Every finding on record at Friendship Manor Nursing & Rehab Center

Based on observation, interview, and record review, the facility failed to provide adequate supervision and functioning elopement prevention measures for one resident (Resident 1). As a result, Resident 1 exited the facility without staff knowledge and was later located outside the facility, placing Resident 1 at risk for serious injury or death. Findings: A review of Resident 1's admission record indicted Resident was admitted to the facility on [DATE] with initial admission on [DATE] with a diagnosis that included paranoia schizophrenia (a serious mental health condition that affects how people think, feel and behave.) On 7/8/26 at 10:34 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated on 6/30/26 at approximately 10:20 P.M., Resident 1 left through hall four egress undetected, using a stolen fob key (small electronic device that allows various functions such as locking, unlocking). The DON stated Resident 1 then used the same fob key to exit the chain linked door, scaled perimeter towards outdoor area of the skilled nursing facility side, then jumped over the low fence out into the street. The DON stated during morning rounds Resident 1 was unable to be located in the facility. The DON stated on 7/4/26, Resident 1 was located and brought back to the facility. The DON stated a staff member left the fob key unattended, and Resident 1 was able to get the fob key and use the fob key to exit the facility. The DON stated the fob key should never be left unsecured. On 7/10/26 at 1 P.M., a telephone interview was conducted with licensed nurse (LN 1). LN 1 stated she was in the locked unit for P.M. shift and received endorsement from the morning shift nurse. LN 1 stated when logging in the fob key she noticed a missing fob key. LN 1 stated she did not notify the DON or Administrator of missing fob key. LN 1 stated she should have escalated the situation to the DON or Administrator when she realized a fob key was missing. A review of the facility policy titled Behavioral Health Elopement, revised date 1/16/26, indicated, To establish a clear, effective process for preventing elopement .2. If a resident is noted to be missing during rounds, notify charge nurse so a search of the area can be started

Based on observation, interviews, and record review the facility failed to implement measures to prevent pressure injury (damage to the skin and underlying tissue caused by prolonged pressure on a specific area of the body) when there was no monitoring for the use of a protective head gear (helmet) for one of the two residents reviewed for pressure injury. (Resident 2).This failure had the potential to cause the development of pressure injury.Resident 2's record was reviewed. Resident 2 was readmitted to the facility on [DATE], with diagnoses which included right hemiparesis and hemiplegia (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) and epilepsy (a condition where a person's brain activity becomes abnormal, causing seizures), per the facility's admission Record.On 7/21/25 at 9:16 A.M., an observation was conducted with Resident 2 in her room. Resident 2 was seated in the wheelchair with the helmet on. Resident 2 was non- verbal, but she was able to answer questions by nodding her head.A record review of Resident 2's nursing readmission record, dated 6/17/25, there was no documentation of the protective head gear as a medical device used for Resident 2.A record review of Resident 2's Treatment Administration Record (TAR) indicated no monitoring was in place to assess the skin potentially being affected by the use of a protective helmet.On 7/21/25 at 3:25 P.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 2 used the helmet when she is out of bed or in her wheelchair.On 7/22/25 at 1:07 P.M., an interview was conducted with a certified nursing assistant (CNA) 1. CNA 1 stated Resident 2 used the helmet when she was out of bed and when seated in her wheelchair. CNA 1 stated the Helmet was to protect her head due to her head surgery. CNA 1 stated whoever the CNA was assigned to Resident 2 would place the helmet on when she was up and would remove the helmet when Resident 2 was back in bed.On 7/23/25 at 10:49 A.M., an observation was conducted with Resident 2 in her room. Resident 2 was up in her wheelchair wearing the helmet.On 7/23/25 at 4:15 P.M, an interview and joint record review was conducted with LN 2. LN 2 stated there was no order found for the use of the helmet and there was no documentation found in Resident 2's TAR that skin integrity was assessed and monitored when Resident 2 used the helmet. LN 2 stated it was important to monitor the skin integrity to prevent pressure injury from the helmet.On 7/24/25 at 8:49 A.M., an interview was conducted with CNA 2. CNA 2 stated Resident 2 used the helmet when she was up in the wheelchair. CNA 2 stated the helmet should be tight enough to ensure the head was stable and not moving. CNA 2 stated she would put the helmet on Resident 2 and would remove it when Resident 2 returned to her bed. On 7/24/25 at 1:29 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that there should have been an order obtained for the helmet and staff should be monitoring the skin to ensure that there were no pressure injury for the use of the helmet.A review of the facility's procedures, titled Prevention of Pressure Injuries, revised on 4/20, indicated . provide information regarding identification of pressure injury risk factors and interventions for specific risk factors.Device - related pressure injuries.review and select medical devices.to minimize tissue damage.monitor regularly for comfort and signs of pressure - related injury. Monitoring . Evaluate, report and document potential changes in the skin.

Based on observation, interview and record review, the facility failed to assess and change a peripherally inserted central catheter line (PICC - a long, thin, flexible tube inserted into a vein in the arm and threaded into a large vein near the heart) dressing for one of 18 sampled resident (Resident 40).This failure had the potential for medical complications related to Resident 40's intravenous (IV - delivery of fluids, medications, or nutrients into the body's bloodstream, usually through a needle or catheter inserted into a vein) therapy. According to the facility's admission Record, Resident 40 was admitted on [DATE] with diagnoses that included chronic osteomyelitis (bone infection) of the left ankle and foot. A record review of Resident 40's physician's order report indicated on 6/14/25 there was an order for PICC line dressing change .every 7 days .measure external length of catheter and upper arm circumference.On 7/21/25, at 9:02 A.M., an observation and interview was conducted with Resident 40 in his room. Resident 40 was observed with an IV line on his right upper arm. Resident 40 refused to show the IV dressing and stated he does not remember when the dressing was changed last.On 7/22/25 at 2:42 P.M., a concurrent interview and record review was conducted with licensed nurse (LN) 6. A review of Resident 40's medication administration record (MAR - a detailed chart or document used in healthcare settings to keep track of every medication given to a patient) for July 2025 indicated that on 7/12/25, Resident 40's PICC line external catheter was not measured and the dressing was not changed as ordered by the physician. LN 6 stated that PICC line care was not done and should have been done.On 7/24/25, at 2:20 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 40's PICC line dressing was not changed but should have been.According to the facility's policy titled Central Venous Catheter Care and Dressing Changes, dated October 2024, the staff must .5. Change the dressing .every 7 days .8. For PICCs, measure arm circumference .

