Every finding on record at Glades West Rehabilitation and Nursing C

Based on observations, interviews and record reviews, the facility failed to respond to call lights to provide ADL (Activities of Daily Living) care for 3 of 23 sampled residents reviewed for ADL's (Resident #99, Resident #110, Resident #70).The findings included:A review of the facility's policy titled Call Bell Policy and revised in December 2024 showed the following: Determine the resident's need, if you cannot perform, leave light on, find Nurse or CNA who can assist. Do not walk by. Turn off the call bell once needs are attended to and ensure it is within reach for the next use. Do not make the resident feel you are too busy to assist or respond.1. Record review revealed that Resident #70 was admitted to the facility on [DATE] with diagnoses of Dysphagia following Cerebrovascular Disease and Chronic Obstructive Pulmonary Disease. The Medicare 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed that the Resident Brief Interview of Mental Status (BIMS) score was 08, which indicates moderate cognitive impairment. Section GG of the MDS showed that Resident #70 needs substantial/maximal assistance during toileting hygiene, shower/bath self and is dependent for toilet transfer.During an observation conducted on 12/15/25 at 11:45 AM Resident #70 was seen lying in bed sleeping with a right knee immobilizer on. At that time, Resident #70 woke up and said that she was going to have a bowel movement. Resident #70 used the call light, as suggested by the surveyor. It was noted that the call light was audible at the nurse's station and the light was turned on in the hallway located on top of the room door. During the observation, it was noted that multiple staff members passed by the room and did not respond to the call light. The surveyor went ahead and called a nurse to assist the resident. The nurse answered that she will call a Certified Nurse Assistant (CNA) because she is not a CNA. Resident #70 persistently called out to the surveyor in distress saying: Muchacha Por favor cambiame. This surveyor went back to the room from the hallway more than 6 times and asked multiple nurses for help. All the nurses' answers were that they are busy. Staff A, the Registered Nurse Supervisor came and explained that the designated CNA is busy with another resident, but she is trying to find another CNA. At 12:15 PM, the Director of Nursing came and entered the room trying to calm Resident #70. A CNA later came into the room to change the Resident at 12:25 PM.2. Record review revealed that Resident #110 was admitted to the facility on [DATE] with diagnosis of Displaced Bicondylar fracture of left tibia and encounter for other orthopedic aftercare. The Medicare 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Brief Interview of Mental Status (BIMS) score was 15, which indicates no cognitive impairment. Section GG of the MDS showed that Resident #110 needs partial/moderate assistance during toileting hygiene, Substantial/Maximal Assistance during shower/bath self and toilet transfer is not attempted due to medical condition or safety concerns.During an interview conducted on 12/15/25 at 12:50 PM, Resident #110 stated that the aides take a long time to come to provide ADL care. When a long time was asked to quantify, Resident #110 further explained that today for example she had been waiting since 8:00 AM to get changed and it's already 12:50 PM. Resident #110 expressed that she felt very uncomfortable and dirty.3. Record review revealed that Resident #99 was admitted to the facility on [DATE] with diagnoses of displaced trimalleolar fracture of right lower leg and chronic atrial fibrillation. The Medicare 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident Brief Interview of Mental Status (BIMS) score was 08, which indicates moderate cognitive impairment. Section GG of the MDS showed that Resident #99 is dependent for toileting hygiene, shower/bath self and toilet transfer is not attempted due to medical condition or safety concerns.During an interview, conducted on 12/15/25 at 12:35 PM, Resident #99 stated that her colonic drainage fell out this morning and that she had been sitting in her dirty brief for over an hour now. The resident pointed to a pair of scrubs on a chair and explained that she wanted to wear them but unfortunately, no one came to help her. Resident #99 was very upset and kept on repeating that she wanted to get changed because she was dirty. At 12:40 PM, the paramedics came with a stretcher to take Resident #99 to the hospital to replace her colonic drainage. Resident #99 was screaming that she did not want to go to the hospital with a dirty brief on and that she had been waiting for hours now to get changed. The paramedics left the room and stood outside. At 12:50 PM, staff members were seen entering the room and the nurse stated that Resident #99 was a very complicated resident.During an interview, conducted on 12/18/25 at 10:00 AM, the Director of Nursing (DON) stated that she has been working in the facility for 3 years now. She further explained that a resident having a bowel movement should be cleaned as soon as possible. And that waiting 30 minutes is not an acceptable time to be changed. The DON was made aware of Resident #99 and explained that the CNA had to finish two residents that had appointments and had to go to therapy prior to changing Resident #99. The DON added that the expectation for the call light is to be answered right away.During an interview, conducted on 12/18/25 at 10:15 AM with the Registered Nurse Supervisor, Staff A, she stated that she has been working in the facility for 4 years. She further stated that she works the morning shift: 7:00 AM to 3:00 PM and that she is the Unit Manager on both floors. Per surveyors' question, Staff A answered that when a resident has a bowel movement, the expectation is to call a CNA or provide immediate help. If a CNA is busy a nurse can change the resident or take the resident to the restroom. When a call light is on, a staff member should go to the residents within minutes and a 30-minute wait is not acceptable. Even if a nurse that is not assigned to the wing is aware the call light is on, they should answer the call light regardless. On the day of the incident (12/15/25) Staff A was present and acknowledged that Resident #70 waiting 40 minutes to be changed after having a bowel movement is not up to the facility's standard.During an interview, conducted on 12/18/25 at 10:30 AM with Certified Nurse Assistant (CNA), Staff B, she stated that she has been working for the facility for 9 years. She further stated that she works the morning shift from 7:00 AM to 3:00 PM and the days vary. Per surveyors' question, Staff B answered that the expectation when a resident has a bowel movement is to use the call light. Staff explained that if she is not busy, she responds to the resident right away but if she is with another resident she asks a nurse to assist the resident until she is done and can get to the resident. If she is busy with a resident and the call light of another resident comes on, the nurse must assist the resident for her because it's teamwork.During an interview, conducted on 12/18/25 at 11:10 AM with Certified Nurse Assistant (CNA), Staff C, she stated that she has been working in the facility for 2 years and works the morning shift from 7:00 AM to 3:00 PM. She explained that once she sees the call light on, she has to go immediately to the room. Staff C further explained that if she is busy with a resident and she gets called because another resident is having a bowel movement, she will call another CNA to ask for help. She further explained that It is unacceptable for a resident to wait 30 to 40 minutes to get changed after having a bowel movement.During an interview, conducted on 12/18/25 at 11:00 AM with Licensed Practical Nurse (LPN), Staff D, she stated that she has been working for the facility for 7 months and works morning shift 7:00 AM to 3:00 PM. She explained that even if she is not assigned to a wing and sees a light on, the expectation is to go to the resident and assist. Staff D explained that if the assigned CNA is busy and a resident has a bowel movement, she will change the resident. She further expressed that it is not up to standard for a patient to wait 20 minutes to get changed, the expectation is to change them as soon as they are aware.

