Every finding on record at Ocala Health and Rehabilitation Center

Based on observation, interview, record review, and policy and procedure review, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) while providing care to residents on enhanced barrier precautions for 6 (Resident #11, #8, #175, #18, #36, and #16) of 12 residents reviewed for infection control and failed to ensure cleansing the needleless connector of a peripherally inserted central catheter and midline catheter according to professional standards of practice and policy and procedure during medication administration for 2 of 3 (Resident #175 and #27) resident observations of intravenous medication administration to prevent the possible spread of infection and communicable diseases.Findings include: 1. Review of Resident #11's face sheet documented diagnosis that included end stage renal disease, type 2 diabetes mellitus with diabetic chronic kidney disease, dependence on renal dialysis, atherosclerotic heart disease of native coronary artery without angina pectoris, and hemiplegia and hemiparesis following cerebral infarction affecting non dominant left side. Review of Resident #11's physician orders dated 7/2/2025, read, CVL(central venous line)/CVC(central venous catheter) dressing change: change dressing as needed cleanse w/antimicrobial agent, pat dry, cover w(with)/transparent dressing change injection caps w/each dressing change. Review of Resident #11's physician orders dated 9/12/2025, read, Enhanced barrier precautions due to right chest central line due to dialysis. During an observation on 9/16/2025 at 8:56 AM, Staff P, Certified Nursing Assistant (CNA) and Staff O, CNA, were assisting Resident #11 with incontinence care and dressing. Both staff members were observed with gloves on, but with no gowns. During an interview on 9/17/2025 at 10:00 AM, Staff P, CNA stated, We should have had a gown on when we got him (Resident #11) up and ready. During an interview on 9/17/2025 at 10:05 AM, Staff O, CNA stated, He (Resident #11) is on enhanced barrier precautions and we should used a gown and gloves when giving care. 2. Review of Resident #8's face sheet documented diagnosis that included end stage renal disease, type 2 diabetes mellitus with diabetic neuropathy unspecified, hemiplegia and hemiparesis following unspecified cerebral vascular disease affecting right dominant side, and dependence on renal dialysis. Review of Resident #8's physician order dated 9/9/2025 read, Enhanced barrier precautions due to right chest perm-a-cath for dialysis every shift. During an observation on 9/17/2025 at 7:33 AM, Resident #8's room had signage on the doorway indicating that Resident #8 was on enhanced barrier precautions. Staff O, CNA, was observed performing hand hygiene and donning gloves. Staff O, CNA was observed providing incontinence care without a gown. During an interview on 9/17/2025 at 2:15 PM, Staff O, CNA stated, She (Resident #8) is on enhanced barrier precautions because of her dialysis catheter. I should have worn a gown. 3. Review of Resident #175's face sheet documented diagnosis that included osteomyelitis of vertebra lumbar region, type 2 diabetes mellitus without complications, hypertensive heart disease with heart failure, and essential primary hypertension. Review of Resident #175's physician order dated 9/10/2025, read, Enhanced barrier precautions due to presence of PICC (peripherally inserted central catheter) line and IV (intravenous) abt (antibiotic). Review of Resident #175's physician order dated 9/10/2025, read, PICC line flush each lumen w(with)/Normal saline flush after medication administration, use at least a 10 cc (cubic centimeter) syringe every shift. Review of Resident #175's physician order dated 9/10/2025, read, PICC line flush each lumen w/heparin lock 10 units/ml (milliliter) use at least a 10 cc syringe every shift. During an observation on 9/17/2025 at 9:02 AM, Staff P, CNA was observed completing incontinence care, staff did not have on a gown while providing care. During an observation of medication administration on 9/17/2025 at 9:21 AM, Staff N, Licensed Practical Nurse (LPN) donned gloves but did not don a gown. Staff N scrubbed the needleless connector with alcohol for less than 1 second, did not allow the needleless connector to dry and immediately administered the normal saline, followed by the heparin. During an interview on 9/17/2025 at 1:53 PM, Staff P, CNA stated, I did not use a gown. She [Resident #175] is on enhanced barrier precautions and I should have done that when I did her incontinence care. During an interview on 9/17/2025 at 1:24 PM, Staff N, LPN stated, I should have used a gown when I flushed her [Resident #175] line, she is on enhanced barrier precautions. I should have cleaned the port (the needleless connector) longer. Review of the policy and procedure titled, Midline Catheter Flushing and Locking, last approval date of 1/20/2025, read, 4. Needleless connectors require vigorous cleansing with alcohol prior to accessing to reduce the risk of catheter-related bloodstream infections. Procedure: 7. Vigorously cleanse needleless connector with alcohol. Allow to air dry. 4. Review of Resident #18's face sheet documented diagnosis that included other streptococcal arthritis right knee, other chronic pain, multiple myeloma not having achieved remission, status gastrostomy, personal history of COVID-19, obstructive and reflux uropathy unspecified, and presence of urogenital implants. Review of Resident #18's physician order dated 8/26/2025, read, Enhanced barrier precautions r/t (related to) foley catheter/PEG (percutaneous endoscopic gastrostomy) every shift. During an observation on 9/17/2025 at 11:10 AM, Resident #18 was being provided incontinence care by Staff Q, CNA. Staff was observed wearing gloves but no gown. During an interview on 9/17/2025 at 11:37 AM, Staff Q, CNA stated, I should have worn a gown when I was changing him [Resident #18]. 