Every finding on record at North Campus Rehabilitation and Nursing Center

Based on observation, interview, and record review the facility failed to ensure medications were secure when unattended, failed to label medications, and failed to discard expired medications. Findings include: 1. During an observation on 4/19/2026 at 9:10 AM of Resident #44's room there were unsecured medications at bedside. The medications consisted of four cups of crushed pills, one cup of clear liquid, and one clear vial of medication. During an interview on 4/22/2026 at 8:45 AM Staff A, Registered Nurse (RN) stated, The medication at bed side are the morning meds. I couldn't tell you each medication. They are part of the med pass, and the vial is the eye drops. Review of Resident #44's medication administration record (MAR) documented the morning medications at the bedside as aspirin chewable 81mg (milligram), cyanocobalamin 1000 mcg (micrograms), escitalopram oxalate oral solution 5 mg/5ml (milliliters), ferrous sulfate 325 mg, lisinopril 20 mg, acidophilus lactobacillus oral capsule, cyclosporine ophthalmic emulsion 0.05 %, oxybutynin 5 mg, hydralazine 50 mg, and carbidopa-levodopa 25-100 mg. 2. During an observation of medication cart #1 on 4/19/2026 at 10:35 AM there was one Lantus insulin with an expiration date of 4/16/2026, one Novolog insulin with an expiration date of 4/16/2026, and four capsules in a medication cup, not in the original pharmacy packaging and unlabeled. During an interview on 4/19/2026 at 10:36 AM Staff C, Licensed Practical Nurse (LPN) stated, The insulin is expired and shouldn't be in the cart. Those are fish oil. They should be in their container. They are not labeled. It should not be like that. 3. During an observation of medication cart #2 on 4/19/2026 at 10:40 AM there was one Novolog insulin with an expiration date of 2/26/2026, one glargine insulin with an open date of 3/1/2026 [expires 28 days after being opened], one Novolog insulin with an open date of 3/1/2026 [expires 28 days after it is first opened], one glargine with an expiration date of 4/15/2026, and one unopened Novolog insulin with pharmacy instructions to refrigerate until opened [to maintain maximum potency and stability to ensure effectiveness]. During an interview on 4/19/2026 at 10:43 AM Staff B, LPN stated, They [the medications] are expired and shouldn't be on the cart. That is not opened [Novolog insulin], it should not be on the cart. 4. During an observation of medication cart #3 on 4/19/2026 at 10:45 AM there were two opened glargine insulins with no open dates [critical to track the 28-day expiration period] and one Novolog insulin with no open date. During an interview on 4/19/2026 at 10:50 AM Staff A, Registered Nurse (RN) stated, They [the medications) should have the dates on them of when they were opened. 4. During the medication administration observation on 4/20/2026 at 8:14 AM of Staff, I, LPN, when the medication cart was opened for Staff I to start preparation for medication administration there was a medication cup that containing a small white pill and a tan colored pill in the drawer. The medications were not in the original pharmacy packaging, and the medication cup was not labeled. During an interview on 4/20/2026 at 8:15 AM Staff I, LPN stated, I do not know what these are. They should not be in the medication cart. We cannot pre pour medications or leave them in the cart without labeling them. During an interview on 4/20/2026 at 1:30 PM the Director of Nursing (DON) stated, All meds [medications] should be labeled when they are opened. We should not have any medications at bedside, and we should have all meds on the cart labeled. Review of the policy and procedure titled, Medication/Biological Storage with a last approval date of 1/13/2026 read, Policy: It will be the policy of this facility to store medications, drugs, biologicals in a safe, secure and orderly manner. Procedure: 1. Medications, drugs, and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received, unless otherwise necessary. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 4. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals.

Based on observation, interview, and record review, the facility failed to ensure food was properly stored in 1 of 3 nourishment rooms (West Unit nourishment room) and failed to ensure food was prepared and/or served in a sanitary manner. Findings include: During an observation on 04/19/2026 at 11:37 AM, the Director of Food and Nutritional Services was wearing gloves and plating meal trays from the steam table for lunch. The Director of Food and Nutritional Services walked to the microwave, removed the glove from her right hand, pushed a button on the microwave with her right hand, and removed a container from the microwave. The Director of Food and Nutritional Services did not perform hand hygiene, walked back to the tray line, and put a new glove on her right hand and continued plating food. During an observation on 04/19/2026 at 11:38 AM, the Director of Food and Nutritional Services was observed handing plates of food to Staff E, Dietary Aide, who was not wearing gloves. Staff E, Dietary Aide was observed handing plates of food to Staff D, Dietary Aide, who was also not wearing gloves. Staff D, Dietary aide was observed with the bare thumb of his right hand touching the inner food contact surface of the plate, touching the mashed potatoes on the plate. Staff D then shook off his hand and placed the plate of food onto a tray, covered the plate, and placed the tray onto the tray cart. During an interview on 04/21/2026 at 10:00 AM, the Director of Food and Nutritional Services stated, If [Staff D, Dietary Aide's name] touched the food with his bare hand, he should have handed the plate back, and had a new, fresh plate of food made.During an interview on 04/21/2026 at 10:01 AM, The Director of Food and Nutritional Services stated, I did not need to do hand hygiene when I took the food out of the microwave because I was just continuing to do the same task, and I did not touch the food with my hands.During an observation on 04/19/2026 at 10:52 AM, an opened container of Med Pass was observed in the [NAME] Unit nourishment room refrigerator. The container of Med Pass was approximately 3/4 empty and did not have an opened date. The container of Med Pass read, After open, consume product within 4 days if properly refrigerated.During an interview on 04/19/2026 at 11:02 AM, the Director of Nursing stated, That Med Pass should have an opened date on it.Review of the policy and procedure titled, Food and Nutrition Services Policy with a last reviewed date of 01/13/2026 read, Policy: The facility shall provide each resident with a nourishing, well-balanced diet that meets daily nutritional and special dietary needs, prepared and served under sanitary conditions and in accordance with professional standards for food safety. B. Food Storage. 4. Foods shall be: Dated and labeled upon receipt/opening. C. Food Preparation 1. Staff shall perform proper hand hygiene before and during food preparation. 2. Gloves shall be used appropriately and changed between tasks.Review the of policy and procedure titled, Meal Distribution with a last reviewed date of 01/13/2026 read, Policy: It is the policy of this facility that meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. 5. Proper food handling techniques to prevent contamination and temperature maintenance will be used during meal delivery and at point of service dining.Review of the policy and procedure titled Hand Hygiene last approval date of 1/13/2026 read, Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5, Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after coming into direct contact with residents. c. before and after handling medications; e. before and after handling an invasive device (e.g. urinary catheter, IV access devices. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. 7. The use of gloves does not replace hand washing/hand hygiene, integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interview, and record review, the facility failed to ensure the implementation of resident care plans for 3 of 6 residents, Residents #86, #73, and #23, reviewed for care plans. Findings include: 1) During an observation on 04/20/2026 at 8:25 AM, Resident #86 was sitting up in bed sleeping with the overbed table in front of her. There were no floor mats on the sides of the bed. Review of Resident #86's care plan dated 04/16/2026 read, Focus: [Resident #86's name] is at risk for falls and/or fall related injury r/t [related to]: generalized weakness, limited endurance, impaired balance, has a hx [history] of falls, has poor safety awareness, has impaired vision, receives psychotropic meds, use of antiplatelet. Interventions: 1/24/26 bilateral floor mats for safety. During an observation on 04/21/2026 at 9:18 AM, Resident #86 was sitting up in bed. The resident was adequately groomed and dressed appropriately for the time of day and the weather. There were no floor mats beside the bed. During an interview on 04/21/2026 at 9:21 AM, Staff F, LPN [Licensed Practical Nurse] stated, To prevent falls for [Resident #86's name], we do every two hour checks on her and supervise her. I don't think she is care planned for floor mats. During an interview on 04/21/2026 at 9:48 AM, the Director of Nursing stated, [Resident #86's name] is supposed to have bilateral floor mats for safety. Review of the policy and procedure titled, Comprehensive Assessments and Care Plans reviewed 01/13/2026 read, Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences, using the resident assessment instrument (RAI) specified by CMS. Guidelines: 8. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 11. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will be provided by qualified persons in accordance with each resident's written plan of care and will also be culturally-competent and trauma- informed. 2) Review of Resident #73 admission record documented diagnosis to include chronic obstructive pulmonary disease (COPD), unspecified, chronic pulmonary edema, dependence on supplemental oxygen, chronic kidney disease, unspecified, chronic diastolic (congestive) heart failure, major depressive disorder, gastro-esophageal reflux disease without esophagitis, hyperlipidemia, unspecified, chronic pulmonary embolism, essential (primary) hypertension, chronic embolism and thrombosis of other specified veins. Review of Resident #73 physician orders dated 1/16/2026 read, Continuous O2 [oxygen] at 2L-3L [liters]/MIN [minute] via NC [nasal cannula] q [every] shift to maintain O2 greater than 93% every shift. Review of Resident #73's comprehensive care plan read, [Resident #73's name] has a potential for complications of respiratory distress r/t [related to] dx [diagnosis of] COPD, hx [history of] CHF [congestive heart failure], hx COVID [Coronavirus Disease]. Interventions: O2 sats [saturations] as ordered. Administer O2 as ordered. During an interview on 4/20/2026 at 1:40 PM Staff J, LPN stated, At times the resident or staff can bump the concentrator, and it will be very sensitive. During an interview on 4/22/2026 at 7:25 AM the Director of Nursing (DON) stated, We should always follow the care plan interventions and have the oxygen running correctly. 3) Review of Resident #23's admission record documented diagnosis to include metabolic encephalopathy, acute on chronic diastolic (congestive) heart failure, brief psychotic disorder, chronic kidney disease, stage 3 unspecified, chronic obstructive pulmonary disease with (acute) exacerbation, chronic respiratory failure with hypoxia, hyperlipidemia, unspecified, hypertensive heart disease with heart failure, iron deficiency anemia, major depressive disorder, recurrent, mild, obstructive sleep apnea (adult) (pediatric), other seizures, other specified anxiety disorders, other symptoms and signs involving cognitive functions following nontraumatic intracerebral hemorrhage, paroxysmal atrial fibrillation, presence of cardiac pacemaker, sick sinus syndrome, sick sinus syndrome and type 2 diabetes mellitus without complications. Review of Resident #23's physician orders dated 4/14/2026 read, Oxygen at 5 liters/minute via nasal cannula, continuously. During an observation on 4/19/2026 at 12:20 PM Resident #23 was on 4 liters of oxygen via nasal cannula. Review of Resident #23 comprehensive care plan read, Problem: [Resident #23's name] has potential for complications r/t an alteration in cardiac function d/t dx of: CHF, hx of MI [myocardial infarction – heart attack] , hyperlipidemia, coronary angioplasty, dx of heart disease. Interventions: O2 sats as ordered. Administer O2 as ordered. During an interview on 4/22/2026 at 7:25 AM the DON stated, We should always follow the care plan interventions and have the oxygen running correctly.

Based on record review and interview, the facility failed to ensure a required Level 2 Preadmission Screening and Resident Review (PASARR) was completed for 1 of 3 residents, Resident #86, reviewed for PASARR. Findings include:Review of Resident #86's medical record documented the resident was admitted into the facility on [DATE]. Dated 02/18/2026 a Level I PASARR was completed related to the resident having a new medical diagnosis of Brief Psychotic Disorder. The Level I PASARR indicated a Level 2 PASARR should be completed. The record did not contain a Level 2 PASARR.During an interview on 04/21/2026 at 9:15 AM, the Director of Nursing stated, I will get with social services and let you know about the PASARR.During an interview on 04/21/2026 at 11:33 AM the Director of Social Services stated, [Resident #86's name's] level 2 PASARR is in the process of being completed. We had attempted to finish it, and submitted it, and [name of the healthcare management partner] closed it.Review of the policy and procedure titled, Role of Admissions and Social Services in PASARR reviewed 01/13/2026 read, Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs by coordinating with the appropriate, State-designated authority. The facility will ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need in the most appropriate setting, when a significant change in their status occurs. IV. Resident Review: 1. The facility Social Service Director/Credentialed user will complete a referral for Level II resident review evaluation for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or a related condition who experience a significant change. 2. Referring all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II Resident Review upon a significant change is status assessment.

Based on observation and interview the facility failed to maintain the facility interior in a sanitary and orderly manner for 3 of 3 medication storage rooms.Findings include:During an observation on 4/19/2026 at 10:51 AM with Staff A, Registered Nurse (RN) of medication room [ROOM NUMBER], the sink had a very thick brown substance on it covering the entire sink basin which was sticky to the touch. There were multiple pieces of paper and medication caps in the sink. There were bags and paper towels on the floor, and the floor had a sticky residue when walking on the floor.During an interview on 4/19/2026 at 10:51 AM Staff A, RN stated, The sink is filthy and there are multiple things in the sink. The floor is dirty and sticky. I don't know the last time it was cleaned.During an observation on 4/19/2026 at 11:20 AM of medication room [ROOM NUMBER], the Director of Nursing (DON) verified there was a brown sticky substance on the sink with multiple papers and medications caps in the sink basin, the floor contained bags, papers and a sticky residue when walking on the floor.During an observation on 4/19/2026 at 11:25 AM of medication room [ROOM NUMBER] with the DON the sink had a brown residue and on the floor were multiple items of paper and medication caps.During an observation on 4/19/2026 at 11:30 AM of medication room [ROOM NUMBER] there was a plastic bag over the sink handles, and the basin was dirty and rusty. The floor was not clean, there were many items on the floor, and the floor was sticky while walking on it.During an interview on 4/19/2026 at 11:31 AM the DON stated, The medication rooms are not clean, the sinks are dirty and need cleaning. There is trash on the floors, and the floors need to be cleaned. Medication room [ROOM NUMBER] has a non-working sink and staff would not be able to wash their hands while in the medication room. I do not know why they [the medication rooms] were not being cleaned, they should be.During an interview on 4/22/2026 at 06:30 AM the Environmental Services Director stated, The rooms [medication rooms] have not been being cleaned regularly. They are in need of deep cleaning. They [the medications rooms] were not on a routine cleaning schedule and should have been.Review of the policy and procedure titled Environmental Services Cleaning Guidelines with a last approval date of 1/13/2026 read, Policy: It is the policy of this facility that the workplace will be maintained in a clean and sanitary condition with a written schedule of cleaning and decontamination based on area of the facility, type of surface to be cleaned, type of soil present and tasks being performed in the area. Procedure: Horizontal surfaces:1. Surfaces such as table tops, window ledges, bedside stands, counters, sinks, tubs, shower floors, toilet seats, floors, and all other surfaces will be cleaned daily using EPA approved hospital grade disinfectant-detergent solution. 2. These surfaces will also be cleaned as needed when spills or soiling occur. Schedule of Cleaning: 1/A cleaning schedule and the employee responsible for these tasks are to be maintained by the Housekeeping Supervisor. Hand washing Facilities: 1. Hand washing sinks will be cleaned and checked daily for adequate function and supplies. Review of the policy and procedure titled, Medication/Biological Storage with a last approval date of 1/13/2026 read, Policy: It will be the policy of this facility to store medications, drugs, biologicals in a safe, secure and orderly manner. Procedure: 1. Medications, drugs, and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received, unless otherwise necessary. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 4. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals.