Based on interview and record review, the facility failed to ensure the pharmacy consultant identified irregularities during a medication regimen review for one of three residents (Resident 1) reviewed for medications. In addition, the facility failed to ensure a pharmacy recommendation for labs was acted upon for Resident 1. These failures placed resident 1 at risk for adverse consequences due to receiving an excessive dose of a medication, and lack of laboratory tests to monitor drug levels. Findings: According to the Admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses which included kidney transplant and immunodeficiency (a weakened immune system) due to medications. A review of Resident 1 ' s After Visit Summary (a document from the hospital which provided instructions for Resident 1 and included a medication list) dated 9/19/24 indicated, tacrolimus (a medication given to organ transplant recipients designed to prevent organ rejection) 0.5MG capsule .Take 2 capsules (1mg) by mouth every morning AND 3 capsules (1.5mg) every evening . A record review of Resident 1 ' s Order Summary Report indicated, tacrolimus Oral Capsule 5mg Give 3 capsule by mouth in the morning for immunosuppression [lowering the body's ability to fight infection] . and Tacrolimus Oral Capsule 5mg .Give 3 capsule by mouth in the evening for immunosuppression . On 1/2/25 at 11:05 A.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated when Resident 1 was admitted , all medication orders, including the dose, were verified with the primary care physician. After the orders were verified, an admission nurse used the Hospital After Visit Summary to transcribe Resident 1 ' s medications into the facility ' s Electronic Health Record (EHR). The ADON stated Resident 1 ' s tacrolimus order was mistakenly entered into the EHR for 5 mg instead of 0.5 mg. The ADON stated Once the orders are in [the EHR], the pharmacy lets us know if there are any issues . and a Medication Regimen Review (MRR-a review by a pharmacist of all medications a patient is currently using designed to prevent, identify, report and resolve medication-related problems, or other irregularities) is conducted by the pharmacy consultant. The ADON stated the error was not identified, and Resident 1 received the incorrect dose of tacrolimus throughout her stay at the facility. On 1/2/25 at 1:44 PM, a telephone interview was conducted with the Pharmacy Consultant (PC) 1. PC 1 stated he performed an Interim Medication Regimen Review (MRR) for Resident 1 on 9/20/24. PC 1 stated he did not identify the error in Resident 1 ' s tacrolimus dose. PC 1 stated during the Interim MRR, the After Visit Summary was not available in Resident 1 ' s chart. PC 1 stated the purpose of an Interim MRR was to ensure newly admitted residents ' medications were reviewed. PC 1 stated all future MRR ' s were performed monthly by another Pharmacy Consultant. PC 1 stated , .[The Interim MRR] is not intended to be an all-inclusive review .I ' m looking for things that would most likely to be harmful to [the resident] or to the practitioner . A review of Resident 1 ' s MRR dated 9/22/24 indicated, To comply with CMS regulations which require monitoring of drug-related lab work, please ask the MD if we can obtain an order for the following lab work for monitoring purposes .Tacrolimus . A review of resident ' s EHR did not indicate the laboratory tests were done to measure Resident 1's tacrolimus level per PC 2 ' s recommendations. On 1/13/25, a telephone interview was conducted with Pharmacy Consultant (PC) 2. PC 2 stated the recommendation to obtain a tacrolimus level was not done by the facility. PC 2 stated, .obtaining [tacolimus] levels would have identified an irregularity, yes. PC 2 stated a second recommendation to obtain Resident 1 ' s tacrolimus level was given to the facility on [DATE]. A review of Resident 1 ' s MRR dated 10/25/24 indicated, To comply with CMS regulations which require monitoring of drug-related lab work, please ask the MD if we can obtain an order for the following lab work for monitoring purposes: Lipids, Tacrolimus, HgA1c . A handwritten note under Follow-Through indicated, [Resident 1] D/C [discharged ] home. On 1/21/25 an interview was conducted with the Director of Nursing (DON). The DON stated, I would expect [the pharmacy] to find irregularities with any new admits [medications] .I would expect them to do a thorough review of medications . The DON stated it was important for pharmacy recommendations to be completed by the facility to prevent harm for patients if they receive medications. A review of the facility ' s policy titled Medication Regimen Reviews, revised May 2019, indicated, The MRR involves a thorough review of the resident ' s medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses .d. inadequate monitoring for adverse consequences .9. An irregularity .may also include the use of medication without adequate monitoring, in excessive doses, and or in the presence of adverse consequences .

Based on interview and record review, the facility failed to ensure one of three residents reviewed for medications (Resident 1) was free from significant medication errors when the prescribed dose of tacrolimus (a medication given to organ transplant recipients designed to prevent organ rejection) was not given per physician ' s orders. This failure placed Resident 1 at risk for adverse effects and health decline. Findings: During a record review on 1/3/25, the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included kidney transplant and immunodeficiency (the body ' s inability to fight against infection) due to drugs. The Admission Record indicated Resident 1 was discharged home on 10/26/24. During a record review on 1/3/25, the After Visit Summary (a document from the hospital which provided instructions for Resident 1 including a medication list) dated 9/19/24 indicated, tacrolimus 0.5MG capsule .Take 2 capsules (1mg) by mouth every morning AND 3 capsules (1.5mg) every evening [to equal 2.5 milligrams per day] . During a record review on 1/3/25, Resident 1 ' s Order Summary Report indicated, tacrolimus Oral Capsule 5mg Give 3 capsule by mouth in the morning for immunosuppression (lessen the body ' s ability to fight infection) . and Tacrolimus Oral Capsule 5mg .Give 3 capsule by mouth in the evening for immunosuppression [to equal 25 milligrams per day] . On 1/3/25 an interview was conducted with the Director of Staff Development (DSD). The DSD stated the medication tacrolimus was incorrectly entered into Resident 1 ' s chart as 5mg instead of 0.5mg when she was admitted . As a result, Resident 1 was given a total of 25mg per day, which is a higher amount of the medication than the physician ordered. On 1/3/25, a review of Resident 1 ' s Medication Administration Record indicated Resident 1 received 25mg daily for 29 out of 37 days during her admission. On 2/5/25 at 8:53 A.M., an interview was conducted with the Medical Director (MD). The MD stated it was important for Resident 1 to receive the correct dose of the medication. The MD stated a higher dose of the medication, .potentially could have led to adverse effects, such as infection . The MD stated it was his expectation for staff to administer the correct dose of the medication. A record review was conducted on 2/3/25. The facility ' s policy titled Administering Medications revised 4/19 indicated, Medications are administered in a safe and timely manner, as prescribed .