5. Review of Resident #36's face sheet documented diagnosis that included vascular dementia, unspecified severity with anxiety, constipation unspecified, and rash and other nonspecific skin eruption. Review of Resident #36's physician order dated 9/10/2025, read, Enhanced barrier precautions due to wound per protocol. Review of Resident #36's physician order 9/10/2025, read, Wound Stage - 2 - site Rt (right) byttock {sic} change dsg (dressing) QD (every day) and PRN (as needed) cleanse w (with)NS (normal saline) dry with 4 x 4 gauze, skin prep periwound, apply hydrogel and cover w foam dressing. Observe area daily x 90 days once a day. During an observation on 9/17/2025 at 11:32 AM, Staff O, CNA, was observed providing incontinence care to Resident #36. Staff O was observed performing hand hygiene, donning gloves, but staff did not don a gown. During an interview on 9/17/2025 at 11:40 AM, Staff O, CAN, stated, I should have had on a gown too. 6. During an observation on 9/15/2025 at 9:54 AM, Resident #16's door had an enhanced barrier sign on the door with personal protective equipment outside of the door. Staff J, CNA, and Staff K, CNA, were using a Hoyer lift to transfer Resident #16. Staff J and Staff K were only wearing gloves and a surgical mask. Staff J, CNA, exited Resident #16 room. Staff K, CNA, was observed making Resident #16's bed without wearing a gown. Review of Resident #16's physician order dated 9/3/2025. read, Wound Stage 2-Site-Sacrum Change DSG [dressing], QOD [every other day] and PRN [as needed]. Cleanse w/ NS [normal saline] Dry with 4x4 Gauze, Skin Prep Periwound and Apply-Hydrocolloid patch observe area daily, x [times] 90 days. Review of Resident #16's physician order dated 9/15/2025, read, Enhanced Barrier Precautions r/t [related to] wound every shift; day, day, day. During an interview on 9/18/2025 at 8:30 AM, Staff K, CNA, stated, I normally work in the memory care unit and when I float [working different sections of the facility], unless the nurse tells, me I do not know if I have to wear the personal protective equipment. I should have used a gown when transferring and making [Resident #16's name] bed. During an interview on 9/18/2025 at 8:35 AM, the Director of Nursing stated, [Resident #16's name] has orders for enhanced barrier precautions. When staff transfer the resident in a Hoyer lift or make the resident's bed the staff should wear a gown and gloves. 7. Review of Resident #27's face sheet documented diagnosis that included acute pyelonephritis, type 2 diabetes mellitus with diabetic neuropathy unspecified, obstructive and reflux uropathy unspecified, sepsis unspecified organism, and urinary tract infection site not specified, and extended spectrum beta lactamase (ESBL) resistance. Review of Resident #27's physician order dated 9/15/2025, read, Meropenem recon (reconstituted) soln (solution) 1 gram: amt(amount): 1 gram: intravenous: Special instructions: Meropenem 1 GM (gram) q (every) 8 hours x (times)10 days. Dx (diagnosis) ESBL in urine. Review of Resident #27's physician order dated 8/27/2025, read, sodium chloride 0.9 % (flush) syringe, with swab cap: amt 10 ml (milliliters): injection; Special instructions: flush pre and post ABT (antibiotic) therapy. During an observation of medication administration on 9/17/2025 at 1:26 PM, Staff N, LPN performed hand hygiene, donned a gown, scrubbed the needleless connector to a right upper arm midline catheter for 1 second, did not allow the needleless connector to dry and then immediately attached intravenous antibiotic. During an interview on 9/17/2025 at 1:36 PM, Staff N, LPN, stated, I should have cleaned the connector longer than I did. I guess I didn't realize I needed to. During an interview on 9/17/2025 at 1:55 PM, the Director of Nursing (DON) stated, Staff should make sure they are wearing PPE when residents are on enhanced barrier precautions and follow all infection control practices. Review of the policy and procedure titled Enhanced Barrier Precautions, last approval date of 1/20/2025, read, Purpose: Multi-drug resistant organisms (MDRO) transmission is common in LTC (Long Term Care), contributing to substantial resident morbidity and mortality. Many residents/guests in nursing homes are at increased risk of becoming colonized and developing infections with MDRO's. Enhanced barrier precautions are an approach to the use of PPE( personal protective equipment) as a strategy to decrease transmission of CDC (Center for Disease Control) targeted MDRO's when contact precautions do not apply. The precautions are to be used during specific high contact resident/guest activities associated with MDRO transmission and do not involve room restrictions. EBP (Enhanced Barrier Precautions) is used in conjunction with standard precautions. Standard: Upon admission/readmission or when a current resident/guest meets the indications for enhanced barrier precautions, based upon CDC recommendations, these should be implemented, and the resident, representative, and staff should be informed. The ICPO (infection control prevention officer) and or DON (Director of Nursing) should maintain a list of all residents/guests that have been determined to require enhanced barrier precautions and if it is questionable whether or not a resident/guest should have these implemented, the DON or ICPO will review and make the final determination. Process: 1. A sign indicating the enhanced barrier precautions should be placed on the resident's door and if it is in a semiprivate room, it should be labeled for which bed. 3. EBP Requires donning of gown and gloves during high contact resident/guest care activities that provide opportunities for transfer of MDROs to staff's hands and clothing. 4. EBP is indicated for residents/guests with any of the following when contact precautions do not apply: Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or wounds and or indwelling medical devices even if the resident/guest is not known to be infected or colonized with a MDRO (wounds generally include chronic wounds, not short or lasting wounds, such as skin tears or skin breaks covered with an adhesive bandage (e.g Band-Aid or similar dressing. Examples of chronic wounds include but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical device's examples include central lines, urinary catheters, feeding tubes, and tracheostomies. 5. EBP is employed while performing high contact resident/guest care activities dressing, bathing showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use central line, urinary catheter, feeding tube, tracheostomy, wound care any skin opening requiring a dressing.