Based on observation, interview, and record review, the facility failed to ensure midline catheter intravenous medication administration was completed according to professional standards of practice for 1 of 2 residents, Resident #16, reviewed with a midline catheters. Findings include:Review of Resident #16's admission record documented diagnosis to include cellulitis, unspecified, other bacterial infections of unspecified site and lymphedema not elsewhere classified.Review of Resident #16's physician order dated 4/14/2026 read, Cefepime HCL [hydrochloride] Intravenous Solution Reconstituted 2 GM (grams), use 2 gram intravenously every 12 hours for cellulitis for 14 days. During an observation of medication administration on 4/22/2026 at 9:39 AM Staff A, Registered Nurse (RN) assembled supplies to administer Cefepime intravenously and entered Resident#16's room. Resident #16 was observed with a left single lumen midline catheter needleless connector that was resting in contact with the resident's arm. Staff A, RN did not scrub the hub of the needleless connector, and attached a 10 milliliter normal saline syringe to the needleless connector. Staff A, RN did not attempt to verify the placement of the midline catheter by assessing for blood return and did not use the push pause method (used to verify patency) when injecting the normal saline quickly in a smooth motion into the midline catheter.During an interview on 4/22/2026 at 9:50 AM Staff A, RN stated, I should have tried to verify placement and didn't. I did not use the push pause method to give it [the normal saline flush]. During an interview on 4/22/2026 at 9:54 AM the Director of Nursing stated, She [the RN] should have attempted to verify line placement before administering meds [medications] and should have used the push pause method when flushing the line. Review of the policy and procedure titled Intermittent Infusion with a last approval date of 1/13/2026 read, Purpose: To provide guidelines and procedures for intermittent infusion parameters. Procedure: 16: Vigorously cleanse the needleless connector with alcohol. Allow to air dry. 17. Maintaining asepsis, attach flush syringe to needleless connector. Verify venous access patency.

Based on interview and record review the facility failed to document in the medical record rationales for the pharmacy recommendations for 1 of 5 residents, Resident #31, reviewed for unnecessary medications. Findings include:Review of Resident #31's admission record documented diagnosis to include cerebrovascular disease unspecified cerebral atherosclerosis, chronic obstructive pulmonary disease unspecified, type 2 diabetes mellitus without complications, schizoaffective disorder bipolar type, morbid severe obesity due to excess calories, pseudobulbar effect, chronic pain syndrome, unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety, Barrett's esophagus with dysplasia, bipolar disorder, post-traumatic stress disorder unspecified, obstructive sleep apnea adult, legal blindness, opioid dependence in remission, personal history of malignant neoplasm of prostate, major depressive disorder recurrent moderate, other specified anxiety disorders, bipolar disorder recurrent episode mixed and moderate, other specified persistent mood disorders, opioid abuse uncomplicated, anxiety disorder unspecified, depression unspecified, acute and chronic respiratory failure with hypercapnia, acute kidney failure unspecified and encounter for palliative care, hypertensive heart disease without heart failure, unspecified convulsions, metabolic encephalopathy.Review of Resident #31's pharmacy recommendation dated 3/29/2026 read, PRN [as needed] lorazepam [Ativan] IM [intramuscular] has been limited to 14 days, however the order continues to lack defined behavioral parameters and clear criteria for IM use in a resident already receiving scheduled lorazepam. Recommendation: Please consider: Defining specific behavioral parameters (e.g., severe agitation, risk to self/others, non-redirectable behaviors. Provider response: Continue IM Ativan. Behavioral recommendations were not added.Review of Resident #31's pharmacy recommendation dated 9/12/2025 read, Medications: lorazepam 0.5 mg po [by mouth] tid [three times a day] + Trazodone 100 mg po tid + Seroquel 200 mg po tid + oxcarbazepine 300 mg po tid. Could we attempt a dose reduction at this time to verify this resident is on the lowest dose if not please indicate response below. The response read, psych there was no signature or date to indicate when this was written.Review of Resident #31's pharmacy recommendation dated 6/11/2025 read, This resident is receiving 2 medications with very similar therapeutic activity: 1. Seroquel 100 milligram PO TID, 2. Seroquel 50 milligram tablet give 75 milligram PO TID suggest discontinuing one of these medications and adjusting the dose of the other if necessary. There was no response documented to the recommendation. There was a provider signature dated 6/24/25.During an interview on 4/21/2026 at 2:30 PM the Director of Nursing (DON) stated, I'm not sure who that signature belongs to. There are no responses to the recommendations and there should be. The nurse practitioners or doctors should provide the rationale and agree or disagree with the recommendations. A request was made for policy and procedures for pharmacy recommendations. None were provided.

Based on observation and interview, the facility failed to prevent the possible spread of infection when not performing hand hygiene and/or maintaining enhanced barrier precautions for 4 of 7 observations of medication administration. Findings include:1) During an observation of medication administration on 4/20/2026 at 8:17 AM Staff I, Licensed Practical Nurse (LPN) did not perform hand hygiene and poured medications into a medication cup for Resident #86, entered Resident #86's room, did not perform hand hygiene, donned gloves and attempted to administer medications. Resident #86 spit out the medications into Staff I's gloved hand. Staff I, LPN doffed the gloves, did not perform hand hygiene, donned new gloves and administered Resident #86's eye drops. 2) During an observation of medication administration on 4/20/2026 at 8:31 AM Staff I, LPN returned to medication cart, retrieved keys from a uniform pocket, unlocked the medication cart, activated and typed on the computer. Staff I, LPN did not perform hand hygiene and began preparing Resident #34's medications, entered the resident's room, did not perform hand hygiene, and administered the medications.3) During an observation of medication administration on 4/20/2026 at 8:37 AM Staff I, LPN returned to the medication cart, retrieved keys from a uniform pocket, unlocked the cart, activated and typed on the keyboard. Staff I, LPN did not perform hand hygiene and poured medications for Resident #9, entered the resident's room, did not perform hand hygiene, donned gloves, and administered the medications. Staff I, LPN doffed the gloves, did not perform hygiene, and returned to the medication cart.During an interview on 4/20/2026 at 8:50 AM Staff I, LPN stated, Oh I didn't realize that I didn't perform hand hygiene. I should have done that.4) During an observation of medication administration on 4/22/2026 at 9:39 AM Staff A, Registered Nurse (RN) was observed in a resident's room completing medication administration. Staff A did not perform hand hygiene prior to exiting the resident's room and returned to the medication cart to prepare medications for another resident. Staff A, RN retrieved keys from a uniform pocket, unlocked the medication cart, activated and typed on the computer. Staff A, RN did not perform hand hygiene, donned gloves, and entered Resident #16's room without donning a gown. Resident #16's left single lumen midline catheter needleless connector was in contact with Resident #16's arm. Resident #16 moved their arm and the needleless connector came in contact with the resident's wheelchair arm. Staff A, RN did not cleanse the needleless connector with alcohol, did not check for the catheter's placement, attached a 10-milliliter syringe of normal saline to the needless connector, and administered the medication. Staff A, RN let go of the needleless connector which came in direct contact with the resident's arm and wheelchair arm. Staff A, RN then attached the IV (intravenous) tubing without cleansing the needleless connector with alcohol, attached the IV medication, and activated the IV pump for the infusion.During an interview on 4/22/2026 at 9:50 AM Staff A, RN stated, I only had gloves on. I should have had on a gown. He is on enhanced barrier precautions. I did not clean the hub before I did the normal saline. I should have tried to verify placement and didn't. I did not use the push pause method [a flushing technique used to verify IV patency and proper placement] to give it [medication] and I should have cleaned it again after I flushed and before I hung the antibiotic.During an interview on 4/22/2026 at 9:54 AM the Director of Nursing stated, She [the nurse] should have worn a gown, she should have cleaned the hub [needleless connector] with alcohol, she should have attempted to verify line placement before administering meds and should have used the push pause method when flushing the line.Review of the policy and procedure titled Intermittent Infusion last approval date of 1/13/2026 read, Purpose: To provide guidelines and procedures for intermittent infusion parameters. Procedure: 16: Vigorously cleanse the needleless connector with alcohol. Allow to air dry. 17. Maintaining asepsis, attach flush syringe to needleless connector. Verify venous access patency. Review of the policy and procedure titled Hand Hygiene last approval date of 1/13/2026 read, Policy: The facility considers hand hygiene the primary means to prevent the spread of infections. Procedure: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5, Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after coming into direct contact with residents. c. before and after handling medications; e. before and after handling an invasive device (e.g. urinary catheter, IV access devices. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. 7. The use of gloves does not replace hand washing/hand hygiene, integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of the policy and procedure titled Enhanced Barrier Precautions [EBP] with a last approval date of 1/13/2026 read, Policy: It will be the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. Procedure: 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy, ventilator, etc.) regardless of MDRO [multidrug resistant organisms] colonization status. 4. For residents whom EBP are indicated, EBP is employed when performing the following high contact resident care activities: g. Device care or use: central line.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a secure manner. Findings include: During an observation on 12/9/2024 at 9:30 AM, there was one bottle of Spring Valley Cinnamon Dietary Support Supplement on Resident #5's bedside table. During an interview on 12/9/2024 at 9:30 AM, Resident #5 stated, I take that for my diabetes. I have permission to have that. During an observation on 12/9/2024 at 9:35 AM, there was one clear plastic cup containing 3 round white tablets on Resident #6's bedside table. During an interview on 12/9/2024 at 9:35 AM, Resident #6 stated, It's my sodium pills and I'm not taking those. They get stuck when I try to swallow them, so I'm not taking them. The cup is from the night before. I just didn't take them. During an interview on 12/9/2024 at 1:15 PM, the Assistant Director of Nursing (ADON) stated, There are never to be medications left at bedside. I expect them [staff] to stand with the resident until they have taken all of their medications. If they [residents] wish to have meds at bedside, then an assessment needs to be conducted to see if it's appropriate, then it would be care planned and we would obtain a lockbox for the resident to have. Review of Resident #5's medical records revealed no order for Cinnamon supplements and no care plan focus to have medication at bedside. Review of the facility policy and procedure titled Medication Administration issued on 4/1/2022 showed it read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure . 3. Medications should be administered in a timely manner and in accordance with the physician's orders.