Based on review of policy and procedure, observation, record review and interview, the facility failed to 1) obtain a physician's order for Oxygen Administration for 1 of 7 sampled residents observed for continuous Oxygen Therapy, Resident #128; and, 2) follow physician's orders for changing of Nebulizer tubing for 1 of 12 sampled residents observed for Nebulizer Treatments, Resident # 10. The findings included: 1) Review of the facility policy titled Oxygen Administration provided by the Director of Nursing (DON) revised October 2010 documented in the Policy Statement: Purpose---The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation---1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration.Documentation---After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual who performed the procedure. 3. The rate of oxygen flow, route, and rationale. 4. The frequency and duration of the treatment. 5.The reason for p.r.n. administration. 6. All assessment data obtained before, during and after the procedure. 7. How the resident tolerated the procedure.9. The signature and title of the person recording the data. Reporting---2. Report other information in accordance with facility policy and professional standards of practice. Resident #128 was re-admitted to the facility on [DATE] with diagnoses which included Respiratory Failure, Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus Type II and Dementia. She had a Brief Interview Mental (BIM) Status score of 9, indicating moderate cognitive impairment. On 12/15/25 at 9:55 AM and 3:45 PM, during an observational room tour, Resident #128 was observed with Oxygen infusing at three (3) liters per minute via nasal cannula through her Oxygen concentrator; with no current physician's order reviewed, in place. On 12/16/25 at 10:51 AM and 4:03 PM, Resident #128 was observed with Oxygen infusing at three (3) liters per minute via nasal cannula through her Oxygen concentrator; with no current physician's order reviewed, in place. On 12/17/25 at 11:29 AM, Resident #128 was still observed with Oxygen infusing at three (3) liters per minute via nasal cannula through her Oxygen concentrator; with no current physician's order reviewed, in place. Record review of Resident #128's Respiratory Care plan initiated and revised on 10/16/25 indicated Focus: Resident #128 has a potential for complications of respiratory distress related to a diagnosis of: Chronic Respiratory Failure, Congestive Heart Failure (CHF). Interventions:.Oxygen saturations as ordered, Administer Oxygen as ordered, Vitals signs as ordered and as needed, Performs Lung Sounds/Respiratory Assessment as needed.Encourage Coughing and Deep Breathing and Observe signs and symptoms of respiratory infection, update physician if noted. Goals: Resident #128 will be able to maintain patent airway and will not exhibit signs of respiratory distress. And, Resident #128 will not observe signs and symptoms of respiratory distress thru next review date. The initial Physician's Order Sheet (POS) dated for 07/25/25 was reviewed; it only documented to, Monitor vital signs and oxygen saturation daily, and report abnormalities as necessary. Record review of the Physician's Pulmonary Progress Note dated 11/11/25 documented, Oxygen continuous, keep Oxygen saturations > 92%. However, further record review conducted of the Physician's Order Sheet (POS) for the month of December 2025 revealed that there were no current physician's orders for Oxygen therapy administration parameters on file, for this resident, since her re-admission to the facility back in July 2025. Moreover, record review of both the Medication Administration Record (MAR) and of the Treatment Administration Record (TAR) further revealed that there were no current physician's orders for Oxygen therapy administration parameters on file, for this resident. During a brief interview conducted on 12/17/25 at 11:32 AM with the Resident #128's daughter, who had been visiting at the time, she was asked about Resident #128's oxygen use; the resident's daughter responded by saying that her mother had been using her Oxygen regularly, on a daily basis. On 12/17/25 at 11:47 AM an interview was conducted with Staff A, Registered Nurse (RN), Primary Care Nurse and Nurse Supervisor, for the 2nd floor, in which she was asked whether or not Resident #128 had been currently receiving Oxygen therapy. Staff A responded, yes, at three (3) liters. Staff A revealed that she was not aware of how long the resident had been receiving Oxygen. She also acknowledged that there was no current physician's order with parameters, on file for the Oxygen therapy. Staff A was unable to provide an explanation as to why there was no current physician order for the Oxygen. On 12/17/25 at 12:47 PM an interview was conducted with the Assistant Director of Nursing (ADON), in which she was also asked whether or not Resident # 128 was currently receiving Oxygen therapy. She responded by saying, yes, I think the oxygen is set at two (2) liters. She also revealed that she was not aware of exactly how long Resident #128 had been receiving Oxygen. A current physicians' order dated 12/17/25 for continuous Oxygen at two (2) liters/minute via nasal cannula every shift, was not written, until after surveyor inquisition. The DON recognized and acknowledged on 12/17/25 at 2:30 PM that a current physician's order should have been obtained, in a timely manner. The findings included: 2) Review of the facility's policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, dated November 2021, included the following: The purpose of this procedure is to guide the prevention of infection associated with respiratory therapy tests and equipment, including ventilators, among residents and staff.Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol:15. Take care not to contaminate internal nebulizer tubes. 16. Wipe the mouthpiece with damp paper towel or glass sponge. 17. Store the circuit in plastic bag, marked with date and resident's name, between uses. 19. Discard the administration set up every seven (7) days. Record review for Resident #10 revealed the resident was re-admitted to the facility on [DATE] with diagnoses that included: Acute and Chronic Respiratory Failure with Hypercapnia; Dementia; Adult Failure to Thrive; Sepsis, Unspecified Organism. Review of Resident #10's Physician's order dated 11/02/25 for Replace nebulizer tubing and mouthpiece weekly, every night shift every Sunday for Prophylaxis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #10 had a Brief Interview for Mental Status (BIMS) of 00, which indicated that she was rarely understood. During the initial facility tour conducted on 12/15/25 at 9:40 AM, Resident #10 was observed in her bed dressed and her private aide was in the room. Further observation revealed Resident #10's nebulizer mouthpiece was lying on top of the bedside table, not contained in a plastic bag, and the nebulizer tubing was dated 12/01/25, photographic evidence obtained. Another observation was conducted on 12/17/25 at 10:00 AM for Resident #10's nebulizer mouthpiece, which was noted to have been placed in a plastic bag and stored in the bedside table drawer. In addition, the nebulizer tubing was observed to have been changed and was dated 12/15/25, photographic evidence obtained. Review of the December Treatment Administration Record (TAR) revealed nurses documented the nebulizer tubing was changed on 12/07/25 and 12/14/25. During an interview conducted on 12/18/25 at 9:25 AM with Staff G, Licensed Practical Nurse (LPN), who stated that she has been working for a few months. She stated that the oxygen and/or nebulizer tubing was to be changed once a week on Sundays. Staff G also stated If she does not see that the tubing has been changed, she will change it at that time. During an interview conducted on 12/18/25 at 10:21 AM with Staff F, Registered Nurse (RN), who stated she has worked at the facility for one and a half years as a floor nurse, unit manager, and every other weekend as the supervisor. She stated that the oxygen tubing is to be changed weekly or as needed and the tube is to be labeled and the nurse would document the tube has been changed in the TAR as per physician's orders. On 12/18/25 at 11:20 AM the Director of Nursing (DON) was made aware of the above concerns.

Number of residents sampled: 8Number of residents cited: 2Based on observations, interviews, record reviews and policy reviews, the facility failed to ensure residents were free of medication errors for 2 of 8 sampled residents (Residents #30 and #79), as evidenced by a medication error rate of 12.9% as a result of 4 errors made during 31 opportunities.The findings included: Review of the facility's policy titled, Administering Medications, undated, included the following: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and ImplementationThe Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame.Medications must be administered within one (1) hour of the prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.1) Record review for Resident #30 revealed that the resident was admitted to the facility on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), Diverticulum of Esophagus, Acquired, Gastro-Esophageal Reflux Disease (GERD). Review of the physician orders included the following orders:Vitamin B-12 Oral Tablet 100 micrograms (mcg) to give 1 tablet by mouth one time a day for supplement.Ferrous Sulfate Tablet 325 (65 Fe) milligram (mg) to give 1 tablet by mouth one time a day for Supplement.Losartan Potassium Oral Tablet 25 mg to give 1 tablet by mouth one time a day for HTN.Sucralfate 1 Gram Tablet to give 1 tablet by mouth before meals for GERD (caused by stomach acid irritating the esophagus). During a medication administration observation conducted on 12/16/25 at 8:40 AM with Staff E, Registered Nurse (RN), who stated that this was her first day on her own after orientation, however, she was a Licensed Practical Nurse (LPN) at another facility and worked the night shift. Prior to dispensing the above medications for Resident #30, Staff E entered the resident's room and asked if he had finished with his breakfast. Resident #30 stated yes and the breakfast tray was noted to be in the room. She then returned to the medication cart and dispensed all the above medications. Staff E again entered the resident's room and administered all the medications to Resident #30, including Sucralfate 1 Gram, which was to be given before meals for GERD. 2) Record review for Resident #79 revealed that the resident was admitted to the facility on [DATE] with diagnoses that included: Multiple Fractures of Pelvis Without Disruption of Pelvic Ring, Subsequent Encounter for Fracture with Routine Healing, Dry Eye Syndrome of Unspecified Lacrimal Gland, Long Term (Current) Use of Aspirin, Parkinsonism, Hypertension.Review of the physician orders included the following orders:Carbidopa-Levodopa Oral Tablet 25-100 mg to give 2 tablets by mouth three times a day for Parkinson disease.Digoxin Oral Tablet 125 mcg to give 1 tablet by mouth one time a day for Atrial fibrillation.Eliquis Oral Tablet 2.5 mg (Apixaban) to give 1 tablet by mouth every 12 hours for Atrial fibrillation. Acetaminophen Tablet 325 mg to give 2 tablets orally every 6 hours as needed for Mild Pain Not to exceed 3gm/ 3000mg in 24 hours.Aspirin Oral Tablet Chewable 81 mg to give 1 tablet by mouth one time a day for Deep Vein Thrombosis (DVT) prevention.Calcium 600+D3 Oral Tablet 600-5 mg-mcg to give 1 tablet by mouth one time a day for hypocalcemia. Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % to instill 1 drop in both eyes two times a day for Dry Eyes.On 12/16/25 at 8:45 AM, a medication administration observation was conducted with Staff E, RN. She dispensed the following medications for Resident #79: Carbidopa-Levodopa 25-100 mg 2 tablets; Digoxin 125 mcg tablet; Eliquis 2.5 mg tablet; and Acetaminophen 325 mg 2 tablets (Resident #79 requested pain medication). Staff E then stated that Resident #79 gets his medications crushed and these are all his morning medications. Verification of the physician orders and reconciliation of the medications administered to Resident #79, revealed that Staff E did not administer the following three medications that were scheduled to be given in the morning: Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % drops, Calcium 600+D3 600-5 mg-mcg tablet, and Aspirin Chewable 81 mg tablet.Review of Resident #79's Medication Administration Record (MAR) revealed that Staff E documented that she administered all of the medications that were scheduled to be given in the morning of 12/16/25. During an interview conducted on 12/16/25 at 8:54 AM, with Staff E, RN, who stated that she reviews the orders on the computer and the ones on the medication bingo sheet. She was asked to review the order for Resident #30's Sucralfate 1 Gram. She stated that the residents were new to her and did not realize that the medication was to be given prior to breakfast. During an interview conducted on 12/16/25 at 10:25 AM with the Director of Nursing (DON), who was told of the medication errors encountered during medication pass observations. She stated that Staff E came in today to cover for a nurse that called out and that she was to be mentored by Staff F, RN. The DON stated Staff E just finished her orientation but has not done medication pass with her yet. She acknowledged that Staff E should not have been administering medications on her own.