Based on interview and record review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment reflecting accurate diagnoses for 2 (Resident #6 and #35) of 5 residents reviewed for Preadmission Screening and Resident Reviews (PASRR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care).Findings include: 1) Review of Resident #6's PASRR dated 8/16/2024 revealed Mood Disorder and PTSD (post-traumatic stress disorder) as the only diagnoses indicated. There was no bipolar disorder checked. Review of Resident #6's admission record revealed that he was initially admitted on [DATE] with medical diagnoses including bipolar disorder, unspecified (Date diagnosed: 8/14/2024); post-traumatic stress disorder, unspecified (8/12/2024); unspecified mood [affective] disorder (8/12/2024). Review of Resident #6's PASRR, Page 2, Section 1, documented under Other the following: Mood Disorder and PTSD (post-traumatic stress disorder). Bipolar Disorder was not checked. The bottom of page 2 read, Finding is based on (check all that apply) - Documented History. It was dated 8/16/2024. Review of Resident #6's Minimum Data Set (MDS), Quarterly Assessment (standardized clinical assessments used in long-term care facilities to gather comprehensive information on residents' physical, functional, cognitive, and psychosocial status) dated 8/27/2025, documented Bipolar Disorder and Post Traumatic Stress Disorder (PTSD) in Section I – Active Diagnoses, under Psychiatric/Mood Disorder. In Section N – Medications, under High-Risk Drug Classes, it was not documented that Resident #6 was taking antipsychotic medications or that there was an indication noted. During an interview on 9/16/2025 at 3:45 PM, the DON (Director of Nursing) stated that [Resident #6's Name] had another PASRR that included bipolar, but that his wife stated he never had a diagnosis of bipolar. A new PASRR was completed without the bipolar diagnosis included. Review of a document provided by the DON included a facsimile cover sheet documenting communication between the facility's Medical Social Worker (MSW) and MSW at [local hospital's name]. The second page was a letter written by the facility's MSW that read, [Resident #6's name] was admitted to [the facility's name] on August 12, 2024. I completed a check of his PASRR on August 13, 2024 and discovered it had an improper diagnosis on it. I spoke with [Resident #6's Name] and his wife and they both confirmed that he has never had bi-polar . I contacted the VA (Veteran's Administration) social worker in reference to confirming if [Resident #6's Name] had ever had a diagnosis of bi-polar I was advised that he has never had a diagnosis of bi-polar . I did log onto Acentra (a company that provides services to manage the Preadmission Screening and Resident Review process) and completed a new PASRR for [Resident #6's Name]. It has listed his PTSD and mood disorder . It was signed by the facility's MSW and dated 8/16/24. During an interview on 9/16/2025 at 4:00 PM, the Staff H, MDS LPN (Licensed Practical Nurse) stated that [Resident #6's Name] MDS Assessment on 8/27/2025 was a quarterly assessment and did not require review of a PASRR. They communicated frequently with the social worker but were not aware that [Resident #6's Name] did not have a diagnosis of bi-polar. During an interview on 9/16/2025 at 4:15 PM, the MSW stated that they had clinical meetings every morning where issues such as changes in residents' diagnoses or similar clinical issues were discussed. Her co-worker had reached out to the case manager at the VA and learned that [Resident #6's Name] had never had a diagnosis of bi-polar and that his hospital records did not list bi-polar as a diagnosis. She would communicate with their team, and they had room for improvement. During an interview on 9/16/2025 at 4:37 PM, the DON stated that the issue regarding [Resident #6's Name] not having a diagnosis of bi-polar was never discussed at a facility level. 2) Review of Resident #35's admission record documented an admission date of 5/12/2025 with diagnoses including mood disorder due to known physiological condition with mixed feature and insomnia. Review of Resident #35's physician order dated 6/12/2025 read, Melatonin tablet; 3mg [milligram]; amt [amount]: 2 tabs [tablets]; oral Special Instructions: 2 tabs=6 mg [two tablets equal six milligrams] for insomnia at bedtime; 9:00PM. Review of Resident #35's Minimum Data Set (MDS) Quarterly assessment dated [DATE], Section I: Active Diagnoses did not document insomnia or mood disorder as an active diagnosis. Review of Resident #35's progress note dated 5/13/2025, read, Plan: Mood disorder: History of seroquel and olanzapine that are no longer active at this time. Continue trazadone. Monitor behaviors. Insomnia. Continue melatonin. Review of Resident #35's psychiatry subsequent note dated 7/17/2025, read, Chief Complaint: Depression, anxiety, dementia, mood disorder, insomnia, and Parkinson's disease. Assessment and Plan: Mood Disorder: The history suggest that the patient has experienced severe mood swings causing emotional distress. As the mood swings are requiring monitoring and as needed intervention, the patient qualifies for that diagnosis. Insomnia: The history suggest that the patient has suffered from significant sleep problems. The sleep disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. During an interview on 9/17/2025 at 1:15 PM, Staff H, Minimum Data Set Licensed Practical Nurse, stated, [Resident #35's Name] MDS did not include insomnia as an active diagnosis. [Resident #35's Name] was taking melatonin for the look back period. The assessment should be corrected. During an interview on 9/18/2025 at 9:41 AM, the Regional MDS Case Manager stated, [Resident #35's Name] should have mood disorder coded in her MDS Section I. We had [Resident #35's Name] care planned, and it was part of her diagnoses. We follow the RAI [Resident Assessment Instrument] for the MDS.

