 1 Screening dated 2/18/20 indicated Resident #1 triggered positive for intellectual disability. Record Review of PASRR Evaluation dated 2/20/20 indicated Resident #1 had an intellectual disability and the local authority recommended specialized OT, specialized PT and DME services to be provided by nursing facility. Record Review of PCSP form dated 3/02/20 indicated Resident #1's Initial IDT meeting on 3/20/20, recommended HC, OT, PT, CMWC. Comments: .He requested new wheelchair to properly fit him. Record Review of Authorization Request for NFSS CMWC form dated 6/8/2020 indicated Resident #1 was total dependent upon a walker or wheelchair for ambulation. His current seating system did not meet the resident's needs because it was heavy making it difficult to ambulate with. It did not provide adequate trunk support and pressure relief. Requested Customized Seating Equipment: Resident #1's current and medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 1/6/22 at 3:15 p.m., Resident #1 was walking down hall using a rolling walker. He voiced no issues or concerns at that time. During an observation on 1/6/22 at 3:18 p.m., Resident #1's custom wheelchair was stored in a building next-door wrapped in plastic and had a sheet of paper with his name on it. During an interview on 1/6/22 at 5:30 p.m., the Administrator, she said she was the Director of Nurses during that time of the incident and the previous the MDS nurse was responsible for handling all the PASRRs, but she no longer worked at the facility. The Administrator said back in 2020 state office had reached out to them and informed them that they were delinquent submitting CMWC paperwork because it was well passed the 20 days' timeframe. She said at the time Resident #1 had declined wanting the wheelchair and the facility disregarded getting Resident #1 the wheelchair since he no longer requested to have it. The Administrator said she did not know the facility was still supposed to get the wheelchair due to the original agreement from 3/20/20 IDT meeting. She said after facility was informed that they were delinquent and had to get Resident #1 the wheelchair they completed the assessment in June 2020, and he was approved for wheelchair. The Administrator said Resident #1's custom wheelchair was kept in storage until he was ready to use it. She said it was plain a simple, they were supposed to get the CMWC paperwork submitted within 20 days, and they did not.

Based on interview and record review, the facility failed to ensure a referral for possible serious mental disorder was completed for 3 of 5 residents reviewed for PASRR. (Resident #s 11, 9, and 47) The facility did not have an accurate PASRR level 1 screening for Resident #11 and did not refer the resident for a PASRR Level 2 assessment. The resident was admitted with [DIAGNOSES REDACTED]. The facility did not have an accurate PASRR level 1 screening for Resident #9 and did not refer the resident for a PASRR Level 2 assessment. The resident was admitted with [DIAGNOSES REDACTED]. The facility did not have an accurate PASRR level 1 screening for Resident 47 and did not refer the resident for a PASRR Level 2 assessment. The resident was admitted with [DIAGNOSES REDACTED]. This failure could place the residents diagnosed with [REDACTED]. Findings included: 1. Physician orders [REDACTED].#11 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. A PASRR Level 1 Screening dated 09/27/19 indicated Resident #11 did not have an indication for mental illness. There was no updated PASRR Level 1 Screening for Resident #11. The annual MDS dated [DATE] indicated Resident #11 in Section A1500 was checked no for PASRR and in Section I an active [DIAGNOSES REDACTED]. A care plan initiated on 06/03/19 and reviewed on 10/01/19 indicated Resident #11 had a decline in interest or pleasure in doing things with interventions to monitor patterns of target behaviors, assess for changes in mood status, and assess for medication therapy. An order dated 01/20/20 indicated Resident #11 was to start on [MEDICATION NAME] (antipsychotic) with a [DIAGNOSES REDACTED]. A care plan initiated on 02/25/19 and reviewed on 10/01/19 indicated Resident #11 had periods of delusions with interventions including to document and notify physician of hallucinations as needed. During an interview on 0[DATE] at 03:01 p.m. the DON and assistant administrator said Resident #11's PASRR Level 1 Screening was incorrect. They said it should have been positive and a PASRR Level 2 Evaluation should have been done with the [DIAGNOSES REDACTED]. She said with the new [DIAGNOSES REDACTED]. 