Based on record review, observations, and interviews, the facility failed to obtain physician orders for a skin tear sustained during a fall and failed to perform a dressing change as per professional standards for 1 of 1 sampled resident (Resident #111) reviewed for skin tears. The findings included: Review of the facility's policy, titled, Skin Tear-Abrasions and Minor Breaks, Care of, revised on 09/2013, documented, in part, .establish a clean field .steps in the procedure .wash and dry your hands thoroughly, put on gloves, loosen tape and remove soiled dressing, pull glove over dressing and discard . wash and dry your hands thoroughly .put on clean gloves .cleanse the wound with ordered cleanser, if using gauze, use clean gauze for each cleansing stroke., clean from the least contaminated area to the most contaminated area (usually, from the center outward) . Review of the facility's policy, titled, Handwashing/Hand Hygiene, revised on 08/2015 documented, in part, .use alcohol-based hand rub .or, alternatively, soap and water for the following situations: .after removing gloves .hand hygiene is the final step after removing and disposing of personal protective equipment .perform hand hygiene before applying non-sterile gloves . Review of Resident #111's clinical record documented an admission on 05/21/24 with no readmissions. The resident's diagnoses included Cerebral Infarction, Memory Deficit Following Cerebral Infarction, Pneumonia, and Major Depressive Disorder. Review of Resident #111's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15, indicating the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals the resident needed supervision to partial assistance from the staff to complete the activities of daily living (ADLs). Review of Resident #111's care plan titled, (Resident's name) is at risk for falls and/or fall related injury related to: generalized weakness, limited endurance, impaired balance, unsteady gait, requires staff assist with transfers and ambulation .06/12/24 Resident fell in his room sustained skin tear to right elbow, treatment applied. The care plan was initiated on 05/29/24 and revised on 06/12/24. The care plan documented an intervention that read . Perform frequent checks of resident . The resident's care plan titled, (Resident's name) has a potential for skin impairment / pressure ulcers and is noted to have skin impairment as follows: -gluteal skin tear-groin rash/redness . The care plan was initiated on 05/29/24. Resident #111's skin care plan did not address the resident's skin tear sustained on 06/12/24. Review of Resident #111's clinical record lacked evidence of a written physician order for the resident's skin tear to the right elbow, sustained during a fall on 06/12/24. Review of the resident's Treatment Administration Record (TAR) for June 2024 lacked written evidence of the right elbow skin tear care and treatment. On 06/17/24 at 12:30 PM, observation revealed Resident #111 in his room sitting in a wheelchair. Further observation revealed a dressing on the resident's right elbow, and the dressing date was unreadable. An interview was conducted with the resident who stated that he fell last week ago and the dressing on his right elbow was placed there then. On 06/18/24 at 11:15 AM, observation revealed Resident #111 in his room sitting in a wheelchair. An interview was conducted with the resident who stated he just came back from therapy. Further observation revealed the resident continued to have the same dressing on the right elbow with an unreadable date as observed on 06/17/24. Consequently, a side-by-side observation of the resident's right elbow dressing was conducted with Staff A, Registered Nurse (RN). Staff A asked the resident if he took a shower and the resident replied Yes. The resident was asked when they put the dressing on his elbow and stated, 'when he fell ' and did not recall when the last time was the dressing was changed. Staff A was not aware the resident had a dressing on his elbow. On 06/18/24 at 11:18 AM, a side-by-side review of Resident #111's clinical record was conducted with Staff A, RN. The review revealed a nursing progress note dated 06/12/24 that documented the resident had a fall and sustained a right elbow skin tear. Staff A confirmed there was not a physician's order for the resident's right elbow dressing changes. On 06/18/24 at 11:34 AM, observation for Resident #111's right elbow's dressing care performed by Staff A, RN started. Staff A retrieved a bottle of normal saline solution, a wad of gauze, one bordered dressing, and one Xeroform dressing placed them on a foam tray, entered the resident's room and placed the tray on top of the dresser. Staff A stated the facility protocol for skin tears was to use Xeroform gauze. Observation revealed Staff A performed hand washing, donned a disposable gown and a pair of gloves, placed a red bag on top of the bed and removed Resident #111's right elbow dressing. Observation revealed the soiled dressing had a dried yellow colored gauze, with dried blood, and the resident had a skin (flap) tear. Staff A was asked for the tear measurements and stated it was about one centimeter by 0.5 centimeter (cm). Further observation revealed Staff A folded the soiled dressing gauze in his gloved left-hand fist and discarded it into the red bag. Continued observation revealed Staff A wearing the same pair of gloves, cleaned the skin tear with a soaked saline gauze with a back-and-forth motion, multiple strokes with the same gauze. Staff A discarded the gauze and with the same pair of gloves, retrieved another saline soaked gauze and cleaned the skin tear area back and forth then applied Xeroform gauze to the skin tear. Further observation revealed Staff A removed the pair of gloves and without performing hand hygiene, donned another pair of clean gloves then applied a bordered dressing to the right elbow. Staff A removed the pair of gloves, removed the gown, and reached into his pocket to retrieve a sharpie marker to date the dressing. Staff A then, without hand hygiene, pulled the privacy curtains opened and donned gloves to tighten up the biohazard bag and discard it. On 06/18/24 at 12:15 PM, an interview was conducted with the facility's Wound Care Nurse (WCN) who stated when a resident sustains a skin tear, the floor nurse will write a progress note, and an incident report. The WCN added the nurses usually reports it to her, she would assess, put a treatment order in and will initiate the treatment. The WCN stated she would do measurements and write the type of wound, and if she was not in the facility the floor nurses initiate the treatment and can put an order in for care. During the interview, the WCN added she had a skin care communication slip that the floor nurses can do and leave it for her either on top of the treatment cart or on each floor wound care binder available to them. The WCN stated she was not aware of Resident #111's skin tear to the right elbow sustained during a fall on 06/12/24. On 06/18/24 at 1:35 PM, an interview was conducted with the Director of Nursing (DON) who stated that on 06/12/24, the floor nurse completed Resident #111's fall incident report that indicated the resident had sustained a skin tear to the right elbow but did not initiate the facility's protocol for skin tear care. On 06/19/24 at 9:30 AM, a joint telephone interview was conducted with Staff B, RN and the DON. Staff B stated Resident #111 was trying to go to the bathroom using the walker and the walker did not roll and he fell . Staff B added the resident sustained a skin tear, she cleaned it with normal saline and applied a Tegaderm dressing to the tear. Staff B stated she called the physician and the resident's daughter right after the incident but did not get a reply and informed the nursing supervisor to follow up on. Staff B was apprised that there was a yellowish color gauze under the bordered dressing and the date was unreadable, Staff B added someone else must have changed the dressing because she did not put a yellow (Xeroform) gauze. Staff B was asked if the facility had a protocol for her to follow when the resident sustained a skin tear and stated she did not know. Staff B was apprised there was not a physician's order for Resident #111's skin tear to the right elbow sustained during the fall on 06/12/24. The DON stated the facility has a Skin Tear Protocol batch order, that the nurse needed to activate when it happened, and this was not done by Staff B. On 06/19/24 at 9:40 AM, a joint interview was conducted with the DON and the Staff Development Educator (SDE). The SDE stated the nurses were educated related to the Skin Tear Protocol and how to utilize it. On 06/19/24 at 10:03 AM, a joint interview was conducted with the DON and the Nursing Supervisor. The Nursing Supervisor stated that she recalled Staff B informed her that Resident #111 had a fall and submitted the incident report. The Supervisor stated she then passed the incident report to the DON for the morning meeting. The DON stated she received the report, did the investigation, the MDS coordinate did the care plan, and therapy assessed. The DON was apprised the Wound Care Nurse was not made aware of the resident's skin tear. The DON acknowledged this. The Nursing Supervisor and the DON were apprised of the concerns related to Resident #111's right elbow dressing, the unreadable date of the dressing change, and the lack of physician order to address the resident's right elbow skin tear. On 06/19/24 at 11:24 AM, an interview was conducted with Staff A, RN, who was apprised of wearing the same pair of gloves during Resident #111's right elbow dressing change observation on 06/18/24. Staff A stated he should have removed the gloves after he cleaned the skin tear, performed hand washing or hand sanitation, and donned gloves before applying the treatment (Xeroform gauze).