Based on observation, interview, and record review, the facility failed to ensure peripherally inserted catheters and midline catheter dressing changes were completed according to professional standards of practice and intravenous fluid was administered according to facility policy and procedure and professional standards of practice for 2 (Resident #175 and #27) of 2 residents reviewed with a peripherally inserted central catheter line or midline catheter.Findings include:1) Review of Resident #175's admission record documented diagnosis that included osteomyelitis (infection of the bone) of vertebra lumbar region, type 2 diabetes mellitus without complications, hypertensive heart disease with heart failure, heart disease unspecified, chronic gastric ulcer without hemorrhage or perforation, unspecified abdominal hernia, anxiety disorder unspecified, adult failure to thrive, hypothyroidism unspecified, depression unspecified, unspecified glaucoma, hyperlipidemia unspecified, retention of urine, anemia unspecified and essential (primary) hypertension. Review of Resident #175's physician order dated 9/10/2025, read, PICC (peripherally inserted central catheter) line dressing change: cleanse with disinfectant, pat dry, cover w(with)/transparent dressing as needed. Review of Resident #175's physician order dated 9/10/2025, read, PICC line flush each lumen w/normal saline flush, after medication administration use at least a 10 cc ( cubic centimeter) syringe every shift. Review of Resident #175's physician order dated 9/10/2025, read, PICC line flush each lumen w/heparin lock 10 units/ml (milliliter) every use, at least a 10 cc (cubic centimeters) syringe every shift. During an observation on 9/16/2025 at 8:53 AM, Resident #175 was observed resting in bed with a left upper arm single lumen PICC line with a date of 9/10/2025, the edges of the transparent dressing were lifting on all sides and exposing the insertion site to air. During an observation of medication administration for Resident #175 on 9/17/2025 at 9:21 AM, Staff N, Licensed Practical Nurse (LPN) cleaned the needleless connector for 1 second with alcohol, did not allow the needleless connector to dry and immediately administered 10 milliliters of normal saline followed by the heparin flush. Staff N, LPN did not attempt to verify placement of the PICC line by attempting to aspirate for blood prior to administering medications. During an interview on 9/17/2025 at 1:24 PM, Staff N, LPN, stated, I should have cleaned the port (the needleless connector) longer. I did not verify placement. I did not aspirate to see if I got blood return. I did not clean the hub between the normal saline and heparin. The dressing should have been changed. During an interview on 9/17/2025 at 1:55 PM, the Director of Nursing (DON) stated all staff should follow the policy for administering medications in a central line. Review of the policy and procedure titled, Midline catheter dressing change, last revision date of 6/2024, read, Considerations: 1. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection. Guidance: 1. Sterile dressing change using transparent dressings is performed: 1.3. If the integrity of the dressing has been compromised (wet, loose or soiled).Review of the Centers for Disease Control and Prevention (CDC) Summary of Recommended Frequency of Replacements for Catheters, Dressings, Administration Sets, and Fluids with a publication date of August 9, 2002, read Replacement of catheter site dressing for midline catheters was to Replace dressing when the catheter is removed or replaced, or when the dressing becomes damp, loosened, or soiled. Replace dressings more frequently in diaphoretic patients. In patients who have large bulky dressings that prevent palpitation or direct visualization of the catheter insertion site, remove the dressing and visually inspect the catheter at least daily and apply new dressing. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5132a9.htm. 2) Review of Resident #27's admission record documented diagnosis that include acute pyelonephritis, type 2 diabetes mellitus with diabetic neuropathy unspecified, obstructive and reflux uropathy unspecified, sepsis unspecified organism, and urinary tract infection site not specified, and extended spectrum beta lactamase (ESBL) resistance. Review of Resident #27's physician order dated 9/15/2025, read, Meropenem recon (reconstituted) soln (solution) 1 gram: amt: 1 gram: intravenous: Special instructions: Meropenem 1 GM (gram) q (every) 8 hours x 10 days. Dx (diagnosis) ESBL in urine. Review of Resident #27's physician order dated 8/27/2025, read, sodium chloride 0.9 % (flush) syringe, with swab cap: amt (amount) 10 ml (milliliters): injection; Special instructions: flush pre and post ABT (antibiotic) therapy. During an observation of medication administration for Resident #27 on 9/17/2025 at 1:26 PM, Staff N, LPN, performed hand hygiene, donned a gown, scrubbed the needleless connector to a right upper arm midline catheter for 1 second, did not allow the needleless connector to dry and immediately administered 10 milliliters of normal saline and attached the intravenous antibiotic to the needleless connector. Staff N, LPN did not attempt to verify placement of the midline catheter by attempting to aspirate for blood prior to administering the medications. During an interview on 9/17/2025 at 1:36 PM Staff N, LPN, stated, I should have cleaned the connector longer than I did. I guess I didn't realize I needed to. I should have tried to verify the placement. Review of the policy and procedure titled, Midline Catheter Flushing and Locking last approval date of 1/20/2025 read, To be performed by licensed nurses according to state law and facility policy. The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. Considerations: 3. Flushing/locking is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. 4. Needleless connectors require vigorous cleansing with alcohol prior to accessing to reduce the risk of catheter-related bloodstream infections. Guidance: 5. Catheter patency must be verified prior to each medication administration. To assess patency, aspirate the catheter to obtain positive blood return. The aspirated blood should be the color and consistency of whole blood. Procedure: 7. Vigorously cleanse needleless connector with alcohol. Allow to air dry. 9. Attach syringe filled with prescribed flushing agent to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access patency. 10. Flush while observing for signs and symptoms of complications/infiltration. 