2. Physician orders [REDACTED].#9 was an [AGE] year-old male admitted on [DATE] with [DIAGNOSES REDACTED]. An order dated 05/05/19 indicated Resident #9 received [MEDICATION NAME] (antidepressant) for major [MEDICAL CONDITION]. An order dated 02/22/17 indicated Resident #9 received [MEDICATION NAME] (antipsychotic) for [MEDICAL CONDITION]. A PASRR Level 1 Screening dated 11/15/18 indicated Resident #9 did not have an indication for mental illness. The annual MDS dated [DATE] indicated Resident #9 in Section A1500 was checked no for PASRR and in Section I an active [DIAGNOSES REDACTED]. A care plan initiated on 11/10/19 indicated Resident #9 had depression with interventions including evaluate effectiveness of medication and side effects and notify physician. A care plan initiated on 05/11/18 indicated Resident #9 was taking [MEDICAL CONDITION] medication [MEDICATION NAME] with interventions including monitor effectiveness of the [MEDICAL CONDITION] medication. During an interview on 0[DATE] at 03:01 p.m. the DON and assistant administrator said Resident #9's PASRR Level 1 Screening was incorrect. They said it should have been positive and a PASRR Level 2 Evaluation should have been done with the [DIAGNOSES REDACTED]. 3. Physician orders [REDACTED].#47 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An order dated 02/11/17 indicated Resident #47 received [MEDICATION NAME] (anticonvulsant to treat certain psychiatric disorders) for [MEDICAL CONDITION] disorder. An order dated 09/20/19 indicated Resident #47 received [MEDICATION NAME] (antipsychotic) for [MEDICAL CONDITION] disorder. The PASRR Level 1 screening dated 11/25/15 indicated Resident #47 had no indication of mental illness. The annual MDS dated [DATE] indicated Resident #47 in Section A1500 was checked no for PASRR and in Section I active [DIAGNOSES REDACTED]. A care plan date 09/20/19 indicated Resident #47 was taking [MEDICAL CONDITION] medication [MEDICATION NAME] for hallucinations with interventions including monitor effectiveness of the [MEDICAL CONDITION] medication. A care plan initiated on 06/04/19 indicated Resident #47 had hallucinations and delusions with interventions including administer behavior medications ([MEDICATION NAME] and [MEDICATION NAME]) as ordered by the physician. During an interview on 0[DATE] at 03:01 p.m. the DON and assistant administrator said Resident #47's PASRR Level 1 Screening was incorrect. They said it should have been positive and a PASRR Level 2 Evaluation should have been done with the [DIAGNOSES REDACTED]. During an interview on 0[DATE] at 04:40 p.m. the facility was asked for additional information at exit, no additional information was provided.

Based on interview and record review, the facility failed to ensure [MEDICAL TREATMENT] service were provided consistently based on professional standards of practice, and the comprehensive care plan for 1 of 2 resident reviewed for [MEDICAL TREATMENT] services. (Resident #71) The facility did not have a physician order for [REDACTED]. This failure could place residents who received [MEDICAL TREATMENT] at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Physician order dated January 2020 indicated Resident #71 was a [AGE] year-old male, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] in Section O: Special Treatments, Procedures and Programs indicated Resident #71 received [MEDICAL TREATMENT]. The care plans last updated 01/22/20 did not indicate Resident #71 received [MEDICAL TREATMENT] services. During an interview on 0[DATE] at 11:01 AM LVN B said Resident #71 has no physician order for [REDACTED]. The LVN said they had one communication form from the [MEDICAL TREATMENT] dated [DATE] in his chart. The LVN said she sent a form with him to [MEDICAL TREATMENT] for them to fill out and it never comes back with him. She said she asked him, and he said they do not ask for the form. The LVN said they had not contacted the [MEDICAL TREATMENT] center to have them send the communication form for the [MEDICAL TREATMENT] visit. During an interview on [DATE] at 11:33 AM LVN/AIT C said they were aware Resident #71 did not have a physician order to be sent to [MEDICAL TREATMENT], a care plan denoting [MEDICAL TREATMENT] or the communication form from [MEDICAL TREATMENT]. The LVN/AIT said the nurses should have informed someone that could do something about not receiving the communication form from [MEDICAL TREATMENT]. During an interview on [DATE] at 11:35 AM MDS D said Resident #71 did not have a care plan for [MEDICAL TREATMENT]. During an interview on [DATE] at 11:41 AM the DON said she could not believe there was not been a care plan for Resident #71 [MEDICAL TREATMENT]. During an interview on 0[DATE] at 3:10 PM the DON said they do not have a policy for [MEDICAL TREATMENT]. A Long Term Care Facility Outpatient [MEDICAL TREATMENT] Services Coordination Agreement, signed by the facility Administrator on 08/04/17 and [MEDICAL TREATMENT] representative on 09/25/17 indicated .E. Mutual Obligations: 1. Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Long Term Care Facility and [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit. Documentation shall include, but not be limited to, participation, as members of an interdisciplinary team, in care conferences, continual quality improvements program .The [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit shall keep the original STCP and LTCP in the medical record of the [MEDICAL CONDITION] Resident and the Long Term Care Facility shall maintain a copy.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 2 errors out of 31 opportunities resulting in a 6% error rate involving Resident #s 8 and 59) MA A did not administer Resident #8 Tums (antacid) as ordered by the physician. MA A did not administer Resident #59 [MEDICATION NAME] 500 mg (diabetic medication) as ordered by physician. This failure could place residents receiving medications at risk for not receiving the intended therapeutic benefit of the medications. Findings included: 1. During an observation of the medication pass on 01/21/20 at 3:41 PM, MA A administered Resident #8 Tums two tablets chewable. A physician order [REDACTED].#8 was to receive Tums one tablet three times a day. 2. During an observation of the medication pass on 01/21/20 at 3:35 PM, MA A administered Resident #59 [MEDICATION NAME] 500 mg one tablet without food. A physician order [REDACTED].#59 was to receive [MEDICATION NAME] 500 mg one tablet twice a day, take with food. During an observation on 01/21/20 at 3:35 PM, Resident #59 did not receive a snack with the [MEDICATION NAME], she did not have any food in her room. During an observation on 1/21/20 at 4:45 PM evening meal was served. During an interview on 01/223/20 at 9:23 AM, the DON said she just wanted to know who made the errors, she needed to in-service them. An Administering Medications policy dated December 2012 indicated .3. Medications must be administered in accordance with the orders, including any required time frame. 4 . medication must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) During an interview on 0[DATE] at 4:40 PM the facility was asked for additional information at exit, no additional information was provided.

Based on observation, interview and record review, the facility failed to prepare and serve food under sanitary conditions in the kitchen. The facility did not acquire pasteurized eggs for serving fried eggs for breakfast for residents. This failure could place residents who want fried eggs for breakfast at risk of dissatisfaction with meals. Findings included: During an observation of the kitchen on 01/27/19 at 2:30 PM, there were no pasteurized eggs in the refrigerator. During an interview on 01/27/19 at 2:32 PM, Cook G said she makes fried eggs and points to the supply of eggs in the cooler. She was told to use them. When she was asked if the eggs were pasteurized, she asked what is pasteurized? During an interview on 01/27/19 at 3:50 PM, the Dietary Manager (DM) looked over the box of eggs in the cooler and he did not find pasteurized marked any where on the box or the eggs. He said how did they let me order these eggs? He said he did not know how long it has been since they had pasteurized eggs. The current Week at a glance menu, dated (YEAR)-19, being used indicated on Monday breakfast the residents were to have egg of choice-1 each The food supplier account invoice dated 1/22/19 indicated the facility ordered egg, SHL X-LG GRD AA WHT FRESH 15 dozen. Shipment was received on 01/23/19. During and interview on 01/27/19 at 2:45 PM Resident #16 said she received runny yolk fried eggs. During an interview on 01/27/19 at 3:04 PM Resident #55 said she received cold sunny side up eggs and sometimes she has to send them back to the kitchen because the whites are snotty. A dietary services policy dated (MONTH) 2014 indicated .11. Only pasteurized shell eggs will be cooked and served when: Residents request undercooked, soft-served or sunny side up eggs: .12. Unpasteurized eggs will be cooked until all parts of the egg (yolk and whites) are completely firm (internal temperature of 160 degrees) .