Based on observations, interviews and record review, the facility failed to store medications in a safe and secure manner for 4 out of 21 sampled residents reviewed for medications at the bedside (Resident #60, #62, #24, #67). The findings included: Review of the facility's policy titled, Storage of Medications included: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 1. During an observation conducted on 04/03/23 at 11:30 AM in Resident #60's room there were medications on the resident's overbed table that included TKO 8 infused tincture 300 mg with an expiration date of 12/2022, Venelex wound ointment (no expiration date), Systane Lubricant eye drops with an expiration date of 07/2024, and Melatonin 10mg with an expiration date of 06/2024 (Photographic Evidence Obtained). During an interview conducted on 04/03/23 at 11:35 AM with Resident #60 when asked about the medications on her overbed table, she stated the ointment is not hers, she found it in one of the nightstand drawers. She stated the eye drops are for dry eyes. She said the TKO 8 infused tincture and the Melatonin help her sleep. She stated she was prescribed the Melatonin but told staff she did not want to take it every night (because it can be addictive) and the staff had the Melatonin discontinued, so her daughter brought the Melatonin in for her. During second observation conducted on 04/04/23 at 10:10 AM in the room for Resident #60, on the overbed table next to the resident was included TKO 8 infused tincture 300 mg with an expiration date of 12/2022, and Systane Lubricant eye drops. During an interview conducted on 04/04/23 at 10:15 AM with Staff A, Registered Nurse (RN), she acknowledged that there were medications of TKO 8 infused tincture 300 mg with an expiration date of 12/2022, and Systane Lubricant eye drops at the bedside. When asked if Resident #60 had been assessed for self-administration of medications, she said no. She immediately took the medications and stated that no resident is to have medications unlocked at the bedside. 2. During an observation on 04/04/23 at 7:45 AM Resident #62 was resting in bed, upon closer observation there were 2 bottles of Cystex UTI (Urinary Tract Infection) Prebiotic cranberry liquid on the resident's overbed table. During an interview conducted on 04/04/23 at 10:25 AM with Resident #62, when asked what had happened to her 2 bottles of Cystex UTI Prebiotic cranberry liquid that were on her overbed table, she stated she had no idea, she knows the nurses have given her cranberry medication in the past. During an interview conducted on 04/04/23 at 10:27 AM with Staff A, Registered Nurse (RN), she stated that Resident #62 had not been assessed to self-administer medications and she should not have had any medications unlocked at the bedside. 45951 3) During the initial meal observation conducted on 04/03/23 12:10 PM, the surveyor noted that Resident #24 had an open bottle of Tums Calcium Chews and an open jar of Vicks Vaporub ointment on her bedside table. The surveyor asked Resident #24 if these were her medications. Resident #24 said yes, I get heart burn when I eat. Record review revealed a Medicare 5-Day Minimum Data Set (MDS) assessment was done on 01/25/23. This MDS documented Resident #24 had a Brief Interview of Mental Status (BIMS) score of 15, which indicates she was cognitively intact. Review of Resident #24's Physician Orders revealed an order was written on 04/04/23 at 11:57 AM by the facility's Director of Nursing (DON) for Calcium Carbonate 500 mg give 1 tablet by mouth after meals and at bedtime for prophylaxis. Further review of the orders revealed there was no prior order for Calcium Carbonate. Review of Resident #24's medical record revealed there was no assessment documented or Care Plan in place regarding Resident #24 being safe to self-administer medications. Further record review revealed an Order Note was written by the facility's DON on 04/04/23 at 12:00 PM which states, Resident and daughter educated on OTC [sic: over the counter] medications being available upon request to MD [sic: doctor] for nursing staff to administer to resident as needed or scheduled depending on resident needs and MD order, daughter and resident verbalized understanding. An interview was conducted with the facility's DON on 04/04/23 at 6:15 PM regarding the note written earlier that day. The DON stated she observed the Tums bottle when she entered Resident #24's room that day to collect her lunch tray. She said she immediately called Resident #24's daughter and explained to both that residents cannot keep medications in their rooms without the staff's knowledge. 38349 4) Resident #67 was readmitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Diabetes Mellitus Type II, Atherosclerotic Heart Disease and Peripheral Vascular Disease. He had a Brief Interview Mental Status (BIM) score of 13 (cognitively intact). During an observational screening tour conducted on 04/03/23 at 11:30 AM it was noted on the bedside table of Resident #67 that there was a plastic tube container of over-the-counter (OTC) Vicks Vapor inhaler nasal decongestant main active ingredient Levmetamfetamine (l-Desoxyephedrine) 50 mg; with no expiration date. (Photographic evidence was obtained). On 04/03/23 at 11:32 AM, during a brief interview with the resident, he stated that the Vicks Vapor inhaler was his, brought from home and added that he uses it whenever he has a stuffy nose. On 04/03/23 at 3:50 PM, during a second observational tour, it was still noted on the bedside table of Resident #67, that there was a plastic tube container of OTC Vicks Vapor inhaler nasal decongestant. 04/04/23 at 1:57 PM, during a third observational tour, it was still noted on the bedside table of Resident #67, that there was a plastic tube container of OTC Vicks Vapor inhaler nasal decongestant. 04/05/23 10:48 AM, during a fourth observational tour, it was still noted on the bedside table of Resident #67, that there was a plastic tube container of OTC Vicks Vapor inhaler nasal decongestant. An interview was conducted with Staff B, a Licensed Practical Nurse (LPN), on 04/05/23 at 10:55 AM, regarding the plastic tube container of OTC Vicks Vapor inhaler nasal decongestant. She acknowledged that the medication should not have been there and should have been properly secured. An interview was conducted with Staff A, a Registered Nurse (RN), Unit Manager for the 2nd and 3rd floor), on 04/05/23 at 10:59 AM regarding the plastic tube container of OTC Vicks Vapor inhaler nasal decongestant. She further acknowledged that the medication should not have been there and should have been properly secured. The plastic tube container of OTC Vicks Vapor inhaler nasal decongestant was not removed, until after surveyor inquisition/intervention. There was no assessment performed for this resident to ensure that he was able to safely and responsibly administer his own medication at the bedside; the facility administers the medications for him, per Staff A, a Registered Nurse (RN)/Unit Manager (UM) for the 2nd and 3rd floor. The Director of Nursing (DON) further acknowledged and recognized that Resident #67's, unattended and unsecured medication should not have been left at his bedside and should have been properly secured; this was not done.

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that include: ensure the dishware is properly sanitized, ensure staff wear hair restraints in food serving and preparation areas, and ensure damaged food cans are eliminated from potential use. The findings include: During the initial food service sanitation tour conducted on 01/03/22 at 9 AM, accompanied with the Dietary Manager and Registered Dietitian, the following were noted: 1) The Dietary Manager (DM) was noted to be working in the food preparation and serving area. During the introduction with the surveyor, it was noted that he had a full beard and was not wearing a beard protector. The surveyor requested the DM to don a beard protector at that time and to remain on at all times while in and part of the Dietary Department . 2) Observation of the dish machine noted that the machine was in use and being loaded with dish racks by 2 dietary staff (Staff A & B). The DM stated that the machine sanitizes dishes via high temperature rinse. An observation of the temperature gauges noted that the wash temperature reached a maximum of 120 degrees F and a final rinse temperature of 129 degrees F. During an interview with Staff A & B, it was noted that they did not have knowledge of the regulatory temperature requirements for the high temperature dish machine. The surveyor requested additional test racks be put through the dish machine, however the final rinse maximum temperature was recorded at 129 degrees F. The surveyor reviewed the regulatory requirements with the DM which included: wash- minimum temperature of 150 degrees F and 180 degrees F - minimum final rinse temperature. The surveyor requested that the DM utilize disposable dishware until the dish machine temperature issue was resolved. On 01/03/22 at 2:30 PM the DM approached the surveyor and stated that the dish machine temperature issue was resolved and could the surveyor observe the machine. At 2:45 PM the dish machine temperatures were observed by the surveyor and it was noted that the wash was recorded at 130 degrees F and the final rinse recorded at 153 degrees F . The surveyor requested that the use of disposable dishware be continued for all resident meals until the the dish machine temperature was resolved. On 01/06/22 the DM informed the surveyor that the dish machine temperature issues had been repaired and resolved. Observation of the dish machine temperature gauges noted that the that the wash temperature was sustained at above 150 degrees F and final rinse temperature of 180 degrees F. 3) During the tour it was noted that Staff C was bagging silverware and stacking meal trays. Further observation noted that Staff C was wiping the silverware and trays with a soiled cleaning rag. The surveyor requested to the DM that Staff C stop and cease the procedure at once, and also requested that the silverware and dining trays be re-sanitized prior to the next use. 4) During the observation of the dry storage room, it was noted the DM to state that the room does not store/house any dented cans. Observation of the can storage rack noted a large dented #10 can of Red & Green Peppers. The surveyor requested that the dented vegetable can be removed from potential use and requested that all cans within the room be observed for dents. 5) During the kitchen tour it was noted that a male in civilian clothing without a hair net was present in the food preparation and serving area. The person was designated by the DM as the Director of Housekeeping/Maintenance. The surveyor requested the Director to leave the department immediately. The surveyor discussed with the DM that only dietary staff are allowed within the department unless repairs are needed. It was also discussed that all staff entering the department must don hair net, and proper PPE.