Based on observation, interview, and record review, the facility failed to ensure food was stored properly and kitchen equipment were kept in a safe and sanitary manner in the main kitchen and 3 of 3 nourishment rooms. Findings include: During an observation on 11/3/2024 beginning at 9:24 AM while conducting the initial tour of the kitchen, there were white substance buildup on the exterior of the ice machine, one package of pork that was wrapped in foil that was gapped open, shredded cheese wrapped in plastic wrap that was not sealed, one undated and unlabeled plastic container of red sauce, one undated container of pancakes in the reach-in refrigerator. The exterior surface of the oven was discolored and splattered with black and brown substances. There was a black substance caked on the gas stove top grates. During an interview on 11/4/2024 at 8:42 AM, the Certified Dietary Manager confirmed there were undated and unlabeled food items in the reach-in refrigerator. She confirmed the ice machine, oven and gas stove top needed cleaning. During an observation on 11/4/2024 at 8:48 AM with the Regional Certified Dietary Manager, the ceiling above the dishwasher was cracked, flaking and missing paint. There was paint missing from both sides of the overhead light in front of the dishwasher. During an interview on 11/4/2024 at 8:48 AM, the Regional Certified Dietary Manager confirmed there was missing, flaking and cracked ceiling paint over the dishwasher that needed repair. During an observation on 11/4/2024 beginning at 8:52 AM, there were one undated and unlabeled blue lunch bag that contained bottled water, juice packets, and one undated and unlabeled plastic container of food in the East Nourishment Room refrigerator. During an interview on 11/4/2024 beginning at 8:52 AM, the Regional Certified Dietary Manager confirmed foods and beverages stored in the nourishment room refrigerators should be labeled and dated. During an observation in on 11/4/2024 beginning at 8:58 AM, there were one undated and unlabeled 32-ounce thermos of liquid in the refrigerator, and one 64-ounce plastic container of peanut butter with an unsecured lid and one undated and unlabeled 16-ounce cup of liquid in the cabinet in the [NAME] Nourishment Room. During an interview on 11/4/2024 beginning at 8:52 AM, the Regional Certified Dietary Manager confirmed foods and beverages stored in the nourishment room refrigerators should be labeled, sealed and dated. During an observation on 11/4/2024 beginning at 9:04 AM in the South Nourishment Room, there were one undated tray of cookies, and three thawed supplements stored in the refrigerator with no thawed-on date noted on the containers. The cartons of the supplements contained directions that the product should be used within 14 days of thawing. Review of the facility policy and procedure titled Food Delivery and Storage with the last review date of 1/23/2024 read, Policy: It will be the policy of this facility that foods shall be received and stored in a manner that complies with safe food handling practices. Procedure: 1. Dietary/Food Services, or other designated staff, will maintain clean food storage areas at all times . 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated. Review of the facility policy and procedure titled Foods Brought in From the Outside with the last review date of 1/23/2024 read, Policy: It will be the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including food and beverages brought to residents by family and other visitors . Procedure . 4) Food Receiving and Storage a) Upon receiving food and beverages products brought in for residents nursing staff will complete the following . ii) Inspect containers for tight fitting lids, iii) Wrapped items will be inspected to assure the wrapping seals tightly, iv) Label containers with food item name and date received . 6) Any item noted without a label and/or date will be discarded . 9) Leftover trays and/or meals will not be kept on the unit. They will be returned to the Food Services Department and disposed - for example: (Resident at an outside appointment such as a follow up and or dialysis and the like).