Based on interview and record review, the facility failed to develop a baseline care plan for each resident within 48 (forty-eight) hours of admission, failed to include the required minimum healthcare information, and failed to provide a written summary of the baseline care plan to the resident and resident representative for 8 of 29 residents reviewed for baseline care plans. (Resident #s 3, 13, 23, 24, 25, 46, 371, and 372) The facility failed to ensure baseline care plans were fully developed within 48 hours of admission and the resident/resident representative received a written summary for Resident #s 3, 13, 23, 24, 25, 46, 371, and 372. This failure could place newly admitted residents at risk of not receiving information regarding care and services. Findings included: 1. A face sheet printed 01/30/19 indicated Resident #3 was an [AGE] year-old male who admitted on [DATE] with [DIAGNOSES REDACTED]. A baseline care plan dated 07/27/18 did not provide information on physician orders, dietary orders or social services. There was no documentation the resident or the representative were provided a written summary of the baseline care plan. 2. The admission MDS dated [DATE] indicated Resident #23 was a [AGE] year-old male who admitted on [DATE]. A face sheet printed 01/30/19 indicated [DIAGNOSES REDACTED]. A baseline care plan dated 03/09/18 did not provide information on dietary orders or social services. There was no documentation the resident or the representative were provided a written summary of the baseline care plan. 3. Physician orders [REDACTED].#371 was an [AGE] year-old male admitted [DATE] with [DIAGNOSES REDACTED]. A baseline care plan dated 1/14/19 for Resident #371 indicated there was no documentation the resident or resident representative were provided a summary of the baseline care. 4. Physician orders [REDACTED].#372 was a [AGE] year-old female admitted [DATE] with [DIAGNOSES REDACTED]. A baseline care plan dated 1/16/19 for Resident #372 indicated there was no documentation the resident or resident representative were provided a summary of the baseline care. 5. Physician orders [REDACTED].#46 was an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. MEDICATION ORDERS FOR [REDACTED]. Diet orders for (MONTH) (YEAR) included regular diet with no sugar added. A baseline care plan for Resident #46 with a start date of 09/28/18 indicated Resident/Representative was involved/informed of care plan on 10/01/18 (3 days after admission); had start dates of areas on the care plan as 10/01/18 (3 days after admission); did not include the resident's [DIAGNOSES REDACTED]. There was no indication a copy was provided to the Resident/Representative on 10/01/18. 6. Physician orders [REDACTED].#13 was [AGE] year-old female, admitted on [DATE] with [DIAGNOSES REDACTED]. An undated electronic baseline care plan for Resident #13 did not have documentation the resident/responsible party was provided a summary of the baseline care plan. 7. Physician orders [REDACTED].#24 was an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. An electronic record dated 09/05/18 for Resident #24 indicated the baseline care plan was not completed until the comprehensive care plan was completed on 09/05/18. There was no documentation the resident/responsible party was provided a summary of the baseline care plan. 8. Physician orders [REDACTED].#25 was a 91-year- old female admitted on [DATE] and had [DIAGNOSES REDACTED]. The clinical record dated 4/16/18 for Resident # 25 indicated the baseline care plan was complete, there was no indication the resident or resident representative was provided a summary. During an interview on 01/29/19 at 04:00 PM the DON said the baseline care plans do not always get done within the specified 48 hours and that residents and resident representatives are verbally informed of the plan of care, but are not provided with a written summary. A Care Plans Baseline Policy dated (MONTH) (YEAR) indicated that a baseline care plan to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The Policy Interpretation and Implementation indicated: 2.including but not limited to a. initial goals ., b. physician orders, c. dietary orders, d. therapy services, e. social services, and f. PASARR recommendations . Item number 4 indicated that The resident and their representative will be provided a summary of the baseline care plan .