Based on interviews and record reviews, the facility failed to ensure one of four nursing staff reviewed had the required continuing education and state certifications for working with the facilty resident population. This failure placed up to 11 residents at risk for harm due to a lack of required education related to patient care. Findings: On [DATE] an unannounced visit was made to the facility in response to a Facility Reported Incident. On [DATE], at 10:24 A.M., a record review of a facility Performance Improvement Plan (PIP), dated [DATE], and interview was held with the Director of Nursing, (DON), and the Administrator (ADM). The PIP reflected a Certified Nursing Assistant (CNA 1) had an expired license as of [DATE], but had been working full time assisting residents and providing care. The ADM stated that there was a lapse in checking licenses; the current Director of Staff Development (DSD) was transferred from another position and was unaware of the cancelling of the COVID blanket waiver that allowed a CNA to work for a period of time without a license due to delays in issuing licenses. On [DATE] at 10:44 A.M., a record review of CNA 1's personnel file was held with the DSD. CNA 1's employment application, dated [DATE], reflects CNA license number 0120xxxx. CNA 1's CNA license was issued [DATE], and expired [DATE]. The last employee review, dated [DATE] reflected that CNA 1 needed to attend required trainings and complete the CNA renewal. Also, CNA 1 had a position change, effective [DATE], from CNA to Direct Care Partner (DCP). On [DATE] at 10:58 the Director of Nursing (DON) was interviewed regarding the differences between a CNA and a DCP. The DON stated the DCP does not involve patient care. DCP tasks would be to assist with interviews, do paperwork, fetch tissues, any non-care task; a DCP could not assist with dressing, feeding, brushing hair or teeth, or any other resident care. The DON also stated that CNA 1 was utilized as a CNA, providing care, until [DATE]. The DON stated there was an unawareness of the change in status for CNA 1 from CNA to DCP in [DATE]. On [DATE] at 12:15 P.M., an interview was held with the DSD. The DSD confirmed that CNA 1 still does not have a new license. The DSD stated she is now aware that CNA 1 should not have been on the schedule to work with a resident providing care. On [DATE] at 2:03 P.M. a second interview was held with the DON and the ADM. The ADM stated having unlicensed staff giving direct care could cause harm to residents; not enough training for the requirements needed to care for the residents. The DON stated for patient safety, personnel need to have knowledge to take care of the resident's medical needs. The document, Duties and Responsibilities of the In-Service Director/Educator (DSD), dated 2003, reflected Administrative Functions include: .Assist licensed nursing personnel (i.e. RNs, LVNs, and Nurse Aides) in obtaining in-service training to keep their license current in accordance with state law.

Based on interview and record review, the facility failed to ensure staff completed annual Federal mandatory abuse training for one of one employee (licensed nurse 1 {LN 1}, reviewed for abuse. As a result, all residents were at risk for possible staff to resident abuse (verbal, physical, financial, sexual, neglect and isolation). Findings: On 5/30/24 an unannounced visit was made to the facility in response to a complaint with an allegation of abuse. A record review was conducted on 5/30/24 at 11:54 A.M., of LN 1's employee file. LN 1 was hired in 5/21/18. LN 1's employee file did not contain evidence of annual mandatory abuse training. Proof of LN 1's last abuse training was requested from the Director of Staff Development (DSD). An interview was conducted with certified nursing assistant 1 (CNA 1) on 5/30/24 at 12:23 P.M. CNA 1 stated abuse training was mandatory and should be done at last once a year. CNA 1 stated abuse training was provided in-person by the DSD and a course was also available on-line. CNA 1 stated abuse training was important to keep the resident's safe and to remind staff what could be considered abuse. An interview and record review was conducted with the DSD on 5/30/24 at 12:33 P.M. Documentation was provided of LN 1 last attending an in-person abuse training on 12/29/22. The DSD stated LN 1 was hired on 5/21/18, then went on leave from 6/20/23 through 2/15/24. The DSD stated she could not find any documentation evidence LN 1 had any abuse training since returning to work February 2024. The DSD stated the facility offered abuse training both in-person and on-line every quarter. The last training was in January 2024. The DSD stated LN 1 should have been provided abuse training upon return in February 2024, but was not. An interview was conducted with the Director of Nursing (DON) on 5/30/24 at 12:41 P.M. The DON stated abuse training was provided to staff and was mandatory on an annual basis. The DON stated the facility often conducts abuse training to staff after any allegations of abuse. The DON stated the training was important for all staff, so they could recognize and handle different situations with residents, to avoid future allegations of abuse. The DON stated LN 1 did not have his annual abuse training and he should have, immediately upon return to work in February 2024. According to the facility's policy, titled In-Service Training, Resident Rights, dated August 2006, .1. All employees are required to attend out facility's resident rights and abuse prevention program in-service training sessions prior to having any resident contact. 2. Our facility's resident rights abuse prevention in-service programs consist of the following information: .b. A review of the facility's abuse prevention and reporting policies and procedures .

Based on interview and record review, the facility failed to ensure the licensed nurse (LN) re-checked the resident's blood pressure (BP - a measure of the heart pumping blood around the body) after administering the medication as ordered by the physician for 1 of 4 sampled residents (1). This failure could delay Resident 1's care needs. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), per the Admission Record. A review of Resident 1's medical record was conducted. Per the Physician's Order dated 9/29/23, the LN was to administer Clonidine Hydrochloride (a medication to lower the BP) three times a day as needed, give if the systolic BP is greater than 160, and re-check the BP after 15 minutes. Per the Resident 1's Weight and Vital Signs Summary: On 1/7/24 at 8 A.M., Resident 1's BP was 184/94 On 1/7/24 at 8:13 A.M., Resident 1's BP was 162/84 On 1/7/24 at 9:40 A.M., Resident 1's BP was 102/54 On 1/7/24 at 10:35 A.M., Resident 1's BP was 102/84 A review of Resident 1's Medication Administration Record, dated 1/7/24. LN 4 administered Lisinopril (a medication to lower the BP) 40 milligrams (mg) and Clonidine Hydrochloride 0.1 mg for a BP reading of 162/84. There was no documented evidence that Resident 1's BP was re-checked after 15 minutes. On 1/18/24 at 3:45 P.M., an interview was conducted with LN 4. LN 4 stated that the Certified Nursing Assistant (CNA) told her Resident 1's BP was 180, and she checked the BP with a manual BP machine, which was 160 plus [162/84]. LN 4 stated Resident 1 had routine BP medication and an as-needed order, and she administered the medicines together. LN 4 further said she continued her medication administration and saw Resident 1 when the family member was present and requested assistance around 10 A.M. On 1/24/24 at 3:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the physician's order was to give Clonidine when the BP was above 160 and to re-check in 15 minutes; the LN should have followed the physician's order, and there was no evidence that the LN did so. Per the facility's policy and procedure, titled Physician Orders, dated 1/17, Orders for medications and treatments will be consistent with principles of safe and effective order .