Based on obseervation, interview, and record review, it was determined that the facility failed to follow the approved menu portions for 31 residents on pureed diets, which included Resident #28, #30, #86, #108, for 15 residents on thickened liquids, including Resident #30, #45, #95 for residents with mechanical soft ground meats total of 9, including Resident #28, #54, #85, and for residents on mechanical soft diets for 17 residents, including Resident #31, #79, and #99. 1) During the initial sanitation tour of the main kitchen on 01/03/22 at 9 AM, accompanied by the Dietary Manager (DM), it was noted that there were approximately 25 portions of thickened milks that were portioned into disposable condiments cups. The DM stated that each serving of the thickened milk was a minimum 4 ounce portion, which also noted that the facility's Registered Dietitian to state the minimum required half portion of thickened milk was also 4 ounces. The surveyor cautioned the DM that the disposable condiment cups are only 3 ounce portions and requested that a sample of the thickened milks be measured. It was noted that the dietary department failed to have a measuring cup and that the nursing department was able to provide the dietary department with a disposable measuring cup that are utilized for resident medication pass. The sample (2 portions) were measured by the DM and recorded at a minimum 2.5-3 ounces. Review of the facility's diet census form for 01/03/22 noted that there were 15 residents with physician ordered thickened liquids (nectar 7 honey thick). Of the 15 residents, 3 residents were noted to be sampled that included Resident's #30, #45, and 395. 2) During the review of the approved menu for the breakfast of 01/04/22, it was noted the following to be served to the residents: * #12 scoop (2 ounces) of pureed eggs for pureed diets. * #12 scoop (2 ounces) of pureed bread for pureed diets. During the observation of the breakfast meal in the main kitchen of 01/04/22, it was noted at 7:30 AM, the following were noted: * #20 scoop (1 ounce) was being used as a serving of pureed eggs to residents requiring pureed diets * #20 scoop (1 ounce) was being used as a serving of pureed bread to residents requiring pureed diets. Review of the facility diet census form for 01/03/22 it was noted that there were 31 residents with physician ordered pureed diet. Of the 31 residents, it was noted that 4 were noted to be sampled residents that included, Resident #28, #30, #86, and #108. 3) During the review of the approved menu for the lunch meal of 01/05/22 , the following foods were to be served to the residents: * 4 Ounces chopped Chicken Fricassee for Mechanical Soft Diets * 4 ounces ground Chicken Fricassee for Mechanical Soft Diets * 4 ounces Pureed Mandarin Oranges for Pureed diets. Review of the facility diet census for 01/03/22, it was noted that there were 26 residents with physician ordered Mechanical Soft Diets and Mechanical Soft Ground meats. Of the 26 residents it was noted that 6 were sampled residents that included Resident #28, #54, #85, #31, #79, and #99. During the observation of the lunch meal in the main kitchen on 01/05/22 the following were noted: * 3 ounce spoodle of chopped Chicken Fricassee was being used as a serving to residents requiring mechanical soft diets. * 3 ounce spoodle of ground Chicken Fricassee was being used as a serving to residents requiring mechanical soft diets. * NO pureed Mandarin Oranges were prepared for residents pureed diets. Interview with the Dietary Manager and Registered Dietitian at the time of observation confirmed that the approved menu for the lunch meal of 01/05/22 was not being followed. 4) During the observation of the lunch meal of 01/05/22 at 11:30 AM, in the main kitchen it was noted that residents receiving pureed diets were being served a portion of plain cooked pureed chicken topped with a pureed tomato. Review of the standardized recipe for Chicken Fricassee noted that a pureed portion of the Chicken Fricassee with bones removed was to be served for pureed diets. Interview with the Dietary Manager at the time of the recipe review stated that he was unaware of the pureed recipe and also was not aware that all foods should be prepared and pureed as the regular recipe.

Based on observations, interviews, and record review, the facility failed to provide fingernail grooming for 1 of 1 sampled residents reviewed for activities of daily living, (Resident #54). The findings included: Review of the facility's policy titled, Fingernails/Toenails Care, revised on February 2018, documented the following: Nail care includes daily cleaning and regular trimming. Review of the Certified Nursing Assistant (CNA), job description provided by the facility documented the following: Assist residents with nail care (i.e. clipping, trimming, and cleaning fingernails). Check each resident routinely to ensure that his or her personal care needs are being met in accordance with his/her wishes. Review of the Licensed Practical (LPN), Job Description provided by the facility documented the following: Ensure that personnel providing direct care to residents are providing such care in accordance with the residents' care plan and wishes. Review of the record showed that Resident #54 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #54 had a Mental Status Score of 13, which indicated she was cognitively intact. Review of Section G of the MDS dated [DATE] documented that Resident #54 required extensive, one person assistance with personal hygiene. Review of the Care Plan dated 10/11/2021 documented that Resident #54 had a self- care deficit with dressing, grooming, and bathing, as evidence needing assistance with personal care tasks and mobility skills. Interventions: Assist with nail shaping, keep nails short and clean. During an observation conducted on 01/03/2022 at 10:57 AM, it was observed the resident's nails were long extending past her finger tips. She also confirmed her nails were longer that she preferred them to be. During subsequent visits on 01/04/2022 at 12:35 PM and 01/05/2022 at 7:56 AM the surveyor noticed resident's nails had not been trimmed. As before her nails extended past her fingertips. During an interview conducted on 01/05/2022 at 8:57 AM with Staff E, CNA (Certified Nursing Assistant), who stated she has worked at the facility for 6 years. She stated nurses were responsible for trimming nails, and that she checked resident's nails everyday. When asked if she documents when residents nails need to be trimmed she stated, I don't document, I just tell the Nurse. During an interview on 01/05/2022 at 9:13 AM with Staff D, LPN (Licensed Practical Nurse), she confirmed that it was the nurse's responsibility to trim resident's nails and that the CNA is responsible for notifying the nurse of resident's whose nails need trimming. At that time, the surveyor asked Staff D, to accompany her into the resident room to see the condition of Resident #54's nails. Staff D, upon looking at resident's nails agreed they were long and needed to be trimmed. Staff D then told the resident she would return to trim her nails.

Based on observation, interview, and record review, it was determined that the facility failed to follow therapeutic diets (Fluid Restriction) prescribed by the attending physician for 1 (Resident #77) of 9 residents sampled for nutrition review. The findings included: During the observation of the breakfast meal on 01/05/21 at 8 AM, it was noted that the tray was served to the room of Resident #77. Observation of the resident tray ticket documented - Renal /No Added salt /CCHO, and 1000 cc Fluid Restriction. Further observation noted the tray ticket to document : 8 ounces of 2% milk, 6 ounces Coffee, and 1 creamer. Observation of the noted the following fluids were served: 8 ounces 2% milk, and 2 portions of-6-8 ounces of coffee. The alert resident stated to the surveyor that she is aware of her fluid restriction and that she receives the same amount of fluids for breakfast daily. Following the observation the surveyor requested the Director of Nursing (DON) and Registered Dietitian to come to the room of the resident to view the resident's breakfast tray. The DON and Dietitian confirmed that the Fluid Restriction for the breakfast meal was not being followed and that an additional 180-240 cc of coffee was served in error. The DON stated that she was unaware if the additional fluids on the tray were provided by dietary or nursing department. During the review of the clinical record of Resident #77 on 01/05/22, it was noted a re-admitted [DATE] with diagnoses that included; Renal Failure, End Stage Renal Disease, and Dependence of [CONDITION(S)] (3 X per week) . Further review noted current physician orders dated for Fluid Restriction - 1000 ml/per day: that included 600 ml from dietary per day and 360 ml from nursing per day.

Based on interview, observation, and record review, the facility failed to provide the necessary services to maintain good nutrition for residents that were unable to carry out activities of daily living for 1 out of 26 sampled residents reviewed for activities of daily living (Resident #37). The findings included: Review of Section C of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #37 had a Brief Interview Mental Status of 05, which indicated that she was severely cognitively impaired. Review of Section G (Eating) of the Quarterly MDS dated [DATE] showed that Resident #37 required limited assistance with one-person physical assist with meals. Review of the Care Plan dated 10/14/20 showed that Resident #37 had decreased feeding ability and was at risk for alteration in nutrition. Goals and interventions for Resident #37 were to consume 75-100% of most meals through next review date and to encourage adequate intake at meals. Review of the Certified Nursing Assistant (CNA) Documentation for Amount Eaten dated 11/18/20-11/30/20 showed that Resident #37 mostly consumed 51-75% of her meals. During the first lunch observation on 11/30/20 conducted from 11:41 AM through 12:25 PM, Resident #37 received her lunch meal. Further observation showed that she was helped with the setup of the meal but was left alone to eat independently. Throughout this observation, staff did not provide any feeding assistance or encouragement. During an observation on 12/01/20 at 8:55 AM, Resident #37's breakfast tray was on the bedside table which was placed against a wall and out of the resident's reach. Staff E, CNA, entered the room and moved the bedside table and breakfast tray in front of Resident #37. When asked what time breakfast started, Staff E stated, Breakfast started 40 minutes ago. Staff E then exited the room without providing feeding assistance or encouragement and left Resident #37 alone to eat independently. Closer observation of Resident #37's breakfast tray showed that the grits, scrambled eggs, and ground sausage were congealed (which appeared to show that the food was sitting on the plate for a long time). Additional observations of the breakfast meal were conducted at 8:59 AM, 9:08 AM, and 9:16 AM, and showed that Resident #37 did not touch her breakfast tray and that staff members were not in her room to provide assistance or encouragement for her meal. During an observation on 12/02/20 at 12:07 PM, Resident #37 was alone in her room and seated in her wheelchair with her lunch meal in front of her. Closer observation showed that she had consumed less than 25% of her meal. An additional observation of the lunch meal was conducted at 12:14 PM and showed that staff members were not in her room to provide assistance or encouragement for her meal. During an interview on 12/02/20 at 8:25 AM, Staff B, MDS Coordinator, stated that she was responsible for determining residents' feeding ability for Section G of the MDS. When asked about Resident #37, Staff B confirmed that she required limited assistance with one-person physical assist with meals. Staff B explained that this meant that a staff member needed to be in the room with Resident #37 throughout the duration of the meal to encourage intake, hand her a spoon, and help her with her meals. She further stated that she would expect staff members to be in Resident #37's room for the duration of the meal. Review of the weights showed that Resident #37 weighed 130 pounds (lbs.) on 06/03/20, 131 lbs. on 07/09/20, 128 lbs. on 08/12/20, 126 lbs. on 09/02/20, 124 lbs. on 10/02/20, 123 lbs. on 11/03/20. This showed that Resident #37 experienced a continuous downward trend in weights over the course of 5 months. During an interview on 12/02/20 at 1:49 PM, Staff E stated that she was familiar with Resident #37 and usually worked with her. When asked about Resident #37's oral intake, Staff E stated that her oral intake varied and that a CNA had to be present during meals to encourage her to eat. She further stated that she noticed that Resident #37 has an improved oral intake when she received assistance and encouragement from a CNA during meals.