11. Disconnect syringe. If heparin is indicated, vigorously cleanse needleless connector with alcohol and allow to air dry. Lock with prescribed heparin flush solution. Clamp extension set, if applicable.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for pain management and adrenergic agonist medication administration for 3 of 8 residents reviewed for medication management (Resident #42, Resident #62, and Resident #152). Findings include: 1) Review of Resident #42's physician order dated 12/09/2024 read, Pain assessment chart highest degree of pain by scale 0-10 for your shift. Chart every shift. Review of Resident #42's physician order dated 4/28/2025 read, oxycodone -Schedule II tablet; 10mg [milligram]; amt [amount]: 1 tab [ tablet]; oral Special Instructions: prn [as needed] for severe pain level 5-10. Review of Resident #42's physician order dated 1/16/2025 read, Oxycodone-Schedule II tablet; 10mg; amt: 1 tab; oral Twice a Day; 06:00AM, 06:00PM. Review of Resident #42's Medication Administration Record (MAR) for the month of August 2025 for as needed Oxycodone 10mg documented on 8/1/2025 at 2:38 PM pain level was 5, 8/2/2025 at 12:57 PM pain level was 8, 8/9/2025 at 11:11 AM pain level was 5, 8/13/2025 at 12:12 PM pain level was 7, 8/15/2025 at 12:47 PM pain level was 5, 8/18/2025 at 10:06 AM pain level was 6, 8/23/2025 at 12:13 PM pain level was 6, 8/24/2025 at 2:08PM pain level was a 6. Review of Resident #42's General Administration History for the month of August 2025 for Pian Assessment every shift documented a zero as the highest pain level for the 7-3 pm shift on 8/1/2025, 8/2/2025, 8/9/2025, 8/13/2025, 8/15/2025, 8/18/2025, 8/23/2025 and 8/24/2025. Review of Resident #42's MAR for the month of September 2025 for as needed Oxycodone 10 mg read, 9/1/2025 at 2:32 PM pain level was a 5, and 9/15/2025 at 12:58 PM pain level was a 5. Review of Resident #42's General Administration History for the month of September 2025 for Pain Assessment every shift documented a zero as the highest pain level for the 7-3 pm shift on 9/1/2025 and 9/15/2025. Review of Resident #42's MAR for the month of September 2025 for scheduled Oxycodone 10 mg documented, 9/2/2025 at 9:18 PM late administration: charted late, 9/4/2025 at 9:56 PM late administration: charted late, and on 9/7/2025 at 7:01 PM late administration charted late. Review of Resident #42's MAR for the month of August 2025 for Oxycodone 10 mg documented, 8/2/2025 at 7:21 AM late administration: charted late, 8/4/2025 at 8:05 PM late administration: charted late, 8/10/2025 at 9:56 AM late administration: other, 8/11/2025 at 7:42 AM late administration: other comment: not late, and 8/15/2025 at 9:14 PM late administration: charted late. Comment: delayed charting. During an interview on 9/16/2025 at 12:50 PM, Staff D, Licensed Practical Nurse (LPN) stated, The pain assessment will pop up on my 7AM to 3PM shift. I wait and ask her [Resident #42] what her pain level is. I will ask her towards the end and see if it's still the 7 or if it has changed and that is what I will document. What the resident verbalizes to be close to end of shift. During an interview on 9/17/2025 at 8:14 AM, the Director of Nursing stated, The staff should be asking throughout the shift and fill out at the pain assessment at the end of shift with the highest pain level that was reported at that shift. The charted late note in the MAR means that the staff are documenting outside the two hour window. The system will say, Hey! Why are you giving it at this time? and the staff will have to write an explanation. Staff are expected to document accurately when medication is given. During an interview on 9/17/2025 at 11:02 AM, Staff E, LPN stated, I think they have a pain assessment in the MAR for the end of shift. I think I need to leave the assessment for the end of shift. I click it off early sometimes. I will ask her [Resident #42] after giving her the pain medication and check back and she will tell me it's a zero and that is what I will document but it's not a zero because I gave her medication for the pain. A lot of the time I give medication, and I forget to click the medication off. I will click prep and give it to the patient and then go to the next patient. Then I remember and come back to it. I always click prep but don't click it off at the end. I give the medication on time it is not late. During an interview on 9/17/2025 at 1:44 PM, Staff F, LPN stated, This system when you click prep and complete the medication pass it is difficult to look back. I am more familiar with [name of clinical software] that you are able to look back at the end of day. I will give the medication on time; it is not late. The pain assessment I normally do it in the morning and when giving her [Resident #42] the medication. I had not been doing the assessment at end of shift. I ask when giving medication and as needed what her pain level is. During an interview on 9/18/2025 at approximately 8:35 AM, the DON stated, The staff are supposed to click prep and then save so that the administration is completed and it does not show in the system as a late administration. They should complete the documentation of one patient before moving on to the next patient when giving medication. 2) Review of Resident #62's physician order dated 9/5/2024 read, Midodrine tablet: 10mg; amt:1 tab oral. Twice a day. 1: 9:00AM, 2: 5:00PM. Special Instructions: Hold for SBP [Systolic Blood Pressure] Greater than 130 may crush. Review of Resident #62's MAR for the month of September 2025 documented Midodrine 10mg was given on 9/1/2025 at 5:00 PM systolic blood pressure was 142, 9/3/2025 at 9:00 AM systolic blood pressure was 140, 9/6/2025 at 5:00 PM systolic blood pressure was 144, and 9/9/2025 at 9:00 AM systolic blood pressure was 135. During an interview on 9/17/2025 at 11:00 AM, Staff E, LPN stated, I am positive I didn't give her [Resident #62] the medication. I might have clicked all medication and gotten the blood pressure and seen the medication should be held and not given to the resident. I normally wait and then click it off. I accidently click off everything. During an interview on 9/17/2025 at 1:44 PM, Staff F, LPN stated, I don't recall that day. I would normally would have held it [midodrine] with that blood pressure. During an interview on 9/18/2025 at approximately 8:35 AM, the DON stated, The nurses should first check the patient's blood pressure and then prep the medication. They should not be clicking all the medications as prep because it can document in the system the medication was given when it was not