Based on interview and record review the facility failed to ensure the staff followed the facility ' s policy on abuse when the alleged staff was assigned to the Resident (1) for the rest of the shift after an allegation of abuse. As a result, there was a potential Resident 1 was unprotected from further abuse. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder. A record review of Licensed Nurse (LN) 1's progress note, dated 1/16/23 at 12 A.M., indicated Certified Nurse Assistant (CNA) 21 informed LN 1 and LN 2 Resident 1 had accused CNA 21 of sexual abuse and kicking. The note did not indicate the Administrator (ADM), or other authority were immediately notified of the alleged abuse. On 1/30/23 at 10:17 A.M., an interview was conducted with CNA 22. CNA 22 stated if there was an allegation of patient abuse, a report must be made immediately to the charge nurses and the ADM. On 1/30/23 at 10:54 A.M., an interview was conducted with LN 2. LN 2 stated she was working the night the Resident 11 made an allegation of abuse against CNA 21. LN 2 stated she did not inform the ADM of the allegation until later that morning. LN 2 stated when a resident made an allegation of abuse, a report should be made immediately to the ADM and the incident must be documented. On 1/30/23 at 11:40 A.M., an interview was conducted with the ADM. The ADM stated the staff should have reported the allegation of abuse to the ADM immediately. The ADM stated she was notified of the allegation of abuse later in the morning. The ADM stated the LN should have reported it to the charge nurse and assigned another CNA or LN to provide care to Resident 11 for the rest of the shift. On 1/30.23 at 12:53 P.M., an interview with LN 3 was conducted. LN 3 stated an allegation of abuse by a resident should be reported to the ADM right away. LN 3 stated the alleged staff should not have taken care of the resident anymore. On 1/30/23 at 1:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated LN 1 was the nurse assigned to Resident 1 on the overnight shift. The DON stated, LN 1 did not report the allegation to anyone during his shift. On 1/30/23 at 1:53 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated LN 1 reported the abuse allegation in the morning. The DSD stated the CNA should not have been assigned to the resident for the rest of the shift and should have been suspended. On 1/30/23 at 4:31 P.M., an interview was conducted with LN 1. LN 1 stated he was informed the allegation occurred when CNA 21 was providing toileting assistance to Resident 1. LN 1 stated he did not witness the event. LN 1 stated CNA 21 continued to work with Resident 1 for the rest of the shift. LN 1 stated he notified the DSD at the end of the shift when the DSD arrived at the facility the morning of 1/16/23. LN 1 stated the facility policy was to report allegations of abuse as soon as possible or at least by the end of the shift. LN 1 stated, if it was required to be reported immediately to the administrator, it was my fault, that did not happen. On 1/31/23 at 8:32 A.M., an interview was conducted with CNA 21. CNA 21 stated the allegation of rape and hitting happened around 12 A.M. on 1/16/23 when she was cleaning Resident 1 after a bowel movement. CNA 21 stated she continued to work with Resident 1 for the remainder of the shift. A record review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, indicated: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2.Immediately is defined as: 3. Within two hours of an allegation involving abuse or result in serious bodily injury; or

Based on interview and record review, the facility failed to ensure the staff followed policy and procedure when the staff did not report an allegation of verbal abuse for one of three sampled residents (Resident 3). As a result, Resident 3 was not protected from inappropriate language use from another resident. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/21/22 a review of records was conducted. Per Resident 2 ' s Behavior Note dated 11/15/22 at 11:40 PM, indicated Resident 2 made inappropriate language and comments to Resident 3 throughout the evening shift. On 11/21/22 at 4:43 P.M, an interview with Licensed Nurse (LN) 3 was conducted. LN 3 stated Resident 2 and 3 were roommates on 11/15/22, evening shift. LN 3 stated she heard Resident 2 said bad words to Resident 3 and to the staff. LN 3 stated since Resident 2 was not physically threatening to Resident 3, she did not think it needed to be reported. On 11/21/22 at 4:53 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the staff should have reported the alleged incident between Resident 2 and Resident 3. The DON stated an investigation should have been conducted on the incident. On 11/21/22 at 5:09 P.M., an interview with LN 4 was conducted. LN 4 stated the language Resident 2 used were considered aggressive and said without respect to Resident 3 and was a form of verbal abuse. LN 4 stated this incident should have been reported to the Director of Nursing (DON), Administrator (ADM) and Social Services (SS). On 11/21/22 at 5:24 P.M., an interview with the ADM and DON was conducted. The ADM stated LN 3 should have reported it to her. The ADM stated Resident 2 and Resident 3 should have been separated immediately and monitored. On 11/22/22 at 11:57 A.M., an interview with CNA 4 was conducted. CNA 4 stated on 11/15/22, he and everyone heard Resident 2 was verbally aggressive and used inappropriate language to Resident 3. CNA 4 stated this incident should have been reported to the ADM who was the facility ' s abuse coordinator. On 11/22/22 at 1:50 P.M., an interview with the Director of Social Services (DSS) was conducted. The DSS stated any incident where a resident used inappropriate or threatening language to another resident should have been reported to the DON and ADM and appropriate agencies notified. Per the facilty ' s policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 09/2022, .Policy Interpretation and Implementation .1. If resident abuse, .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.

Based on observation and interview, the facility failed to ensure sanitary conditions were maintained when one can of condensed milk was dented, and two cans of white hominy (a type of corn from white corn kernels) had rusted lid and were not removed from the storage. These failures had the potential to cause widespread food borne illnesses among residents who consume food from the kitchen. Findings: On 8/8/22 at 11:05 A.M., an observation and interview were conducted with the Certified Dietary Manager (CDM) of the dry storage room. On the shelf, one can of condensed milk was dented. On the lower shelf, 2 cans of white hominy had rusted lids. The CDM stated she and the staff checked the storage room every day for outdated food items, dented cans, and rusty lids. The CDM further stated, those canned food items should have been removed from the shelf. Per the facility's policy, dated 2020, titled Storage of Food and Supplies, indicated .15. Foods in unlabeled rusty, leaking, broken containers or cans with side seam dents, rim dents or swell shall not be retained or used.