Based on observation, record review and interview, the facility failed to follow orders for 3 out of 3 sampled residents reveiwed for Tube Feeding, Residents #70, #246 and #13. The findings included: 1). Resident #70 was admitted to the facility on [DATE] and readmitted for current stay on 11/03/20. According to her most recent assessment, a Quarterly/Medicare 5-day Minimum Data Set (MDS), the resident was not assessed for cognition due to resident is rarely/never understood. Resident #70's [DIAGNOSES REDACTED]. In the section of the MDS related to swallowing disorders, the assessment documented that resident had coughing or choking during meals or when swallowing and mouth or facial pain, discomfort or difficulty when chewing Resident's orders for Tube feeding were Enteral Feed Order two times a day [MEDICATION NAME] 1.5 50ML/HR X 20 hours. On at 2PM off at 10AM as of 11/04/20. Based on the order, Resident #70 is to have consumed 1000 ML within the 20 hours. An observation of Resident #70's tube feeding, on 11/30/20 at 10:39 AM, revealed the feeding pump was not running, the bottle that was hung by staff was dated 11/30/20 with no time documented on the container and no documentation in the resident's record to show when the container was initially placed. There was no documentation to show that the resident was removed from the Tube feeding or that the feeding had been stopped at any time. An observation of Resident #70's tube feeding, on 12/01/20 at 8:32 AM, while the feeding pump was dispensing to the resident at 50 ML/HR, the label of the container documented that the container was placed at 6:00 AM. There was approximately 50 ML dispensed, according to the amount still left in the 1000 ML container, with the monitor displaying that 131 ML had been dispensed. At a rate of 50 ML/HR over 2.5 hours, 150 ML should have been dispensed from container that had 950 ML of the 1000 ML container left. There was no documentation to show that the resident was removed from the Tube feeding or that the feeding had been stopped at any time. An observation of Resident #70's tube feeding, on 12/02/20 at 9:30 AM, whie the feeding pump was dispensing to the resident at 50 ML/HR. At the time of the obseration, there was approximately 100 ML dispensed, according to the amount still left in the 1000 ML container. According to the label on the container, the container was placed at 5:50 AM. At a rate of 50 ML/HR over 3.5 hours, 150 ML should have been dispensd to the resident. There was no documentation to show that the resident was removed from the Tube feeding or that the feeding had been stopped at any time. 2). Resident #246 was admitted on [DATE] and readmitted for current stay on 11/13/20 after being admitted to the hospital for PEG tube placement. According to Resident #246's most recent assessment, a Medicare 5-day MDS, completed on 11/17/20, the resident had a Brief Interview for Mental Status of 09, indicating that the resident was 'moderately impaired'. The resident's [DIAGNOSES REDACTED]. In the section of the MDS related to swallowing disorders, the assessment documented that the resident had No swallowing disorders and no dental issues/concerns Further record review revealed Resident #246's orders for Enteral feed were Enteral Feed Order two times a day [MEDICATION NAME] 1.5 80 ML/HR X 20 HRS. On at 2PM Off AT 10AM During an observation of the resident's tube feeding, on 11/30/20 at 12:20 PM, with the feeding pump off, there was 450 ML reamaining of the 1000 ML container. The label on the container documented that it was placed at 1:20 AM. At a rate of 80 ML/HR for 8.5 hours, the resident should have consumed 680 ML. There was no documentation to show that the resident was removed from the Tube feeding or that the feeding had been stopped at any time. During an observation of the resident's tube feeding, on 12/01/20 at 8:36 AM, with the feeding pump dispensing at 80 ML/HR, there was 900 ML remaining of the 1000 ML container. The label on the container doucmented that it was placed at 6:00 AM. At a rate of 80 ML/HR for 2.5 hours, 200 ML should have been consumed by the resident. The monitor on the pump displayed that the resident had been fed 2905 ML. There was no documentation to show that the resident was removed from the Tube feeding or that the feeding had been stopped at any time. During an observation of the resident's tube feeding, on 12/02/20 at 9:40 AM, with the feeding pump dispensing at 80 ML/HR, there was 550 ML remaining of the 1000 ML container. The label on the container documented that it was placed at 1:00 AM. at a rate of 80 ML/HR for 8.5 hours, the resident should have been fed 680 ML. There was no documentation to show that the resident was removed from the Tube feeding or that the feeding had been stopped at any time. During an observation of the resident's tube feeding, on 12/03/20, at 8:49 AM, with the feeding pump dispensing at 80 ML/HR, there was 300 ML remaining of the 1000 ML container. The label on the container documented that it was placed at 10:00 PM, at a rate of 80 ML/HR for 10.5 hours, the resident should have been fed 840 ML. The monitor on the pump displayed that the resident had been fed 4950 ML. There was no documentation to show that the resident was removed from the Tube feeding or that the feeding had been stopped at any time. During an interview, on 12/03/20 at 8:30 AM, with Staff H, LPN/Nurse Supervisor, when asked who was responsible for initiating the residents' tube feedings, she replied, the nurses hang the tube feeding. During an interview, on 12/03/20 at 8:51 AM, with Staff P, LPN, when asked about the process of placing the tube feeding, he replied, I will be initiating the TF this afternoon. I make sure that the placement is accurate, I aspirate to see how much content is in his stomach, once I go there, I look at the instructions (order), I make sure that everything is in place, I connect the feeding and make sure that evething is open. I then make sure that the machine reading the right ml/Hr and make sure that his head is elevated as well. I start the machine and make sure that everything is running smoothly and that he is okay. We start from the bottle that was already in use. I usually wait until there is a little bit above the neck to change the bottle and start a new one. When the bottle is empty, the machine will beep, I try to change it ahead of time. The beginning of the feeding would be documented in the Nurse's notes I would do it visually when I come in and check the feeding from when it was hung and do the calculations. the only time that it would be disconnected is when he is coughing or aspirating. I have not had to disconnect him fromt the tube feeding for more than 10-15 minutes for the aides to do ADL care. During an interview, on 12/03/20 at 12:06 PM, with the Registered Dietician, the concerns were brought to her attention, and she stated that the facility would have to initiate documentation to make sure that the residents are receiving the full benefit of the tube feeding orders. 3. In an observation conducted on 11/30/20 at 10:08 AM, showed a tube feeding formula ([MEDICATION NAME] 1.5) hanging on a feeding pump located next to Resident #13's bed. Closer observation showed that the tube feeding was not running, and the tube feeding bottle was completely full at a total of 1000 milliliters. The date on the tube feeding bottle was 11/30/20. In another observation conducted on 12/01/20 at 9:05 AM, showed the tube feeding formula was hanging on a feeding pump located next to Resident #13's bed. Closer observation showed that it was not running and that the tube feeding bottle was at 750 milliliters out of 1000 milliliters full capacity. It further showed that 250 milliliters (375 calories) have been dispensed since last observation and not the needed 480 milliliters (720 calories) as per physician order. This indicated that Resident #13 did not receive the remaining 230 milliliters (345 calories) from his tube feeding. This bottle was dated 11/30/20 which showed that it was the same tube feeding bottle from the previous day. Review of the physician's orders [REDACTED]. Further review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Record review of Resident #13 showed that he was readmitted on [DATE] with Brief Interview of Mental Status (BIMS) score of 03 which is severely cognitively impaired. In an interview with conducted on 12/03/20 at 9:40 AM, Staff A, Licensed Practical Nurse, she reported that all tube feeding bottle are labeled with the time and the date before administration. She further reported that the same tube feeding bottle may be used up to 48 hours for the same resident. When asked about Resident #13 tube feeding, she stated that he is tolerating it very well. Staff A also stated that the tube feeding is running every night from 10 PM to 6 AM in the morning and that it is not stopped for nursing care. During an interview on 12/03/20 at 12:39 PM, Registered Dietitian (RD) stated that Resident #13 had a history of [REDACTED]. She reported that Resident #13 does not always eat his meals and that the tube feeding would ensure that he receives adequate nutrition. When asked about the importance of tube feeding, RD stated that it was very important that Resident #13 receive his tube feeding as ordered.