Based on observation, record review, and interview, the facility failed to ensure residents received appropriate respiratory care for 3 of 4 residents reviewed for respiratory care, Residents #21, #19, and #36. Findings include: 1) During an observation on 11/3/2024 at 10:20 AM, Resident #21's nebulizer mask was stored on the resident's bedside table next to a soiled cushion (photographic evidence obtained). During and observation on 11/4/2024 at 10:45 AM, Resident #21's nebulizer mask was on the resident's bedside table open to air next to a soiled cushion. During and observation on 11/5/2024 at 12:08 PM, Resident #21's nebulizer mask was laying on the resident's bedside table open to air next to a soiled cushion. Review of Resident #21's admission record showed the resident was initially admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease, chronic pulmonary edema, dependence on supplemental oxygen, chronic diastolic (congestive) heart failure, and chronic pulmonary embolism. Review of Resident #21's physician order dated 6/5/2023, read, Albuterol Sulfate Nebulization Solution (2.5 mg/ 3ml) [2.5 milligram/3 milliliter] 0.083%. 3 ml inhale via nebulizer four times a day for shortness of breath related to chronic obstructive pulmonary disease. During an interview on 11/5/2024 at 12:30 PM, Staff A, Licensed Practical Nurse (LPN), stated, The mask should be stored in a clean bag. During an interview on 11/5/2024 at 1:00 PM, the Assistant Director of Nursing (ADON) stated that her expectation was to have the staff properly store masks in the plastic bags. 2) During an observation on 11/3/2024 at 10:00 AM, Resident #36 was receiving oxygen via nasal cannula at 3.5 liters per minute (photographic evidence obtained). During an observation on 11/4/2024 at 10:40 AM, Resident #36 was receiving oxygen via nasal cannula at 3.5 liters per minute. Review of Resident #36's admission record showed the resident was admitted on [DATE] with diagnosis to include congestive heart failure, and presence of aortocoronary bypass graft. Review of Resident #36's physician order dated 4/11/2024 read, Oxygen at 2 liters/minute Via -NC [nasal cannula] with no humidification. During an interview on 11/5/2024 at 1:00 PM, the Assistant Director of Nursing (ADON) stated, [Resident #36' name] should be set at what the physician orders are. [Resident #36's name] order reads O2 [oxygen] at 2 liters. 49444 3) During an observation on 11/3/2024 at 8:40 AM, Resident #19's nebulizer mouthpiece and tubing was uncovered on the table in her room. Review of Resident #19's physician order dated 8/23/2024 read, Albuterol Sulfate Inhalation Nebulization Solution 2.5 mg/3 ml. 2.5 mg inhale orally via nebulizer every 6 hours as needed for wheezing or shortness of breath. During an interview on 11/5/2024 at 8:45 AM, the Regional Registered Nurse confirmed Resident #19's nebulizer mouthpiece and tubing were improperly stored. Review of the facility policy and procedure titled Respiratory Care with the last review date of 1/23/2024, read, Policy: It is the policy of this facility to provide respiratory care and safe oxygen administration to meet the needs of the residents. Procedure: 1. Verify that there is a physician's order for respiratory procedures or oxygen use. Review the physician's orders for oxygen administration, nebulizer treatments, inhalers, trach care, chest tube/PleurX care, BiPap, CPAP or medication administration . 10. Oxygen, trach and nebulizer tubing is changed weekly and dated as verification that the tubing was changed. Tubing change may be recorded in the clinical record but is not required. Tubing should be store appropriately when not in use.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 3 of 3 reviewed medication carts, and failed to ensure the medications were not unattended (Photographic evidence obtained). Findings include: During an observation on 7/31/2023 at 9:00 AM, there was a bag on the floor in the conference room, which contained four unopened normal saline syringes. During an interview on 7/31/2023 at 9:15 AM, the Director of Nursing (DON) stated, We had an IV [intravenous] class for nurses that is why it was there. During an observation of North Wing Medication Cart on 7/31/2023 at 9:30 AM with Staff A, License Practical Nurse (LPN), there were one opened Advair with opened date of 5/14/2023, three opened bottles of Latanoprost with no opened date, and one opened Lantus insulin pen with no opened or expiration date. During an interview on 7/31/2023 at 9:37 AM, Staff A, LPN, stated, Upon opening medication, we should label it with an open and expiration date, and if medication is expired, it should come off the cart and it should be reordered. During an observation of [NAME] Wing Medication Cart on 7/31/2023 at 9:41 AM with Staff B, LPN, there were two opened bottles of Artificial Tears eye drops with opened dates of 6/25/2023, and two opened bottles of Artificial Tears eye drop with opened dates of 6/20/2023. During an interview on 7/31/2023 at 9:47 AM, Staff B, LPN, stated, Once expired, medication should be taken out of the cart. During an observation of East Wing Medication Cart on 7/31/2023 at 9:50 AM with Staff C, LPN, there were two opened bottles of Artificial Tears eye drops with no opened dates. During an interview on 7/31/2023 at 9:55 AM, Staff C, LPN, stated, Once medication is opened, the bottle should be labeled with an open date. The staff wrote the actual expiration of the medication. I think eye drops are good for 90 days after opening them. During an observation of Resident #13's room on 7/31/2023 at 9:58 AM, there was a tube of Zinc Oxide ointment on top of the drawer. During an observation Resident #26's room on 7/31/2023 at 10:26 AM, there were vials of Albuterol Sulfate Inhalation Solution on top of the drawer next to the nebulizer mouthpiece. During an interview on 8/2/2023 at 7:34 AM, Staff I, LPN, stated, [Resident #26's name] should not have any Albuterol vials in her room. During an interview on 8/2/2023 at 7:40 AM, the Director of Nursing stated, There should not be any expired medications in the medication carts. Anything that is open should be labeled. We administer [Resident #13's name] medication for her. The ointment should not have been in her room. [Resident #26's name] does not have a self-administration order. The staff would do a self-administration assessment making sure resident is able to administer the medication. We would provide a lock box for medication storage in room. Review of the facility policy and procedures titled Medication/Biological Storage last reviewed on 1/17/2023 reads, Policy: It will be the policy of this facility to store medications, drugs and biologicals, in a safe, secure and orderly manner. Procedure . 4. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 3 of 7 residents reviewed, Residents #13, #35, and #78. Finding include: 1. During an observation on 7/31/2023 at 12:00 PM, Resident #13 was sitting in her room, with oxygen being administered via nasal cannula. During an observation on 8/1/2023 at 9:00 AM, Resident #13 was sitting in her wheelchair, with oxygen being administered via nasal cannula. Review of Resident #13's MDS 5-day Significant Change in Status assessment dated [DATE] reads, Section O. O0100. Special Treatments, Procedures and Programs . C. Oxygen. 1. While NOT a Resident: No, 2. While a Resident: No. Review of Resident #13's physician order dated 5/4/2023 reads, Monitor O2 [oxygen] sats [saturation] as needed for SOB [Shortness of Breath]/Respiratory Distress . Monitor O2 sats every shift for O2 monitoring. Review of Resident #13's physician order dated 5/5/2023 reads, May apply O2 @ [at] 2 LPM [liters per minute] via nasal cannula as needed to maintain sats above 92% as needed for monitoring O2 sats > or = 92%. Review of Resident #13's Weights and Vitas Summary reads, 05/09/2023, 20:00 [8:00 PM] 95% (Oxygen via Nasal Cannula), 05/08/2023, 18:04 [6:04 PM] 90% (Oxygen via Nasal Cannula), 05/07/2023, 18:11 [6:11 PM] 95% (Oxygen via Nasal Cannula), 05/06/2023, 19:34 [7:34 PM] 98% (Oxygen via Nasal Cannula), 05/06/2023, 15:49 [3:49 PM] 98% (Oxygen via Nasal Cannula), 05/06/2023, 13:35 [1:35 PM] 98% (Oxygen via Nasal Cannula), 05/05/2023, 22:33 [10:33 PM] 98% (Oxygen via Nasal Cannula), 05/05/2023, 15:43 [3:43 PM] 95% (Oxygen via Nasal Cannula), 05/04/2023 at 22:33 [10:33 PM] 97% (Oxygen via Nasal Cannula). During an interview on 8/2/2023 at 7:52 AM, the MDS Coordinator stated, [Resident #13' name] MDS dated [DATE] is marked no for oxygen, but she did have oxygen administered. It needs to be corrected. 2. During an observation on 7/31/2023 at 10:27 AM, Resident #35 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. During an observation on 8/2/2023 at 6:05 AM with Staff K, Registered Nurse (RN), Resident #35 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. Review of Resident #35's physician order dated 7/27/2023 reads, Continuous O2 at 2 L/MIN via NC [Nasal Cannula] every shift. Review of Resident #35's Quarterly MDS dated [DATE] reads, Section O. O0100. Special Treatments, Procedures and Programs . C. Oxygen . 2. While a Resident: No. Review of Resident #35's Weights and Vitals Summary reads, 05/23/2023, 17:11 [5:11 PM] 94% (Oxygen via Nasal Cannula), 05/21/2023, 17:37 [5:37 PM] 98% (Oxygen via Nasal Cannula). During an interview on 8/2/203 at 7:58 AM, the MDS Coordinator stated, [Resident #35's name] has so many things going on with her. She sure did use oxygen. 40559 3. Review of Resident #78's records revealed the resident was admitted to the facility on [DATE] with diagnoses including lobar pneumonia, pyuria, cardia murmur, congestive heart failure and chronic kidney disease. Resident #78 was discharged home with family on 7/7/2023. Review of Resident #78's MDS Assessment Discharge Return Not Anticipated dated 7/7/2023 reads, Section A. Identification Information . A2100. Discharge Status: 03. Acute hospital. Review of Resident #78's Social Services Progress Note dated 7/7/2023 reads, Pt [Patient] given d/c [discharge] instructions/ med list, verbalized understanding all. all meds sent with pt. discharged approx. [approximately] 12 noon . Discharge Planning- [Resident #78's name] has requested to discharge today at noon with her daughter . During an interview on 8/1/2023 at 2:00 PM, the MDS Coordinator confirmed that Resident #78's was discharged home with her daughter, but the discharge MDS showed the resident was discharged to a hospital. During an interview on 8/2/2023 at 10:30 AM, the Director of Nursing stated, Yes, [Resident #78's name] discharged home with her family. Her MDS shows she discharged to the hospital. Review of the facility policy and procedure titled MDS Assessments with the last review date of 1/17/2023 reads, Procedures: 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements .

Based on interview and record review, the facility failed to ensure a resident who was diagnosed with a serious mental illness was referred for level II Preadmission Screening and Resident Review (PASRR) for 1 of 3 residents reviewed, Resident #49. Findings include: Review of Resident #49's admission records showed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cognitive communication deficit, dementia, major depressive disorder, anxiety disorder, and schizophrenia (onset date of 9/18/2022). Review of Resident #49's records revealed no referral for Level II PASRR screening when the resident received the diagnosis of schizophrenia. During an interview on 8/2/2023 at 10:00 AM, the Director of Nursing stated, We did not conduct a new Level I screen when [Resident #49's Name] was officially diagnosed with schizophrenia. Review of the facility policy and procedures titled P&P Role of Admissions and Social Services in PASRR last reviewed on 1/17/2023 reads, Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services . Procedure . IV. Resident Review . 2. Referring all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition who experience a significant change.

Based on interview and record review, the facility failed to ensure a resident who was admitted with a diagnosis of a serious mental received a referral to the appropriate state-designated authority for Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination for 1 of 3 residents reviewed, Resident #39. Findings include: Review of Resident #39's admission record revealed the resident was admitted most recently to the facility on [DATE] with diagnoses including cerebral atherosclerosis, psychotic disorder with delusions, unspecified psychosis not due to a substance or known physiological, general anxiety disorder, mood disorders, major depressive disorder, neurocognitive disorder with Lewy bodies and encounter for palliative care. Review of Resident #39's level II Preadmission Screening and Resident Review (PASRR) dated 6/3/2022 reads, Section IV: PASRR Screen Completion . Individual may not be admitted to an Nursing Facility. Use this form and required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of [Check on of the following]: X Serious Mental Illness and Intellectual Disability. During an interview on 8/2/2023 at 10:00 AM, the Director of Nursing (DON) stated, We did not send out a referral for a level II screening for [Resident #39's Name]. It should have been referred out. Review of the facility policy and procedure titled P&P Role of Admissions and Social Services in PASRR) last reviewed on 1/17/2023 reads, Policy: The facility will ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services . Procedure: I. Preadmission Screening . 3. If the result of the PASRR (Level 1) screening indicates that serious mental illness (SMI) and/or intellectual disability (ID) or related condition appears to exist (positive Level I screen) and the individual does not meet a Provisional or Hospital Discharge Exemption, the individual will be referred to KEPRO [Keystone Peer Review Organization] for a Level II screening prior to the individual being accepted for SNF [Skilled Nursing Facility] admission.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for 1 of 5 residents reviewed for nutrition, Resident #30, and failed to develop a person-centered care plan for 1 of 4 residents reviewed for respiratory services, Resident #13. Findings include: 1. During an observation on 7/31/2023 at 12:10 PM, Resident #30 was eating independently in her room. The meal tray had a plate with green beans and pasta on the same plate, rice pudding in a bowl and a cup of coffee. During an observation on 8/1/2023 at 8:13 AM, Resident #30 was eating independently in her room. The meal tray contained scrambled eggs and toast on the same plate and a bowl of oatmeal. During an observation on 8/1/2023 at 11:59 AM, Resident #30 was eating in the restorative dining room area. The plate contained macaroni and cheese, chopped meat, spinach, and a roll. All items were together on the same plate (Photographic evidence obtained). Review of Resident #30's care plan with revision date of 4/4/2022 reads, Focus: [Resident #30's name] has an alteration in visual function AEB [As Evidenced By]: dx [diagnosis] of glaucoma, is legally blind, is only able to see shapes, lights. Assist with meals as needed . Interventions: Per [Resident #30's name] request, her food will be put in separate bowls for easier self-feeding. During an interview on 8/2/2023 at 7:57 AM, the Registered Nurse Assessment Coordinator stated, [Resident #30's name] food should come in separate bowls. During an interview on 8/2/2023 at 1:27 PM, the Director of Nursing stated, [Resident #30's name] food should have come in separate containers as mentioned in the care plan. We had been talking about this with staff. 2. During an observation on 7/31/2023 at 12:00 PM, Resident #13 was sitting in her room, with oxygen being administered via nasal cannula. During an observation on 8/1/2023 at 9:00 AM, Resident #13 was sitting in her wheelchair, with oxygen being administered via nasal cannula. Review of Resident #13's physician order dated 5/4/2023 reads, Monitor O2 [oxygen] sats [saturation] as needed for SOB [Shortness of Breath]/Respiratory Distress . Monitor O2 sats every shift for O2 monitoring. Review of Resident #13's physician order dated 5/5/2023 reads, May apply O2 @ [at] 2 LPM [liters per minute] via nasal cannula as needed to maintain sats above 92% as needed for monitoring O2 sats > or = 92%. Review of Resident #13's care plan revealed no focus for respiratory care or oxygen use. During an interview on 8/2/2023 at 7:49 AM, the Registered Nurse Assessment Coordinator stated, I see under cardiac functions to monitor O2 [oxygen] sats. I do not see [Resident #13's name] care plan for respiratory or oxygen concerns. I will add it. During an interview on 8/3/2023 at 8:54 AM, the Director of Nursing stated, I have been made aware that [Resident #13's name] did not have a respiratory/oxygen care plan developed. There should have been one. Review of the facility policy and procedure titled Oxygen Administration last reviewed on 1/17/2023 reads, Procedure . 9. The use of oxygen should be reflected in the resident's plan of care. Review of the facility policy and procedure titled Care plans, Comprehensive Person-Centered last reviewed on 1/17/2023 reads, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure that residents received care in accordance with professional standards of practice for medication administration for 1 of 7 residents reviewed, Resident #180. Finding include: During an observation of medication administration for Resident #180 on 8/2/2023 at 8:26 AM, Staff L, Registered Nurse (RN), pulled Depakote Delayed Release 250 mg (milligram) blister pack out of the medication cart and verified the order and medication on hand. Staff L placed one tablet in a clear plastic sleeve, crushed the medication, and placed the crushed medication into a plastic medication cup. Staff L proceeded to prepare Citalopram Hydrobromide 10 mg and Metoprolol 25 mg, crushed the medications individually and placed them in separate medication cups. Staff L stated to review how many milliliters of water each medication should be mixed with. When asked to review Depakote delayed release medication order one more time, Staff L stated, It says delayed release. We should not be crushing this medication, but that is what the order reads. I guess I can ask my DON [Director of Nursing] for clarification. Staff L walked to the DON's office. The DON was not available in her office. Staff L returned to the unit and asked Staff E, License Practical Nurse (LPN), about the medication. Staff E stated a delayed release medication could not be administered via gastric tube and would contact the doctor for clarifications. Review of Resident #180's physician order dated 7/27/2023 reads, Depakote Oral Tablet Delayed Release 250 mg, give 3 tablet enterally three times a day for mood disorder. Review of Resident #180's physician order dated 7/26/2023 reads, Nothing by mouth diet, nothing by mouth texture, nothing by mouth consistency, for nutrition. Review of Resident #180's Medication Administration Record (MAR) for July 2023 revealed staff initials for administration of Depakote Oral Tablet Delayed Release 250 mg on 7/27/2023, 7/28/2023, 7/29/2023, 7/30/2023, 7/31/2023 at 9:00 AM, 1:00 PM and 5:00 