Based on observation, interview, and record review, the facility failed to observe infection control measures when: 1. Nursing staff failed to properly disinfect resident's glucometer for four randomly selected residents (Residents 241, 46, 67, 34) according to manufacturer's specifications. 2. Nursing staff failed to remove personal protective equipment gown after resident care prior to leaving resident room. 3. Tube feed formula was not discarded upon completion. 4. Tube feed tubing was not labeled. 5. An indwelling catheter bag was in contact with the floor. These deficient practices have the potential for the development and the spread of infection to all residents. Findings: 1. During a medication pass observation on 8/8/22 at 8:07 A.M., at North Station, Hall 1, LN 60, LN 60 was observed using a glucometer to check Resident 67's concentration of blood glucose. LN 60 was observed wiping the glucometer with bleach disposable wipes for approximately 12 seconds, then placing the glucometer on the medication cart. During a medication pass observation on 8/8/22 at 9:07 A.M., at North Station, Hall 1, with LN 60, LN 60 was observed using a glucometer to check Resident 34's concentration of blood glucose. LN 60 was observed wiping the glucometer with bleach disposable wipes for approximately 12 seconds, then placing the glucometer on the medication cart. During a medication pass observation on 8/8/22 at 11:44 A.M., at South Station, Hall 4, with LN 41, LN 41 was observed using a glucometer to check Resident 46's concentration of blood glucose. LN 41 was observed wiping the glucometer with alcohol wipes for approximately 7 seconds, then placing the glucometer on the medication cart. During a medication pass observation on 8/8/22 at 12:14 P.M., at South Station, Hall 4, with LN 41, LN 41 was observed using a glucometer to check Resident 241's concentration of blood glucose. LN 41 was observed wiping the glucometer with alcohol wipes for approximately 7 seconds, then placing the glucometer on the medication cart. During an interview on 8/8/22 at 3:18 P.M., with LN 41, LN 41 stated, Before you start, you have to clean with alcohol wipes and after you use it you have to clean . When asked about contact time (time for bleach wipes to effectively killing pathogens), LN 41 stated, contact time is to make sure all bacteria or pathogen is cleaned off glucometer. LN 41 acknowledged she did not use the appropriate wipes to disinfect the glucometer and did not allow for contact time after using the glucometer to check Resident 46 and 241's blood glucose. During an interview on 8/8/22 at 4:17 P.M., with LN 60, LN 60 stated, she had cleaned the glucometer before and after using it. LN 60 stated, she was unaware what the contact time and reviewed the manufacturer specification for the bleach wipes. LN 60 stated the contact time for the bleach wipes was two minutes and acknowledged she did not allow contact time for two minutes after using the glucometer to check Residents 67 and 34's blood glucose. During an interview on 8/8/22 at 4:32 P.M., with the DSD, the DSD stated, the expectation was for nursing staff to sanitize the glucometer after each use and to follow manufacturer's instructions for wet to dry time. The DSD stated, If not disinfected, not killing pathogens effectively . using glucometer for other patient so can transmit pathogen. During an interview on 8/11/22 at 2:29 P.M., with the DON, the DON stated, anytime glucometer is used, expectation for nursing staff to disinfect glucometer according to manufacturer and allow wet to dry time before using it on another patient . important for infection control, making infections don't spread across the facility. During a review of the manufacturer's instructions for dwell time for the bleach wipes provided by the facility, the manufacturer's instructions indicated, Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry. During a review of the facility's policy and procedure titled, Assure Platinum Glucose Monitor Cleaning/Disinfecting, indicated, The glucose meter should be cleaned and disinfected after use on each patient. Commercially available EPA-registered disinfectant or detergent of germicide wipe may be used to clean and disinfect the Assure Platinum Glucose Meter. Open disinfectant package. Follow product label instructions to disinfect the meter. 2. During a medication pass observation on 8/8/22 at 12:02 P.M., at South Station, Hall 4, LN 41 was observed wearing personal protective equipment gown out of Resident 289's room after patient care, to medication cart in the hallway. During a medication pass observation on 8/8/22 at 12:14 P.M., at South Station, Hall 4, LN 41 was observed wearing personal protective equipment gown out of Resident 241's room after patient care, to medication cart in the hallway. During an interview on 8/8/22 at 3:23 P.M., with LN 41, LN 41 acknowledged she did not remove her gown after performing patient care for Residents 289 and 241, prior to leaving the residents' room. LN 41 stated, Wear gown for contact precaution so we don't share bacteria or virus to other patients . Yes, supposed to take off gown before leave room . if don't remove gown, going back and forth to medication cart can cause contamination. During an interview on 8/9/22 at 9:39 A.M., with the DSD, the DSD stated, expectation for nursing was, Every time you exit room, you have to do doffing-removing of gown, and when you enter, have to do donning (put on gown) all over again . important because once you go in, its considered contaminated and you don't want to contaminate other residents. During an interview on 8/11/22 at 2:29 P.M., the DON, the DON stated, any time glucometer is used, expectation for nursing staff to disinfect glucometer according to manufacturer and follow wet to dry time before using it on another patient . important for infection control, making sure staff is staff, and making sure infections don't spread across the facility. During a review of the facility's policy and procedure titled, Personal Protective Equipment (PPE), indicated, Doffing (taking off) PPE: Remove gown or upper torso covering with sleeves. Disrobe in a manner that prevents touching of the outside of the garment. Dispose in trash receptable if disposable, or place in laundry receptacle if reusable. HCP[healthcare professional] may now exit resident room. 3. Resident 241 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/8/22 at 9:19 A.M., an observation, interview and record review with LN 41 of 241's room was conducted. The following was noted hanging at Resident 241's bedside: 8/6/22 hung at 1800PM Water flush bag 200cc's 8/7/22 hung at 1800PM Water flush bag 300cc's 8/7/22 hung at 1800PM Tube feed 300cc's 8/8/22 hung at 0050AM Tube feed 200cc's LN 41 validated the above findings. LN 41 stated, she was not sure why the bags of tube feeds and water flushes were still hanging in Resident 241's room. A review of Resident 241's MAR (medication administration record) with LN 41 indicated, tube feedings of Fiber Source HN (a supplemental nutritional formula) at 130cc/hr from 6:00 P.M. to 6:00 A.M. via G-Tube (a tube inserted into the stomach for nutrition). LN 41 stated, the bags of tube feed and water flushes should not be hanging as the feedings and water flushes have been completed. LN 41 stated, she was not sure how long the bags of tube feed and water flushes were good for. LN 41 further stated, the tube feed and water flushes should have been thrown away after completion of the tube feeding infusion; to ensure they are not mistakenly given to the resident as they can make the resident sick. On 8/10/22 at 10:56 A.M., an interview with the IPIC (Infection Preventionist Infection Control) nurse was conducted. The IPIC nurse stated, she was not sure how long the bags of tube feeds or water flushes were good for. The IPIC further stated, the tube feeds and water flushes should have been discarded after completion of the tube feed to prevent the resident from potentially getting sick from old tube feed formula. On 8/10/22 at 1:56 P.M., an interview with the DON was conducted. The DON stated, it is the expectation for the staff to dispose tube feeds and flush bags as per the facility policy, and they are not. A review of the facility's policy titled, Ready to Hang Tube Feed Formula - Suggested Setup Procedure, not dated, indicated, .the maximum safe hangtime is 24 hours . 4. Resident 241 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/8/22 at 9:19 A.M., an observation, interview and record review with LN 41 of 241's room was conducted. The following was noted hanging at the bedside: 8/6/22 hung at 1800PM Water flush bag 200cc's; Tubing with no label, date and time 8/7/22 hung at 1800 Water flush bag 300cc,s; Tubing with no label, date and time 8/7/22 hung at 1800PM Tube feed 300cc's; Tubing with no label, date and time 8/8/22 hung at 0050AM Tube feed 200cc's; Tubing with no label, date and time LN 41 validated the above findings. LN 41 stated, the tube feed and water flush tubing where not labeled with a date and time. LN 41 stated, she was not sure how long the tubing for the tube feed or water flush was good for. LN 41 stated, the tubing for the tube feed and water flush should have been labeled in order to know when it needed to be change. On 8/10/22 at 11:00 A.M., an interview with the IPIC nurse was conducted. The IPIC nurse stated, she was not sure how long the tubing for the tube feed or water flush was good for. The IPIC further stated, the tubing for the tube feed and water flush should have been labeled in order to maintain safe infection control practices. On 8/10/22 at 1:56 P.M., an interview with the DON was conducted. The DON stated, it was the expectation for the staff to follow the facility infection control policy in order to prevent the spread of infection to residents and staff. A review of the facility's policy titled, Best Practice Guidelines for Tube Feeding Appendix D: Preventing Contamination of Formula and Delivery System, dated 1997-2006, indicated, .4. Change tubing at least every 24 hours . 5. Resident 78 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 8/10/22 at 9:00 A.M., in Resident 78's room, Resident 78 was in a reclined position in his bed, with an indwelling urinary catheter (a tube in the bladder to drain urine). Resident 78's catheter bag was on the floor. During an interview with CNA 1 on 8/10/22 at 9:45 A.M., CNA 1 stated, indwelling urinary catheter bags should be off the floor at all times to prevent infection. During an interview with LN 1 on 8/10/22 at 2:54 P.M., LN 1 stated, part of the catheter care was to make sure drainage bags were placed below the bladder of the resident and should not be touching the floor to prevent infection. During an interview with IPIC on 8/11/22 at 8:03 A.M., IPIC stated, it was very important for indwelling catheter drainage bags not be on the floor to prevent infections. During an interview with the Director of Nursing (DON) on 8/11/22 at 10:30 A.M., the DON stated, LNs should make sure indwelling drainage bags were off the floor at all times. DON further stated, indwelling catheter drainage bags touching the floor was an infection control issue and should have been avoided. Per the facility's policy titled Urinary Tract Infections ( Catheter- Associated), Guidelines for Preventing, revised September 2017, .6.Maintain .Do not place the drainage bag on the floor