given. Documentation should be accurate. Review of the facility policy and procedure titled, Charting and Documentation Guidelines with a last review date of 1/20/2025, read, Process: I. Rules for charting and Documentation: b) Be concise, accurate and complete and use objective terms. Avoid meaningless entries. IV. Late Entries. Clearly identify late entries. Entries are labeled as late entry. Record the time and date of the entry and identify the time and date entry should have been made. 3) Review of Resident #152's physician orders dated 03/30/2022, read, Midodrine [a prescription oral medication primarily used to treat severe symptomatic orthostatic hypotension, a condition that causes a sudden drop in blood pressure] tablet 5 mg (milligrams): amt (amount) 1 tab (tablet) Oral. Special Instructions: Dx (diagnosis) Hypotension [blood pressure is abnormally low, preventing adequate blood flow to the brain and hear]; Do not give post 6 pm; Hold for systolic [the pressure in your arteries when your heart pumps blood throughout your body. It is represented by the top number in a blood pressure reading.] BP (blood pressure) greater than 120. Review of Resident #152's MAR from 07/01/2025 through 09/16/2025 documented 3 instances when administration of Midodrine was not documented accurately. Review of Resident #152's MAR for July 2025 showed that the documentation for Midodrine 5 mg tablet with corresponding blood pressure reading was incorrectly documented for systolic blood pressure greater than 120 on 07/10/2025 at 6:00 PM, no B/P documented, medication held; 07/24/2025 at 6:00 PM, no B/P documented, medication held. Review of Resident #152's MAR for August revealed that the documentation for Midodrine 5 mg tablet with corresponding blood pressure reading was incorrectly documented for systolic blood pressure greater than 120 on 08/11/2025 at 6:00 PM, no B/P documented, medication held. Review of Resident #152's MAR for September 2025 revealed that the documentation for Midodrine 5 mg tablet with corresponding blood pressure reading was incorrectly documented for systolic blood pressure greater than 120 on 09/04/2025 at 12:00 PM, B/P documented as 122/76, medication given; 09/08/2025 at 6:00 PM, no B/P documented, medication held. Review of Resident #152's face sheet documented a most recent admission date of 01/03/2019, with medical diagnoses that included other specified symptoms and signs involving the circulatory and respiratory systems, essential (primary) hypertension [a medical condition where blood consistently flows through Review of Resident #152's MDS (Minimum Data Set) assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 03 [indicate severely impaired cognition]. Review of Resident #152's resident centered plan of care documented, Problem: Potential for fall and fx (fracture [of bones]) r/t (related to) osteoporosis [disease where bones become weak and brittle, increasing fracture risk], pvd (peripheral vascular disease), incont (incontinence) status, psych meds ([receiving] psychiatric medications), htn (hypertension), unspec (unspecified) intellectual deficits . Goal: I don't want to fall for 90 days. Approaches: Medication review; Orthostatic bp (blood pressure) [medication] as ordered. During an interview on 09/17/2025 at 4:10 PM, Staff B, LPN stated that if he charted that he gave Resident #152's Midodrine on 9/04/2025 at 12:00 PM then he felt certain he had given it. He was familiar with the parameter to hold the medication if the systolic blood pressure was greater than 120. He did not think he would have given the medication outside of the parameter, but he might have documented the wrong blood pressure when he charted 122/76. During an interview on 9/17/2025 at approximately 5:15 PM, the DON (Director on Nursing) stated that she expected nurses to follow the physician's orders, including parameters, when administering medications. If a medication was held, she expected the correct information to be documented and the physician to be notified that the medication was held.

Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs, specifically without adequate monitoring or adequate indications for use, in 2 (Resident #62 and Resident #152) out of 7 residents reviewed for unnecessary medications. 1) Review of Resident #152's physician orders dated 03/30/2022 read, Midodrine [a prescription oral medication primarily used to treat severe symptomatic orthostatic hypotension, a condition that causes a sudden drop in blood pressure] tablet 5mg (milligram): amt (amount) 1 tab Oral. Special Instructions: Dx (diagnosis) Hypotension [blood pressure is abnormally low, preventing adequate blood flow to the brain and heart]; Do not give post 6pm; Hold for systolic [the pressure in your arteries when your heart pumps blood throughout your body. It is represented by the top number in a blood pressure reading.] BP (blood pressure) greater than 120. Review of Resident #152's Medication Administration Record (MAR) for July 2025 documented Midodrine 5mg tablet was administered outside of physician's parameters for systolic blood pressure greater than 120 on 07/04/2025 at 6:00 AM, B/P 123/64; 07/08/2025 at 12:00 PM, B/P 122/70; and 07/23/2025 at 6:00 PM, B/P 129/71. Review of Resident #152's MAR for July 2025 documented Midodrine 5mg tablet was held outside of physician's parameters for systolic blood pressure less than 120 on 07/21/2025 at 12:00 PM, B/P 116/70. Review of Resident #152's MAR for August 2025 documented Midodrine 5mg tablet was administered outside of physician's parameters for systolic blood pressure greater than 120 on 08/06/2025 at 6:00 PM, B/P 128/79; 08/20/2025 at 6:00 PM, B/P 127/87; 08/23/2025 at 12:00 PM, B/P 122/70; 08/31/2025 at 6:00 PM, B/P 128/78. Review of Resident #152's MAR for September 2025 documented Midodrine 5mg tablet was administered outside of physician's parameters for systolic blood pressure greater than 120 on 09/07/2025 at 12:00 PM, B/P 122/60; 09/07/2025 at 6:00 PM, B/P 122/78; 09/14/2025 at 6:00 AM, B/P 121/57; 09/14/2025 at 6:00 PM, B/P 129/69. Review of Resident #152's MAR for September 2025 documented Midodrine 5mg tablet was held outside of physician's parameters for systolic blood pressure less than 120 on 09/21/2025 at 12:00 PM, B/P 104/60. Review of Resident #152's face sheet documented a most recent admission date of 01/03/2019, with medical diagnoses that included other specified symptoms and signs involving the circulatory and respiratory systems, essential (primary) hypertension [a medical condition where blood consistently flows through arteries at a