PM Review of Resident #180's MAR for August 2023 reads revealed staff initials for administration of Depakote Oral Tablet Delayed Release 250 mg on 8/1/2023 at 9:00 AM, 1:00 PM and 5:00 PM. During an interview on 8/2/2023 at 10:43 AM, the Attending Physician A stated, Depakote delayed release should not be crushed. I was not notified prior to today that the order was incorrect. The medication should not be crushed because it is supposed to be released along some time. What will happen is that the resident will have a higher dose in a short period of time, but it will wear out in a short period of time. The facility will need to check levels. I have an order in place for the levels to be checked this upcoming Monday to make sure of the resident's therapeutic level. I do not see any potential harm since it takes time to build a steady level. It will not be immediately. I would not have a devastating consequence. The medication is not for seizures, but due to behavior. During an interview on 8/2/2023 at 11:04 AM, Staff E, LPN, stated, If I gave it, I probably gave it as ordered. Delayed release medication should not be usually crushed. I had not realized the medication was extended release until today when you and [Staff L's name] approached me. I kind of float all over the building and it is hard for me to keep up. When I am going to administer medication, I read the order and double check the route and dose. I missed that. I crushed the Depakote and put it through his tube. During an interview on 8/2/2023 at 11:57 AM, Staff G, LPN, stated, I do not recall. I do not know of any other way I would have administered medication other than [Resident #180's name] gastric tube. Honestly, I did not realize the Depakote was delayed release. I would have called the doctor since the resident is NPO [Nothing by Mouth] and had the doctor change it to something else. During an interview on 8/2/2023 at 12:01 PM, Staff H, LPN, stated, I administered the medication via g-tube [gastric tube]. I did not realize the order was delayed released since I gave it via g-tube. I would have called the doctor to clarify and get it changed to something crushable. During an interview on 8/2/2023 at 1:24 PM, the Director of Nursing (DON) stated, I would have expected staff to call the doctor and get the medication changed to something that is not extended release and can be administered via gastric tube. [Resident #180's name] is NPO. During an interview on 8/2/2023 at 4:57 PM, Staff F, LPN, stated, I crushed and administered via [Resident #180's name] gastric tube. Next time, I will call the doctor and get clarification on the orders. Review of the facility policy and procedure titled Medication Administration Via Enteral Feeding Tube last reviewed on 1/17/2023 reads, Policy: Medications shall be prepared and administered according to the following established guidelines . Residents with enteral tubes should be provided liquid medications whenever possible to prevent buildup of residue within the tube inner lumen. Procedure . Common Medications Not to Crush: Some medications and dosage form should not be crushed. If there are any questions regarding the crushing of medications, call the pharmacy.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 3 of 4 residents reviewed for respiratory services, Residents #26, #30, and #35 (Photographic evidence obtained). Findings include: 1. During an observation on 7/31/2023 at 12:10 PM, Resident #26 was lying in bed, with the nebulizer mouthpiece on top of the drawer with no bag. There were vials of Albuterol next to the mouthpiece, and the oxygen tank tubing was dated 04/09. During an observation on 8/1/2023 at 8:32 AM, Resident #26 was lying in bed, with the nebulizer mouthpiece on top of the drawer with no bag. There were vials of Albuterol next to the mouthpiece, and the oxygen tank tubing was dated 04/09. During an observation on 8/2/2023 at 7:34 AM with Staff I, License Practical Nurse (LPN), Resident #26 was resting in bed with her eyes closed. The nebulizer mouthpiece was on top of the drawer with no bag. There were vials of albuterol next to the mouthpiece. The nebulizer mask was on top of the chair with no date on tubing or bag. The oxygen tubing connected to the oxygen tank attached to the wheelchair was dated 4/9/2023. During an interview on 8/2/2023 at 7:38 AM, Staff I, LPN, stated, Tubing should be changed every week by night shift. Tubing and mask should be bagged when not in use. Review of Resident #26's physician order dated 4/7/2023 reads, Continuous O2 [oxygen] at 3 L/MIN [liters per minute] via NC [Nasal Cannula] q [every] shift every shift. Review of Resident #26's physician order dated 4/18/2023 reads, Check oxygen saturations Q shift every shift. Review of Resident #26's physician order dated 6/7/2023 reads, Albuterol Sulfate (2.5 MCG/3 ML) [2.5 microgram per 3 milliliters] 0.083% Nebulization Solution, 3 ml inhale orally via nebulizer every 8 hours and as needed for COPD [Chronic Obstructive Pulmonary Disease]. Review of Resident #26's physician orders revealed no orders for tubing change. 2. During an observation on 7/31/2023 at 10:26 AM, Resident #30 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. During an observation on 8/1/2023 at 8:00 AM, Resident #30 was lying in bed, with oxygen being administered via nasal cannula at 2.5 liters per minute. Review of Resident #30's physician order dated 1/19/2023 reads, Continuous O2 at 2 L/MIN via NC q shift. During an interview on 8/2/2023 at 7:44 AM, the Director of Nursing stated, Oxygen tubing should be changed weekly, and equipment should be stored in a bag when not in use. Staff are expected to follow physician orders and verify flow rates unless resident is prn [as needed] or has orders to wean. 3. During an observation on 7/31/2023 at 10:27 AM, Resident #35 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. Oxygen tubing was not dated. During an observation on 8/2/2023 at 6:05 AM with Staff K, Registered Nurse (RN), Resident #35 was lying in bed, with oxygen being administered via nasal cannula at 3 liters per minute. Oxygen tubing was not dated. During an interview on 8/2/2023 at 6:07 AM, Staff K, RN, stated, [Resident #35's name] oxygen is supposed to be running at 2 liters per minute not at 3 liters and tubing should be dated. Review of Resident #35's physician order dated 7/27/2023 reads, Continuous O2 at 2 L/MIN via NC q shift. Review of the facility policy and procedures titled Oxygen Administration last reviewed on 1/17/2023 reads, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . 3. Assemble the equipment and supplies as need . 7. Weekly oxygen tubing changes can be documented in the medical record as a reminder to the staff but is only required to have tubing dated appropriately demonstrating that the tubing was changed.

Based on observation, interview, and policy and procedure review, the facility failed to ensure foods in the refrigerator and storage area of the kitchen were dated and/or labeled, and failed to ensure the expired or outdated foods were discarded. Findings include: During an initial walk-through of the kitchen on [DATE] at 9:17 AM with the Dietary Manager (DM), there were eight containers of cranberry juice cocktail with a manufacturer stamped expiration date of [DATE] on the shelves in the stock room; a container of sour cream with a manufacturer used by date of [DATE] in the reach-in cooler; an unidentified Styrofoam hinged container with no label or date in the walk-in cooler; and a large container of red potatoes, a large container of sauce, and a large container of sliced ham with no label identifying the contents and a date of [DATE] on the lid. During an interview on [DATE] at 9:29 AM, the DM stated that the cranberry juice cocktail was expired and should have been pulled and discarded on [DATE], the sour cream container showed an expiration date of [DATE] and should have been discarded on that date, the hinged Styrofoam container should have been labeled with the contents and dated, and the containers of potatoes, sauce, and ham should have had identifying labels as well as the date to show when the item was prepared and a use by date. Review of the facility policy and procedures titled Receiving with the last review date of [DATE] reads, Policy Statement: It is the center policy that safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. Action Steps . 6. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation.