Based on interview and record review, the facility failed to ensure professional standards of practice were followed for one of 21 sampled residents (48) when the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: Resident 48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/22 at 2:48 P.M., Resident 48's record review was conducted. Resident 48 was discharged to the general acute hospital on 6/15/22 due to chest pain and she was readmitted back to the facility on [DATE]. The Medication Reconciliation / Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/22 at 3:07 P.M., an interview was conducted with Licensed Nurse (LN) 31. The LN 31 stated, Resident 48 was receiving [MEDICATION(S)] Insulin (medication for blood sugar) according to her Insulin sliding scale (Medication dose based on the blood sugar level). On 8/11/22 at 10:26 A.M., a concurrent interview with LN 32 and review of Resident 48 record was conducted. LN 32 stated, the Medication Reconciliation/Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LN 32 stated the order for [MEDICATION(S)] Insulin sliding scale was missing the additional instruction which indicated If patient receives evening snack (2100), administer one-half (1/2) the calculated sliding scale dose. LN 32 reviewed Resident 48's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/11/22 at 10 A.M., an interview was conducted with CNA 36. CNA 36 stated, Resident 48 received snacks at night. On 8/11/22 at 10:51 A.M., an interview was conducted with Resident 48. Resident 48 stated she received snacks at night. On 8/11/22 at 11:30 A.M., an interview was conducted with the DON. The DON stated, Medication Reconciliation /Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's provided policy, dated November 2017, titled Physician Medication Orders, indicated . 4. orders must be transcribed immediately in the resident's chart by the person receiving the order .

Based on observation, interview, and record review, the facility failed to ensure the manufacturer's setting for air loss mattress was followed for one of 21 sampled residents (Resident 339). This failure had the potential to affect Resident 339's skin integrity and comfort. Findings: Resident 339 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/9/22 at 11:04 A.M., an observation and interview were conducted with Resident 339. Resident 339 was in his bed. Resident 339 was awake and responded verbally. He stated he was tired after his therapy. Resident 339 stated dressing on his right and left lower leg were changed daily. Resident 339 observed to have an air loss mattress in his bed. The air loss mattress setting was set on # 5 or equivalent to 210 pounds. Resident 339 stated his weight was about 300 pounds. On 8/10/22 at 9:17 A.M., an observation and interview were conducted with Resident 339. Resident 339 was in bed and stated that he had pain in his indwelling catheter site (soft, plastic or rubber tube that is inserted into the bladder to drain the urine) and uncomfortable in bed. Resident 339 refused his dressing changed and repositioned in bed. Resident 339 air loss mattress setting was #5 or equivalent to 210 pounds. On 8/10/22 at 10:06 A.M., an interview was conducted with Licensed Nurse (LN) 31. LN 31 stated the setting for Resident 339 air loss mattress was incorrect. The mattress setting should have been based on resident's weight. LN 31 stated that Resident 339 air loss mattress should have been set at # 7 which was equivalent to his weight. Joint record review was conducted with LN 31. LN 31 stated Resident 339 weight as of 8/6/22 was 300.2 lbs. On 8/10/22 at 10:12 P.M., an interview was conducted with LN 41. LN 41 stated, Resident 339 air loss mattress was set to #5. LN 41 stated, the number displayed on the panel should have been based on the weight and comfort of the resident. On 8/10/22 at 10:31 A.M., a joint record review and interview was conducted with the DON. The DON stated correct setting for the air loss mattress was very important to prevent skin breakdown and distribute the patient's body weight. A review of the user manual for air loss mattress, provided by the facility, page 22 indicated . The Comfort Control LED displays the patient comfort pressure levels from 0-9 and provides a guide to the caregiver to set approximate comfort pressure level depending on the patient weight .

Based on observation, interview and record review, the facility failed to ensure that fall prevention interventions were implemented for one Resident (64). In addition, the facility failed to ensure adequate supervision to residents when an exit door was propped open. This failure caused Resident 64 to experience a fall and the potential for residents to go outside the facility without staff supervision. Findings: 1. Resident 64 was admitted to the facility on [DATE] with diagnoses that included right sided stroke and [CONDITION(S)] (muscle weakness that affects one side of the body) and [CONDITION(S)] ([CONDITION(S)] on one side of the body), per the facility's Admission Record. An observation of Resident 64 was conducted on 8/8/22 at 3:00 P.M. Resident 64 was reclining in bed watching TV. A review of Resident 64's fall risk assessment, dated, 7/5/22 indicated a score of 20 (high risk). A review of Resident 64's record was conducted on 8/9/22 at 9:15 A.M. The record indicated Resident 64 had a fall on 7/24/22. The change of condition (COC): indicated .patient had an assisted fall @ 9:30. During the transfer from bed to wheelchair (w/c), the left side of the w/c started to roll, causing the patient weights shifted on her right sided weakness, CNA eased her down to the floor . An interview was conducted on 8/10/22 at 9:32 A.M., with certified nurse assistant (CNA) 11. CNA 11 stated, Resident fell while I was transferring her; she is a 2-person transfer; I assisted her to the ground. I called for help (for the transfer) and I should have waited for help and done a 2-person transfer. The ADL (activities of daily living) care plan says 1-2 person transfer. An interview was conducted with the director of nursing (DON) on 8/10/22 at 9:57 A.M. The DON stated, The CNA could not support the resident's weight; the resident sometimes needs 2 person assist, care plan says 1-2. A joint interview was conducted with the DON and Administrator (admn) on 8/11/22 at 11:13 A.M. The admn and DON stated, The CNA should have called for help to prevent falls. A review of the facility's policy, dated 4/2018, titled, Fall/Accident Management, indicated, .the facility strives to provide each resident with adequate supervision and assistance to minimize the risks associated with falls . 2. On 8/8/22 at 12:50 P.M., an observation was conducted during the initial screening. The exit door leading to the smoking area was opened. The door was propped with a piece of wood. An unsampled resident (55) was seen wheeled outside the door by a visitor; no alarm was triggered and no staff present at the smoking area. A sign inside the door above the fire alarm indicated Close door at all times. On 8/8/22 at 1:02 P.M., an interview was conducted with CNA 37. CNA 37 stated the door should be closed at all times. CNA 37 stated, the door was propped open during the smoking time. The door will alarm only for those residents who have WanderGuard bracelet (a device that trigger alarm for residents trying to leave unattended) On 8/8/22 at 1:10 P.M., an interview was conducted with the Admission Coordinator, who was assigned to supervised residents during the scheduled smoking time. The Admission Coordinator stated, the exit door should be closed at all times to make sure residents were monitored and supervised during smoking times. On 8/9/22 at 4:03 P.M., an observation of the exit door propped open. An interview was conducted with CNA 38. CNA 38 stated, the exit door was opened with a piece of wood until 5:00 P.M. Residents were observed going in and out of the exit door. There was no staff at the smoking area. On 8/11/22 at 7:30 A.M., an interview was conducted with the Maintenance Director. The Maintenance Director stated, all exit door should be closed at all times and should not be propped open to ensure the safety of the residents. On 8/11/22 at 11:36 A.M., an interview with the DON was conducted. The DON stated, exit doors should be closed at all times. A review of the facility's policy, dated 7/1/20, titled Safety Supervision of Residents, indicated . Resident safety and supervision and assistance to prevent accidents are facility - wide priorities . Resident supervision is a core component of the system approach to safety . The facility did not provide a specific policy regarding doors.