higher-than-normal pressure] and unspecified intellectual disabilities. Review of Resident #152's MDS (Minimum Data Set) assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 03 [indicate severely impaired cognition]. Review of Resident #152's resident centered plan of care documented, Problem: Potential for fall and fx (fracture [of bones]) r/t (related to) osteoporosis [disease where bones become weak and brittle, increasing fracture risk], pvd (peripheral vascular disease), incont (incontinence) status, psych meds ([receiving] psychiatric medications), htn (hypertension), unspec (unspecified) intellectual deficits . Goal: I don't want to fall for 90 days. Approaches: Medication review; Orthostatic bp (blood pressure) [medication] as ordered. During an interview on 09/17/2025 at 3:42 PM, Staff A, RN (Registered Nurse), Unit Manager stated that he did administer Resident #152's Midodrine at 6:00 PM on 9/14/2025 and that he should have held it because her systolic blood pressure was outside of the parameter in the physician's order. During an interview on 09/17/2025 at 4:18 PM, Staff C, LPN (Licensed Practical Nurse), stated that she gave the medication if her name was there [on the Medication Administration Record (MAR)]. During an interview on 9/17/2025 at approximately 5:15 PM, the DON (Director on Nursing) stated that she expected nurses to follow the physician's orders, including parameters, when administering medications. 2) Review of Resident #62's physician order dated 9/5/2024 read, Midodrine tablet: 10mg [milligram]; amt [amount]:1 tab oral. Twice a day. 1: 9:00AM, 2: 5:00PM. Special Instructions: Hold for SBP [Systolic Blood Pressure] Greater than 130 may crush. Review of Resident #62 Medication Administration Record for the month of September 2025 documented Midodrine 10mg was given on 9/1/2025 at 5:00PM with a systolic blood pressure of 142, 9/3/2025 at 9:00 AM with a systolic blood pressure of 140, 9/6/2025 at 5:00PM with a systolic blood pressure of 144, and on 9/9/2025 at 9:00AM with a systolic blood pressure of 135. During an interview on 9/16/2025 at 1:42 PM, Staff G, Licensed Practical Nurse (LPN), stated, If my name is on the MAR and it documents I gave it then I did give it. During an interview on 9/17/2025 at 8:20 AM, the DON stated, Nursing staff are to check the residents blood pressure and follow the parameters when giving medication and follow physicians order.

Based on interview and record review the facility failed to ensure accurate nurse staffing information was posted on a daily basis on 1 of 4 days of the survey. Findings include:During an observation on 9/15/25 at 9:00 AM, the nurse staffing information was posted and dated for 9/12/25 (photographic evidence). During an observation on 9/15/25 at approximately 3:00 PM, nurse staffing information was posted and dated for 9/12/25. During an interview on 9/16/25 at 11:20 AM, the Administrator, stated, I noticed the posting was not updated. The expectation is for the staffing to be posted daily, it was in the process of being updated.

Based on observation, interview, and record review the facility failed to provide wound care dressing changes within professional standards of practice for 2 (Resident #127 and #92) of 4 residents reviewed for wound care.Findings include: 1) During an observation on 9/15/2025 at 10:39 AM, Resident #127 was observed in bed with a dressing on her chin that was dated 9/13/2025. Review of Resident #127's admission record documented diagnosis that included unspecified asthma uncomplicated, personal history of transient ischemic attack (TIA) and cerebral infarction (a stroke) without residual deficits, personal history of venous thrombosis and embolism (a blood clot in a vein), chronic obstructive pulmonary disease unspecified, hyperlipidemia specified (high cholesterol), atherosclerotic heart disease of native coronary artery (a condition where the arteries in the heart become narrow or blocked with plaque) without angina pectoris (chest pain), unspecified convulsions (seizures), and essential primary hypertension (high blood pressure). Review of Resident #127's physician order dated 9/9/2025 read, [NAME] change dressing cleanse w(with)/NS (normal saline) pat dry cover with dry dressing, observe area daily x 90 days special instructions: Dx (diagnosis):boil once a day. Review of Resident #127's treatment administration record (TAR) for September 2025 documented a dressing change day shift on 9/14/2025. During an interview on 9/15/2025 at 10:47 AM, Staff M, Licensed Practical Nurse (LPN) verified that the date on the dressing was 9/13/2025 and stated that it is ordered as a daily dressing and should have been changed. 2) During an observation on 9/15/2025 at 9:38 AM, Resident #92 was sitting in his wheelchair in his room. There was a dressing on each of his legs dated 9/12/25. [photographic evidence obtained] During an observation on 9/15/2025 at 11:20 AM, Resident #92 was in his room getting ready to be transported by a staff member, dressings on lower legs dated 9/12/25. Review of Resident #92's physician orders dated 9/5/2025, read, Arterial wound site LT [left] lower leg change DSG-QOD [dressing-every other day] and prn [as needed]. Cleanse w/ns [with normal saline] dry with 4x4 gauze apply skin prep peri wound, apply collagen powder, cover w [with]/foam dressing observe area daily x [times] 90 days once a day every other day. Review of Resident #92's physician order 9/5/2025, read, Arterial wound site RT [right] lower leg change DSG-QOD and prn cleanse w/ns dry with 4x4 gauze apply skin prep peri wound, apply collagen powder, cover w/ foam dressing observe area daily x 90 days once a day every other day. Review of Resident #92's progress notes from 9/14/2025 did not document any attempts to do dressing changes. During an interview on 9/17/2025 at 1:50 PM, Staff I, Licensed Practical Nurse, stated, I don't recall what happened on Sunday [9/14/2025]. If the system does not show that I need to do a dressing change that day I would not know that the resident has wound care due. During an interview on 9/17/2025 at 3:00 PM, the Director of Nursing stated, The staff should be doing dressing changes as ordered and prn. If the dressing was done earlier, it [dressing] should also be changed as scheduled and also when needed. Review of the policy and procedure titled, Dressing-Clean, with a last review date 1/20/2025, read, Purpose: To provide guidelines for the care of wounds and soiled dressing, to decrease the potential for nosocomial infection. Each wound site should be treated individually.