Based on observation, interview and record review, the facility failed to remove expired medications from the medication cart. Additionally, a nurse left the medication cart unlocked and unattended during medication cart review. The findings included: A review of the facility's policy titled Storage of Medications, Policy # 4.1, Effective Date 9/2018 and Revision Date 8/2020 was conducted. The policy stated medication and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under section I General Guidance stated the following: Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access. 8) Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 1. On 12/1/20 at 9:12 AM during an observation with Staff H on the 2nd floor blue medication cart review, it was revealed the cart contained (6) [MEDICATION NAME] Kits 1 mg that were each expired. (2) expired on 06/2020, (2) expired on 03/2020, and (2) expired on 05/2020. (photographic evidence provided) Staff H immediately stated those should not be in there. On 12/01/20 at 2:45 PM, during an interview with the Director of Nursing. She stated that she doesn't know how this happened with the expired [MEDICATION NAME] Kits in the med cart, because they have been checking all the med carts to make sure they have been in order. The expired [MEDICATION NAME] should not have been in the med cart. 2. On 12/1/20 at 9:26 AM during an observation with Staff F on the 2nd floor red medication cart review, at 9:28 AM Staff F walked away from the medication cart and the surveyor without saying a word leaving the med cart unlocked. She then went to talk to a CNA, during that time the nurse had her back to the medication cart and the surveyor. On 12/1/20 at 9:32 AM, during an interview when Staff F returned to the 2nd floor red medication cart, and was asked why she had left the medication cart unlocked she stated she just thought she would give the surveyor some privacy to review the medication cart.

Based on observation, record review and interview, it was determined that the facility failed to ensure that it maintained the confidentiality of a resident's wound health status record for 9 of 9 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #9). The findings included: During a wound care observation on 08/25/19 at 10:50 AM, it was noted that Staff A, a Registered Nurse (RN), wound care nurse, was observed leaving a copy of the resident's skin/wound Quality Improvement (QI) log containing nine (9) resident's (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #9) wound health information exposed and available, on top of the 3rd floor wound cart visible to other residents, staff and visitors, all during Resident#3's entire wound care dressing change procedure. This log contained the information including resident names and other confidential wound care documentation for the 3rd floor residents dated 08/21/19. There were residents, staff and visitors observed in the hallway at the time of the observation. An interview was conducted with Staff A, an RN, wound care nurse on 08/25/19 at 11 AM regarding the 9 exposed resident's wound health information. Staff A, an RN, admitted that afterwards she realized that she should not have left this personal/confidential resident health information uncovered and exposed on the 3rd floor wound care cart, for all others to see/view. An interview was conducted with the DON (Director of Nurses) on 08/25/19 at 11:15 AM regarding the 9 exposed personal resident's wound health information and she admitted and agreed that this information should never have been left un-covered, available and exposed for other residents, staff and visitors to view.

Based on observation, interview and review of the facility's policy and procedure, it was determined that the facility failed to practice appropriate hand hygiene during and following wound care for 1of 1 sampled residents (Resident #3). The findings included: Review of facility policy and procedure on 08/25/19 at 12:15 PM for Handwashing/Hand Hygiene provided by the DON revised (MONTH) (YEAR) indicated that this facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors Procedure .washing hands vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature . During a wound care observation on 08/25/19, at 10:48 AM, the wound care nurse was observed washing her hands on five (5) separate occasions for only 10-20 seconds, throughout the entire wound care procedure. Resident #3, was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Brief Interview Mental Status (BIM) listed the resident as severely cognitively impaired. Following a wound care observation on 08/25/19 at 11:10 AM, the wound care nurse was observed opening the garbage lid of a trash can in the soiled utility room with her bare hand and subsequently opening and then closing the soiled utility room door again, with her bare hand and then leaving this area to return to the resident's room, all without washing her hands prior to leaving this area. An interview was conducted with Staff A, Registered Nurse (RN), wound care nurse on 08/25/19 at 11:17 AM, in which she admitted that she had not washed her hands for the full 20 seconds each time throughout Resident #3's wound care procedure. She stated that she realized afterwards that she should have washed her hands after touching both the garbage lid and the soiled utility room door prior to exiting the room. An interview was conducted with the DON (Director of Nurses) on 08/25/19 at 11:30 AM regarding both Staff A's inappropriate hand hygiene during and following wound care and as well as Staff A's absence of hand hygiene prior to exiting the soiled utility room. The DON agreed and admitted that appropriate hand washing should always be performed according to policy, during and after wound care procedures.

Based on observation and interview, it was determined that the facility failed to post current nurse staffing information at 2 of 2 nursing stations (Second and Third floors). The findings included: During an observational tour on 08/25/19 at 9:27 AM, it was noted that the daily posted staffing roster located at each nursing station which included Facility name, Date, # of staff, hours and Census; accuracy and adequacy noted. The wrong/incorrect date was noted to be posted at both 2nd and 3rd floor nursing stations, with a date of 08/23/19. On 08/25/19 at 9:30 AM, an interview was conducted with Staff B, RN, Weekend Building Supervisor, regarding the incorrect nurse staffing posted date and she stated that she didn't know why and she said that it was done in error. On 08/25/19 at 10:04 AM, an interview was conducted with the DON (Director of Nurses) regarding the wrong nurse staffing posted date on both 2nd and 3rd floor nursing units. She stated that she didn't understand why it was not changed because it is normally changed by the night supervisor.

Based on observations, interviews and record review, the facility failed to revise and update the care plan for eating assistance for 1 out of 21 sampled residents (Resident #16) reviewed for Care Plans. The findings included: In an observation conducted on 03/19/19 at 8:30 AM, Resident #16 was observed sitting in a chair with the breakfast tray in front of her. Closer observation revealed that the meal ticket had assistance written on it. Resident #16 was observed playing with her food with no assistance from staff with her meal. Further observation at 8:50 AM revealed Resident #16 with only 10% of her breakfast meal consumed and no staff in the room. In an observation conducted on 03/20/19 at 8:42 AM, Resident #16 was observed eating her breakfast meal with no assistance from staff. Closer observation showed that Resident #16 only ate 25% of her meal. Record review of Resident #16 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented that Resident #16 needs extensive assistance with one person assist when eating. Care plan initiated on 04/11/18 documented that Resident #16's interventions for nutrition are as follow, encourage adequate intake of meals, provide hands on assist at meals and as needed, and provide alternate as needed. In an observation conducted on 03/20/19 at 12:35 PM, Resident #16 was observed eating her lunch meal with no assistance from staff. Record review of the Certified Nurse Assistant meal intake documentation showed that on 03/19/19, Resident #16 ate 50-75% for breakfast and 50-75% for dinner. Surveyor discussed discrepancies with Staff C and she acknowledged the findings. In an interview with Staff F, Minimum Data Set Coordinator on 03/20/19 at 1:01 PM, she stated, when a Resident has extensive assist with one person assist for eating, it means that someone needs to put food in the Resident's mouth at one point. When asked by the surveyor if staff needed to be in the room while the resident is eating, she responded yes. In an interview with the Assistant Director of Nursing, (ADON) on 03/21/19 at 12:45 PM, she acknowledged the findings.

Based on observation, interview, and record review it was determined that the facility failed to provide care and services in accordance with activities of daily living including fingernail grooming, for 2 of 21 sampled residents (Resident #66 and #26) reviewed for activities of daily living. The findings included: 1. In an observation conducted on 03/18/19 at 9:15 AM, Resident #66 was observed lying in bed. Closer observation revealed Resident #66 with long uncleaned fingernails. Review of the record revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Section C of the Minimum Data Set (MDS) assessment dated [DATE] documented no score for the Brief Interview for Mental Status (BIMS). Section G of the MDS for personal hygiene documented that Resident #66 needed extensive assist with one person physical assist. Further record review of the care plan dated 02/27/19 documented that Resident #66 has a self care deficit with grooming. One of the goals noted for Resident #66 is to have clean and neat appearance with staff to assist. In an observation conducted on 03/19/19 at 3:00 PM, Resident #66 was observed lying in bed with long uncleaned fingernails. In an interview conducted on 03/20/19 at 7:57 AM with Staff A, Certified Nurse Assistant (CNA) she reported that if she notices that a Resident has long/dirty fingernails she will then ask the Registered Nurse if it's okay to cut the nails. She further stated that some Residents are Diabetic and the Registered Nurse is the one that will cut or trim their fingernails. When asked by Surveyor as to where the information regarding care is documented, she said it is under tasks/personal hygiene in the Resident's Electronic Record. Record review of the personal hygiene showed that Resident #66 needed extensive to total dependence for her personal hygiene needs. The documentation was not specific as to what type of personal hygiene was given to Resident #66 from 03/08/19 to 03/20/19. In an interview with Staff C, License Practical Nurse (LPN) on 03/20/19 at 8:03 AM, she reported that nurses will cut or trim Resident's fingernails. She further reported that they rely on the Certified Nurse Assistant to let them know which Residents need their fingernails trimmed or cut. In an interview with Staff G, (CNA) on 03/20/19 at 8:36 AM she reported that she will let the Registered Nurse know if a Resident needs his/her fingernails trimmed or cut. She further stated that she will not cut or trim the fingernails but lets the Nurse know and he/she will do it. She further confirmed that Resident #66's fingernails were too long and needed to be cut and cleaned. 2. In an interview conducted with Resident # 26 on 03/18/19 at 11:00 AM, it was noted that the resident was lying in the bed reading a book. His fingernails were noted to be long and dirty underneath. During this interview, Resident #26 was asked if he is okay with his fingernails looking unkept and dirty. Resident #26 reported that he only had his fingernails cut once since he has been at the facility and that he told staff he wanted them cut and trimmed, but nothing was done. Record review showed that Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review of the Minimum Data Set assessment dated [DATE] documented that for personal hygiene Resident #26 needed extensive assist with one person assist. Section C of the Brief Interview for mental Status (BIMS) showed a score of 11, which indicates moderate impaired. In an observation conduced on 03/20/19 at 9:00 AM, Resident #26 was noted to be lying in bed with his fingernails dirty, long and unkept. In an interview on 03/20/19 at 10:00 AM with Staff G, Registered Nurse Assistant she confirmed that Resident #26's fingernails needed to be cut and trimmed.