Based on observation, interview and record review, the facility failed to provide appropriate care and treatment to a Gastrostomy Tube (GT, a tube placed surgically directly into to the stomach to deliver liquid food) for one of one sampled resident (Resident 82) when the LN did not verify GT placement prior to administering medication. This failure increased the risk for Resident 82 to develop complications related to improper GT placement. Findings: During a medication pass observation on 8/8/22 at 9:28 A.M., at North Station, Hall 1, with LN 60. LN 60 prepared Resident 82's medications which included a [MEDICATION(S)] (medication for seizures and mental disorders). LN 60 used a stethoscope (medical instrument for detecting sounds) to hear Resident 82's bowel sound. LN 60 then administered Resident 82's medications through the GT and restarted the liquid food. During an interview on 8/8/22 at 4:25 P.M., with LN 60. LN 60 acknowledged she did not check Resident 82's gastric residual volume prior to administering [MEDICATION(S)]. LN 60 stated, We are supposed to check gastric residual volume [GT placement] before giving medication. During an interview on 8/8/22 at 4:32 P.M., with the DSD. The DSD stated, the nursing staff was expected to check gastric residual volume for residents with GT prior to administering medications. The DSD stated, We want to make sure resident not getting too much fluid. During an interview on 8/11/22 at 2:29 P.M., with the DON. The DON stated, Prior to administering medications, nurse should be checking placement for any G-tube medication by aspirating prior to medication administration to verify placement and verify medication correctly . patient could be at risk for vomiting or aspiration if they have too much fluid, so important to check fluid volume . During a review of ASPEN Safe Practices for Enteral Nutrition Therapy, a nationally recognized guideline for enteral nutrition indicated, A gastric residual volume of between 250 and 500 mL should lead to implementation of measures to reduce risk of aspiration

Based on observation, interview, and record review, the facility failed to obtain and follow physician's order for residents receiving oxygen therapy for two of four sampled residents (Resident 25,340). This deficient practice had the potential to result in complications from lack of or excessive oxygen therapy. Findings: 1. Resident 25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/9/22 at 1:45 P.M, an observation with Resident 25 was conducted inside the resident's room. Resident 25 was in her bed and wore a nasal cannula (device used to deliver oxygen through the nose). The oxygen was set and delivered at 4.5 L(litter)/min. On 8/10/22 at 9:39 A.M., an observation was conducted with Resident 25. Resident 25 observed in her bed without an oxygen. On 8/10/22 at 2:44 P.M., a concurrent observation with Resident 25 and an interview with certified nurse assistant (CNA) 36 was conducted. Resident 25 was observed in bed without an oxygen. CNA 36 stated, Resident 25 required oxygen when her blood saturation level was low. On 8/10/22 at 3:13 P.M., an interview was conducted with the Licensed nurse (LN )31. The LN 31 stated, Resident 25 did not require oxygen therapy. Oxygen therapy would have been administered when Resident 25 oxygen saturation level was low. On 8/10/22 at 3:15 P.M., a concurrent record review and interview with LN 31 was conducted. Resident 25's physician order, dated 8/2/22, indicated Oxygen at 2 liters per minute every shift. LN 31 stated, Resident 25 should have received oxygen at 2L/min at all times. A review of Resident 25's undated care plan indicated, Resident 25 oxygen setting was at 2 liters per minute via nasal cannula every shift. 2. Resident 340 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/9/22 at 1:54 P.M., an observation of Resident 340 was conducted in his room. Resident 340 had an oxygen set at 3L (litter)/ (per) minute through nasal cannula (device used to deliver oxygen through the nose). On 8/10/22 at 12:12 P.M., a concurrent observation with Resident 340 and an interview with CNA 36 was conducted. Resident 340 was in bed with the oxygen set at 3.5 L per minute through nasal cannula. CNA 36 stated resident 340 used oxygen at all times. On 8/10/22 at 12:27 P.M., concurrent record review and interview with the LN 31 was conducted. LN 31 stated there was no physician order found for oxygen therapy. LN 31 further stated, Oxygen therapy should have a physician's order. On 8/11/22 at 11:40 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated, licensed staff should have obtained and followed physicians order related to oxygen therapy to make sure that residents received the proper oxygen treatment. A review of the facility policy titled, Oxygen Administration, dated, 7/1/2020, indicated, .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .

Based on observation, interview and record review, the facility failed to ensure a fluid restriction order for a resident (390) having [CONDITION(S)] was followed. This failure had the potential to cause fluid overload for the resident. Findings: Resident 390 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/09/22 at 9:28 A.M., and observation was conducted for Resident 390. Resident 390 was in bed, alert, and eating breakfast (eggs,juice,milk). In addition, there were two plastic (16.9 ounces) water bottles on the overbed table. On 8/10/22 at 8:30 A.M., a review of Resident 390's medical record was conducted. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/22 at 8:56 A.M. a concurrent record review and interview was conducted with the charge nurse (CN). The CN stated, The water bottles should not be there, he is on fluid restriction of 1200 cc per day. Any additional water can cause fluid overload. On 8/11/22 at 11:16 A.M., a joint interview was conducted with the Administrator (admn) and the Director of Nursing (DON). The DON stated, The nursing staff should assess compliance with fluid restriction; it is important so residents can reach their goals. A review of the facility's policy dated,11/2017, titled, [CONDITION(S)] Management, Purpose: to provide residents who require [CONDITION(S)] care, services consistent with professional standards of practice .