Based on observation, interview, and record review, the facility failed to ensure resident records were complete and accurate for 4 of 15 residents reviewed, Residents #42, #229, #61, and #182. Findings include: 1. Review of Resident #42's physician order dated 7/6/2023 reads, Weight resident daily on 11-7 shift. Notify MD [Medical Doctor] for 3 lbs [pounds] weight gain in 24 hours or 5 lbs weight gain in 1 week. every night shift for prophylaxis. Review of Resident #42's Treatment Administration Record (TAR) for July 2023 revealed no weights recorded for 7/6/2023, 7/10/2023, 7/15/2023, 7/23/2023, 7/24/2023, and 7/25/2023, and NA [Not Applicable] recorded for 7/7/2023, 7/8/2023, 7/9/2023, 7/12/2023, 7/17/2023, 7/21/2023 and 7/22/2023. Review of Resident #42's Weight and Vital Summary reads, 7/7/2023: 260 lbs, 7/12/2023: 259 lbs, 7/15/2023: 262 lbs, 7/17/2023: 261.7 lbs, 7/19/2023: 260 lbs, 7/20/2023: 258.4 lbs, 7/27/2023: 261 lbs, 7/31/2023: 259.6 lbs. Review of Resident #42's care plan revised on 6/28/2023 reads, Interventions . Provide diet as ordered. Observe for compliance with diet. Weights as scheduled. During an interview on 8/1/2023 at 1:29 PM, the Director of Nursing (DON) stated, [Resident #42's name] has some refusals and some weights documented. The empty spaces on the treatment record mean staff are not documenting the weights in the system like they should be. 2. During an observation of Staff E, Licensed Practical Nurse (LPN), and Staff F, LPN, providing wound care for Resident #229 on 8/2/2023 at 4:25 PM, Staff E washed her hands and proceeded to place barrier under the resident's legs. Resident #229's right leg had a gauze dressing dated 8/2/2022. Staff E performed wound care on the resident's right leg. During an interview on 8/2/2023 at 4:26 PM, Staff E, LPN, stated [Resident #229's name] wounds are all located in his right leg. Review of Resident #229's physician order dated 7/26/2023 reads, Cleanse left shin with ns [normal saline], pat dry, apply xeroform, abd [abdominal] and wrap with kerlix daily every evening shift for wound healing. Review of Resident #229's physician order dated 8/1/2023 reads, Cleanse left heel with ns, pat dry, apply betadine and leave open to air every evening shift for wound healing . Cleanse top of left foot with ns, pat dry, apply Santyl and medihoney and cover/wrap with kerlix daily every evening shift for wound healing. Review of Resident #229's Healing Partners Wound Assessment Report dated 7/28/2023 reads, Location: right heel, Etiology: Pressure, Stage/Severity: Unstageable . Location: right foot, Etiology: Pressure, Stage/Severity: Stage 3. During an interview on 8/3/2023 at 9:15 AM, the Regional Nursing Consultant stated, I will review [Resident #229's name] record and see. Sometimes it can get confusing, the labeling of side. 44571 3. Review of Resident #182's bladder continence task record from 7/14/2023 through 7/31/2023 reads, Task: Bladder Continence: Resident is incontinent of bladder and requires assistance of 1 for all per care. Review of the calendar showed no entries documented for 7/24/2023 and 7/25/2023. During an interview on 8/1/2023 at 11:30 AM, the DON stated that her expectations was for the staff to chart in the task area when changing an incontinent resident, and staff were expected to accurately document and only document when they performed the task. During an interview on 8/1/2023 at 1:55 PM, Staff D, Certified Nursing Assistant (CNA), stated, We check incontinent residents every 2 hours, and it is an error of data input as I don't put it in the computer every time. Review of the facility policy and procedure titled Perineal/Incontinent Care last reviewed on 7/17/2023 reads, Procedure . 8. Document completion of care rendered as is appropriate or required to demonstrate needs of resident have been met. 40559 4. Review of Resident #61's shower task record for July 2023 reads, Task: Resident shower days are on Monday-Wednesday-Friday on 7-3 with assist of 1 and shower chair between the hours of 7 am and 8 am. Review of the calendar showed no entries documented for Friday 7/14/2023, Monday 7/17/2023, Friday 7/21/2023, and Wednesday 7/26/2023. During an interview on 8/2/2023 at 2:20 PM, the DON stated, My expectation is for the staff to document on the shower task sheet each time they give a shower or when the resident refuses. During an interview on 8/3/2023 at 8:03 AM, Staff J, CNA, stated, When it shows on the task list that a resident is due a shower, we mark on the list on the computer that we give it or that they have refused. We also document any PRN [as needed] showers on the list. Review of the facility policy and procedures titled Charting and Documentation with last review date of 1/17/2023, reads, Procedure: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical records.

Based on record review and interview, the facility failed to ensure 1 of 5 residents reviewed for accident prevention, Resident #56, in a total sample of 22 residents, received adequate assistance and supervision during bed mobility to prevent accidents resulting in injury. Resident #56 suffered from injury of her leg. Findings include: Review of Resident #56's records revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 10/26/2020 at 10:49 AM, Resident #56 stated she had cut her leg on her bed the night before on the end of the side rail. On 10/26/2020 at 10:49 AM, an observation of Resident #56's bed revealed the side rail end was discolored a red/brown color and was missing paint at the end. The plastic end cap that covers the end of the metal side rail was missing. (Photographic evidence obtained) An observation of Resident #56's bed with the Director of Nursing on 10/26/2020 at 2:00 PM revealed the end cap on the side rail had been replaced and the side rail was rusty at the end of the side rail. During an interview on 10/27/2020 at 9:45 AM with the Director of Nursing, a review of the incident report for Resident #56 was conducted, which showed the resident called the nurse to the room and stated she had hit her leg on side rail; physician was notified at 10:45 PM, first aid was administered by LPN (Licensed Practical Nurse), and the vital signs were taken that all were stable; the resident had small skin tear (2 centimeters x 2 centimeters) obtained to right outer calf when she hit the bed rail; the resident on Anticoagulant ([MEDICATION NAME] 4 mg every evening) and aspirin 81 mg daily; no behavior conditions. The Director of Nursing stated her follow up included maintenance to put an end cap on the resident's bed/side rail. She called the doctor about the rust on the side rail and he ordered a tetanus shot. Review of Resident #56's progress notes revealed no documentation related to the skin tear. Review of the last documented skin assessment dated [DATE] for Resident #56 revealed no new skin impairments. Review of Resident #56's care plan reads, 8/15/2020- Resident is now receiving [MEDICATION NAME] on a daily basis and is at risk for abnormal bleeding. During an interview on 10/28/2020 at 11:00 AM, the Director of Nursing confirmed there was no documentation in the resident's medical record related to the skin tear injury for Resident #56. During an interview on 10/28/2020 at 11:57 AM, Staff G, LPN (Licensed Practical Nurse), stated, The certified nursing assistant called me to (Resident #56's name) room. The resident was sitting on the side of the bed. She had a skin tear on her leg. It was barely bleeding. I can't remember exactly what it looked like but remember the skin was pulled back. The resident stated she had hurt her leg on the bed. I felt the side of the bed and along the side rail and did not feel any sharp edges. I did not know that there was no end cap on the side rail. I did not report anything to maintenance as I could not find anything wrong with the bed. I did not document the incident in the resident's clinical record because I usually just do the incident report. Review of the facility policy titled Skin Tears - Abrasions and Minor Breaks, Care of, revised in August 2011, annually reviewed on September 23, 2020 read, Purpose. The purpose of this procedure is to guide the prevention and treatment of [REDACTED]. Preparation. 1. Obtain a physician's order as needed. 2. Review the resident's care plan, current orders, and [DIAGNOSES REDACTED]. 1. An abrasion is an area on the skin that has been damaged by shearing, scraping, rubbing or trauma. A skin tear is the disruption of epidermis resulting in a lifting or shearing of the skin. Documentation. Record the following information in the resident's medical record: 1. The site and description of the abrasion or wound. 2. The date and time the abrasion was discovered. 3. The date and time the injury occurred, if known. 4. The date and time the wound care was given. 5. The name and title of the individual performing wound care. 6. All assessment data (i.e. bleeding, size of wound, tissue loss, etc.) obtained when inspecting the wound. 7. How resident tolerated the procedure. 8. Any problems or resident complaints related to the procedure. 9. Any complications related to the abrasion. 10. If the resident refused treatment. 11. Interventions implemented or modified to prevent additional abrasions. 12. The signature and title of the person recording the data and the date and time it is recorded.