Based on observation, interview and record review, the facility failed to provide ongoing resident centered activities for 1 of 3 sampled (Resident #35) residents reviewed for activities. The findings included: In an observation conducted on 03/18/19 at 12:00 PM, Resident #35 was noted to be in bed asleep with no activities or stimulation. In an observation conducted on 03/18/19 at 3:00 PM, Resident #35 was noted to be in bed asleep with the television on in an English speaking channel. In an observation conducted on 03/19/19 at 9:00 AM, Resident #35 was noted to be in bed asleep with no activities or stimulation. In an observation conducted on 03/19/19 at 3:00 PM, Resident #35 was observed lying in bed with no activities or stimulation. In an observation conducted on 03/20/19 at 9:00 AM, Resident #35 was seen lying in bed with no activities or interaction of any kind. Record review of Resident #35 revealed that she was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was admitted to hospice care on 08/09/18 and was taken off crisis care on 03/15/19. The Minimum Data Set assessment dated [DATE] showed a Brief Review of Mental Status (BIMS) score of 99 which indicates cognitive ability could not be assessed. Further review of the care plan dated 08/09/18 showed that for activities the interventions are: invite and escort to social events, provide her bible, provide one to one interaction and sensory stimulation. An activity progress note dated 01/28/19 showed that Resident #35 is to be taken to group activities, she enjoys reading and the bible, listening to French religion services, and when in room , one to one room visit. Record review of of the Individual Resident Daily Participation Record showed that Resident #35 attended current/events, music, social/parties and television in the main activities room on 03/18/19 and 03/20/19. Review of the Record One to One Activities showed that Resident #35 participated in lotion and aroma therapy on 03/18/19 and 03/19/19. In an interview with the Staff B, an Activity Aid, on 03/20/19 at 10:42 AM, she reported that Resident #35 attended current events, social parties and watched television on 03/18/19 and 03/19/19 in the main activity room on the 3rd floor. When asked at what time did Resident #35 attend these activities outside her room, she said around 12:00 PM. When surveyor pointed out that Resident #35 was observed in her room for the last few days and was not seen in the activity room on 03/18/19 and 03/19/19 she stated that the documentation must have been a mistake. Staff B further reported that she visited Resident #35 in her room on 03/18/19 and 03/19/19 and provided aroma and lotion therapy. According to Staff B, one to one room visits are done between 9:30 AM and 10:30 AM every day. In an interview with the Activity Director on 03/20/19 at 1:05 PM, she reported that Staff B made a mistake in her documentation. She further stated that when residents do not come to group activity, they provide room visits. The Activity Director stated that Resident #35 did not feel well on 03/18/19 and 03/19/19 and did not come out of her room. In an interview with Staff A, on 03/20/19 at 1:40 PM she reported that she worked the day shift on 03/20/19. According to Staff A, no in room activities were provided to Resident #35. In an interview on 03/20/19 at 1:45 PM with Staff D, Registered Nurse, she stated that she did not see Staff B provide in-room activities on the 3rd floor. She further reported that it is difficult to provide one to one activities with only one assistant.

Based on observation, interview and record review, the facility failed to ensure adequate nutrition parameters were monitored and evaluated for 1 of 4 sampled residents reviewed for Nutrition (Resident #35), as evidenced by failing to adequately track the consumption of meals for a resident with identified weight loss. The findings included: In an observation conducted on 03/18/19 at 12:25 PM, Resident #35 was noted in her room with the lunch tray at the bedside. Observation at 12:35 PM showed staff in the room assisting the Resident with her meal. At 12:50 PM, the Resident was observed with staff at the bedside assisting her with her meal. In an observation conducted on 03/19/19 at 8:10 AM, Resident #35 was noted in bed with no breakfast tray at the bedside. At 8:35 AM the breakfast tray was placed at the bedside with Staff A, Certified Nurse Assistant, (CNA) feeding Resident #35 her meal. Further observation revealed that at 8:40 AM, Staff A removed the breakfast tray from the room. When approached by the Surveyor to ask why the tray was removed from the room after 5 minutes, she stated that Resident #35 is refusing to eat. Staff A further proceeded to aid another resident in room [ROOM NUMBER] with her breakfast meal. In an observation conducted on 03/20/19 at 8:15 AM, Resident #35 received her breakfast tray. At 8:35 AM, Staff N, Certified Nurse Assistant was observed feeding Resident #35 in he room. Further observation at 8:55 AM revealed Staff N was sitting by the bedside talking and assisting Resident #35 with her meal. Staff N reported that if you speak to the Resident and encourage her she eats well. Record review of Resident #35 revealed that she was readmitted on [DATE] with [DIAGNOSES REDACTED]. She was admitted to hospice care on 08/09/18 but was taken off crisis care on 03/15/19. The Minimum Data Set assessment dated [DATE] documented a Brief Review of Mental Status (BIMS) score of 99 which indicates the resident's cognitive ability could not be assessed. An order dated 3/12/19 documented to discontinue thin liquids and change to nectar thick liquids via spoon and no straws. Residents #35's weight was noted to be at 119 pounds on 03/01/19 and dropped to 106 pounds on 03/17/19 which is 10.92% weight loss. Progress dietary note dated 03/08/19 showed that the Registered Dietitian documented the resident's weight of 119 pounds and an order for [REDACTED].>In an observation conducted on 03/19/19 at 8:15 AM, Resident #35 was observed with a Styrofoam cup at the beside. Closer observation showed a straw placed inside the water cup. Record review of Resident #35's CNA documentation for percentage of meals showed that on 03/19/19 she refused Breakfast and Lunch which was documented by Staff A. Intake on 03/05/19 for Residents #35 showed that she refused Breakfast and Lunch which was documented by Staff A. Further record review for 03/19/19 showed that Resident #35 ate 25%-50% for Breakfast and Lunch which was documented by another CNA. Care plan which was initiated on 08/09/18 showed that Resident #35 needed to be provided with cues and encouragement during eating. In an interview with the Clinical Dietitian on 03/20/19 at 9:33 AM, she reported that she was not aware that Resident #35 had an order for [REDACTED].#35 was not eating much. According to the Registered Dietitian it was not until 03/17/19 that she realized that significant weight loss. In an interview conducted on 03/20/19 at 10:07 AM with Staff E, Speech Language Pathologist, she reported that Resident #35 needed to have liquids with only a spoon and no straws. She further stated that it is safer to use spoons and no straws to minimize aspiration for Residents who are on nectar thick liquids.

Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to discard an expired eye ointment medication in 1 of 6 medication carts for 1 sampled resident (Resident #99). The findings included: On [DATE] at 10:46 AM, a Medication Storage Observation was conducted of the 2nd floor red medication cart with Staff J, a Licensed Practical Nurse (LPN). During the observation, a tube of over-the-counter (OTC) Refresh PM eye ointment, with an engraved expiration date on the bottom of the medication tube of (MONTH) 2019 for current Resident #99, was noted. The pharmacy packaging for the medication tube indicated that it was ordered on [DATE], to be sent to the facility on [DATE], but was noted that there was a hand-written recorded open date of [DATE]. And, a hand-written expiration date of [DATE]. On [DATE] at 11:05 AM, an interview conducted with both Staff J, an LPN and with the Assistant Director of Nursing (ADON), in which both confirmed that the medication was expired and should have been discarded. On [DATE] at 11:10 AM, an interview was conducted with the DON regarding the expired eye ointment, and she also agreed and confirmed that the medication should have been discarded. During a telephone interview conducted with Staff M, Head Pharmacist of the dispensing pharmacy, on [DATE] at 12:03 PM, he admitted that this (OTC) medication was sent out in error by the pharmacy and he stated that he takes full responsibility for sending out the expired medication. On [DATE] at 01:37 PM, a record review was conducted of the resident's Medication Administration Record [REDACTED]. On [DATE] at 01:43 PM, a further record review was conducted of the resident's (MAR) indicated that the this expired eye ointment had been given nightly by two different licensed night nursing staff members consistently on five different consecutive days at 9 PM by Staff K an LPN, on Friday [DATE] and by Staff L an LPN, on Saturday [DATE] through Tuesday [DATE]. On [DATE] at 01:46 PM, a record review was conducted of the physician's orders [REDACTED]. Review of facility policy and procedure on [DATE] at 12 PM for Storage of Medications provided by the Administrator, reviewed [DATE], indicated that Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists Expiration dates (beyond-use date) of dispensed medications shall be determined by the pharmacy at the time of dispensing. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date .The nurse will check the expiration date of each medication before administering it. No expired medication will be administered to a resident Nursing staff should consult with the dispensing pharmacist for any questions related to medication expiration.