Based on interview, and record review, the facility failed to implement its pharmaceutical policies and procedures when nursing staff did not ensure accurate controlled substance (CS, medications that can be easily abused and are under strict government control) accountability for two of two CS records reviewed (for Residents 40 and 88). This failure had the potential for diversion (used illegally) of controlled substance medications (a drug that can be abused or cause addiction). Findings: During an observation on 8/9/22 at 11:18 A.M., with LN 31 at the medication cart on South Station, Hall 3 was inspected. The medication cart was observed to have [MEDICATION(S)]-acetaminophen (controlled pain medication) 5-325 milligrams (mg- unit of measurement) for Resident 40 and [MEDICATION(S)]-acetaminophen (controlled pain medication 5-325mg for Resident 88. During an interview on 8/9/22 at 3:40 P.M., with the DON. The DON was asked for the July 2022 narcotic records for [MEDICATION(S)]-acetaminophen 5/325mg for Resident 40 and [MEDICATION(S)]-acetaminophen 5-325mg for Resident 88. The DON stated, that he was unable to locate the July 2022 narcotic (controlled drugs) records because they were unorganized. When asked what system the facility had in place to periodically reconcile controlled drug records, the DON stated, he was not aware that controlled drug records for schedule II drugs were supposed to be separated and did not separate the controlled drug records. The DON stated, No, we do not have a system to accurately keep track of CII [schedule II drugs] delivery forms. We have some delivery forms but no nurse signatures During a telephone interview on 8/11/22 at 11:20 A.M., with the Independent Consultant RPh (Registered Pharmacist). The IC - RPH stated that he was not familiar with control drug system keeping. During an interview on 8/11/22 at 2:29 P.M., with the DON. The DON stated, that the facility was expected to have appropriated track controlled medication to deter drug diversion. The DON stated, Without a proper system in place, facility at risk for drug diversion. During a review of the facility's policy and procedure titled, Controlled Substance Prescriptions, indicated, Receipt of Orders from Nurse Practitioners, Physician Assistants, Clinical Nurse Specialists, and Pharmacists . applicable formularies, protocols, or prescribing guidelines are kept on file in the facility and area followed closely.

Based on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 25) was free from an unnecessary [CONDITION(S)] (drugs that affects brain activities associated with mental processes and behavior) medication when licensed nurses did not attempt non-pharmacological interventions prior to the use of [MEDICATION(S)] (medication for mental illness), administered multiple medications ([MEDICATION(S)] and [MEDICATION(S)]-medication for depression) for the same indication, and administered [MEDICATION(S)] without appropriate behavioral monitoring. These failures increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of [CONDITION(S)] medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: During a review of Resident 25's Admission Record, dated 8/11/22, the Admission Record indicated, Resident 25 was admitted to the facility on [DATE], and had diagnoses including dementia, [CONDITION(S)], depression, and [CONDITION(S)]. During a review of Resident 25's Order Summary Report, dated 8/11/22, the Order Summary Report indicated a provider order for : 3/8/22 [MEDICATION(S)] 50 mg at bedtime for anti-psychotic/anti-manic 8/1/22 [MEDICATION(S)] 37/5 mg at bedtime for depression 3/8/22 [MEDICATION(S)] 40 mg in the morning for depression 8/1/22 [MEDICATION(S)] 40 mg in the morning for pain During a review of Resident 25's Medication Administration Record (MAR), dated 7/1/22-7/31/22 and 8/1/22-8/31/22, the MAR indicated, Anti-Psychotic monitor of episodes of depression AEB [as evidenced by]: inability to fall asleep drug: [MEDICATION(S)] every shift . antidepressant monitor of depression AEB: verbalization of sadness. Drug: [MEDICATION(S)] every shift. During a concurrent interview and record review on 8/10/22 at 11:26 A.M. with LN 32, Resident 25's medical records and MAR dated 7/1/22-7/31/22 and 8/1/22-8/31/22 were reviewed. LN 32 stated, she was unable to find resident specific behavioral interventions for depression prior to the initiation of [MEDICATION(S)] for Resident 25. LN 32 stated, that maybe there was a certain reason why Resident 25 was sad, and behavioral intervention could help Resident 25, without her needing medication. LN 32 stated, Because of side effects, adding medication that is not really needed and can affect her [Resident 25] kidney and change her behavior. During an interview on 8/10/22 at 2:35 P.M., Resident 25's Physician Order Summary dated 8/11/22, and MAR dated 71/22-7/31/22 and 8/1/22-8/31/22 were reviewed. LN 32 acknowledged [MEDICATION(S)] and [MEDICATION(S)] were both indicated for depression, Resident 25 was being administered both medications concurrently, and both medications were initiated at the same time. LN 32 stated, No, not appropriate for Resident [25] to be on two medications that treat same condition yes, we have both [MEDICATION(S)] and [MEDICATION(S)] for depression, it will enhance toxic effects . no, cannot tell if one drug is lowest effective dose but both started at once. When asked about the behavioral monitoring to evaluate the effectiveness of Resident 25's [MEDICATION(S)] dose, LN 32 stated, They put [MEDICATION(S)] for behaviors of inability to fall asleep. LN 32 acknowledged [MEDICATION(S)] was not indicated for [CONDITION(S)], and inability to fall asleep was not the behavior manifested by Resident 25 for depression. LN 32 acknowledged that Resident 25 had a diagnosis of dementia and [MEDICATION(S)] had a black box warning (BBW- warning required by the government for certain medications that carry dangerous side effects). LN 32 stated, Yes, [MEDICATION(S)] has BBW, increased mortality in elderly patient with dementia . yes this patient [Resident 25] has dementia]. During an interview on 8/11/22 at 10:15 A.M., with the ADON of Resident 25's Hospital Discharge Summary dated 3/8/22, and Facility Psychiatrist Evaluation dated 6/13/22 were reviewed. Resident 25's Hospital Discharge Summary indicated Resident 25 did not have a diagnosis for antipsychotic or anti-manic, and Resident 25 was discharged to the facility on [DATE]. The ADON acknowledged Resident 25 did not have a diagnosis for antipsychotic or anti-manic and stated, No, antipsychotic or anti-manic is not an appropriate indication for [MEDICATION(S)] [brand name for [MEDICATION(S)]] . no history of behavior, can be considered chemical restraint, can have negative outcomes and can affect normal daily life and participating in life. The ADON was unable to provide documentation of a diagnosis of [CONDITION(S)] or manic for Resident 25's Facility Psychiatrist Evaluation. During a telephone interview on 8/11/22 at 10:59 A.M., with MD 60, MD 60 stated Resident 25 was on [MEDICATION(S)] because Resident 25 had agitation and [CONDITION(S)] in the past and would discontinue the medication. During a telephone interview on 8/11/22 at 11:20 A.M., with the IC-RPh (Independent Consultant RPh), the IC-RPh stated, [MEDICATION(S)] was not appropriate for Resident 25 if Resident 25 did not have a history of behavior problems. The IC-RPh acknowledged it was not appropriate to give two medications for the same indication, and stated, .usually start with one [medication] and go slow. During an interview on 8/11/22 at 2:29 P.M., with the DON, the DON stated, [CONDITION(S)] meds should be used appropriately to treat patients who require medication as indicated because patients can experience side effects if used incorrectly non-pharmacological interventions as primary interventions before use of [CONDITION(S)] medications . using two medications at once to treat same condition to treat patient could cause increased side effects . unable to determine if having one medication is effective versus having two medications at once. During a review of the facility's policy and procedure titled, Psychoactive Medications dated 10/17, indicated, The IDT [interdisciplinary team-group of healthcare professionals working together to ensure best care for resident] will check the physician orders for the medication to ensure the order contains the name of the medication, dose, route, times and behavior(s) for which the medication is being administered. The order may also include monitoring requirements for the behavior(s) and the diagnosis