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each (including procedures that assure accurate storage and discarding of expired medications in 2 of 3 medication carts (100/200 Hall and the 200/300 Hall nurse cart) and 1 of 1 medication rooms reviewed for pharmacy services. The facility did not maintain the 100/200 hall nurse cart it contained insulin vials and inhalers with no open dates and expired insulin. The facility did not maintain the 200/300 hall nurse cart it contained inhalers with no open dates and expired insulin. The facility did not maintain the medication room it contained eye drops with no open date and expired medications. This failure could place residents at risk of not receiving the therapeutic benefits of their prescribed medications. Findings included: During an observation and interview with LVN B on 01/28/19 at 09:55 a.m., the following was noted on the 100/200 Hall nurse cart: * a vial of [MEDICATION NAME] with no open date; * a vial of [MEDICATION NAME] R with an open date of 12/10/18, 49 days after opening; * a vial of Humalog with an open date of 12/18/18, 41 days after opening; and * a [MEDICATION NAME] Inhaler with no open date. LVN B said insulin and inhalers should have an open date and short acting insulins were only good for 28 days and should be removed. During an observation and interview with LVN D on 01/28/19 at 10:10 a.m., the following was noted on the 200/300 Hall nurse cart: * a Humalog insulin pen with an open date of 12/26/18, 33 days after opening; and * a [MEDICATION NAME] Inhaler with no open date. LVN D said short acting insulins were only good for 28 days and should be removed and inhalers should have open dates on them. During an observation and interview with MA E on 01/29/19 at 10:30 a.m., the following was noted in the medication room: * a Kardex of Trazadone 50mg expired on 11/30/18; in the residents' individual slotted spaces; * a bottle of Latanoprost solution 0.005% eye drops with no open date in the refrigerator; and * a vial of [MEDICATION NAME] with an expiration date of 01/04/19 in the refrigerator. MA E said eye drops should have an open date on them and expired medications should be pulled and discarded. During an interview on 01/29/19 at 04:34 p.m. the DON said expired medications should be removed from resident use and open dates should be put on eye drops, inhalers, and insulins. An Insulin Administration policy revised (MONTH) 2014 indicated Steps in the Procedure: 4. Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening). According to the manufacturer package insert for Humalog Insulin revised 11/2015 16.2 Storage and Handling: Do not use after the expiration date. In-use HUMALOG vials, cartridges, and HUMALOG Kwik Pen should be stored at room temperature, below 86°F (30°C) and must be used within 28 days or be discarded, even if they still contain HUMALOG According to the manufacturer package insert for [MEDICATION NAME] approved by the FDA dated 11/2018 indicated the prefilled pen could be used 28 days after opening. According to the manufacturer package insert for [MEDICATION NAME] (latanoprost) eye drops revised (MONTH) 2011 Storage: Protect from light. Store unopened bottle(s) under refrigeration at 2° to 8°C (36° to 46°F). During shipment to the patient, the bottle may be maintained at temperatures up to 40°C (104°F) for a period not exceeding 8 days. Once a bottle is opened for use, it may be stored at room temperature up to 25°C (77°F) for 6 weeks. According to the manufacturer package insert for [MEDICATION NAME] inhaler revised (MONTH) (YEAR) 16 How Supplied/Storage and Handling: After assembly, the [MEDICATION NAME] RESPIMAT inhaler should be discarded at the latest 3 months after first use or when the locking mechanism is engaged, whichever comes first

Based on observation, interview, and record review, the facility failed to ensure drugs were labeled in accordance with currently accepted professional principles for 1 of 3 medication carts (200/300 Hall nurse cart) and to secure all medications in 1 of 3 medication carts (100/200 Hall nurse cart). * The facility did not ensure medications on the 200/300 Hall nurse cart had an pharmacy label. * LVN A did not close the bottom drawer of the medication cart when she locked the cart She went into a room and was not within the line of site. These failures could put residents at risk for not receiving the intended therapeutic benefit of their medications and treatment and drug diversion. Findings included: 1. During an observation and interview on 01/28/19 at 10:10 a.m. of the 200/300 Hall nurse cart with LVN D indicated: * 2 bottles of [MEDICATION NAME] tablets with no prescription label; and * a [MEDICATION NAME] pen with no prescription label. LVN D said all medications were to have a prescription label. A Labeling of Medications Containers Policy revised (MONTH) 2007 indicated Policy Statement: All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations 2. During an observation and interview on 01/27/19 at 04:55 p.m. LVN A removed needed items from the 100/200 Hall nurse cart. The bottom drawer contained resident medications and locked narcotic drawers. She locked the cart but the bottom drawer was not closed. LVN A said the cart was to be locked with all drawers closed but sometimes the drawers did not close all the way. She said she should have made sure the drawers were closed completely. A Storage of Medications Policy revised (MONTH) 2007 indicated Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use During an interview on 01/29/19 at 04:34 p.m. the DON said medications should have prescription labels and all drawers were to be secured before the medication cart was locked.