Based on record review and interview, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was accurately completed for 1of 6 residents reviewed for behavioral health management. (Resident #42) Findings include:Review of Resident #42's admission record documented an admission date of 9/05/2024 with diagnoses including depression [onset date 9/05/2024]. Review of Resident #42's PASSR dated 9/5/2024 did not show depression disorder under mental illness or suspected mental illness under Section I: PASSR Screen Decision-Making. Review of Resident #42's physician order dated 9/13/2024 read, Mirtazapine tablet; 7.5mg [milligram]; amt [amount]: 1 tab [tablet]; oral [Dx (Diagnoses): Depression, unspecified]. Review of Resident #42's psychiatry subsequent note dated 11/14/2024 read, Chief Complaint: depression and anxiety. During an interview on 9/17/2025 at 12:11 PM, the Director of Nursing stated, [Resident #42's name] PASSR was incorrect. Upon admission of the residents the admission department looks to make sure it [PASSR] is accurate and social services is responsible for submitting a new one if it is not accurate. Sometimes the hospital will not send the PASSR until the resident is in the building.During an interview on 9/18/2025 at 8:29 AM, the Social Service Director stated, [Resident #42's name] should have had an updated PASSR upon admission to include the depressive diagnosis. Review of the facility policy and procedure titled Pre-admission Screening for Mental Retardation and Mental Illness with a last approved date of 1/20/2025 read, Purpose: To ensure that individuals with mental retardation or mental illness receive the care and services they need, in the most appropriate setting and have medical needs that outweigh their mental needs. Process: The nursing facility is responsible for ensuring that a Level I screening is completed, submitted and has a Level I Determination and/or a Level II if indicated, on or before nursing home admission and regardless of payment source.

Based on interview and record review the facility failed to submit a Preadmission Screening and Resident Review (PASRR) Level II for 1 of 6 reviewed for behavioral health management. (Resident #35) Findings include:Review of Resident #35's admission record documented an admission date of 5/12/2025 with diagnoses including mood disorder due to known physiological condition with mixed feature, depression, anxiety, and adjustment disorder. Review of Resident #35's PASSR dated 1/30/2024 read, Section IV: PASRR Screen Completion. Individual may not be admitted to a Nursing Facility. Use this form and required documentation to request a Level II PASSR evaluation because there is a diagnosis or suspicion of (Check one of the following): Serious Mental Illness. Review of Resident #35's progress note dated 5/13/2025 read, History of Present Illness: Did require soft restraints to avoid self-harm while in hospital. Had as needed Seroquel in place however was discontinued while in hospital with olanzapine started twice daily x 3 days then reduce to daily with trazadone twice daily as needed in place. Plan: Mood disorder: History of Seroquel and olanzapine that are no longer active at this time. Continue trazadone, monitor behaviors. Depression. Continue Remeron, monitor weights. Dementia with agitation continue donepezil. Monitor behaviors. Review of Resident #35's record did not document a PASSR Level II evaluation or completion. During an interview on 9/18/2025 at 7:29 AM, the Social Services Director stated, I don't see a PASSR Level II for [Resident #35's name]. I would have to look in the system. During an interview on 9/18/2025 at 8:04 AM, the Director of Nursing stated, PASSR Level II was not done for [Resident #35's Name], resident came from another facility, and we assumed that it was done. We would have to complete one and submit it. Review of the policy and procedure titled, Pre-admission Screening for Mental Retardation and Mental Illness with a last review date of 1/20/2025, read, Purpose: To ensure that individuals with mental retardation or mental illness receive the care and services they need, in the most appropriate setting and have medical needs that outweigh their mental needs. Process: The nursing facility is responsible for ensuring that a Level I screening is completed, submitted and has a Level I Determination and/or a Level II if indicated, on or before nursing home admission and regardless of payment source.

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while providing direct care for 2 of 5 residents on transmission-based precautions, Residents #154 and #96, and failed to ensure staff followed infection control standards by not cleaning the multi-use medical equipment in between resident use, not sanitizing the surface area during medication administration and not cleaning the medication syringe after enteral medication administration to prevent the possible spread of infection and communicable diseases. Findings include: 1. During an observation on 6/26/2024 at 8:45 AM, Residents #154 and #96's room had a sign posted on the door that read, STOP: Special Droplet/Contact Precautions . Everyone must: including visitors, doctors & staff: Clean hands when entering or leaving a room, Wear face mask, Wear eye protection (face shield or goggles), Gown and glove at the door. During an observation on 6/26/2024 at 8:46 AM, Staff G, Certified Nursing Assistant (CNA), opened the door from inside the room of Residents #154 and #96. Staff G was not wearing eye protection (a face shield or goggles). Staff G handed a tied bag of trash to the housekeeper and closed the door from inside the room. During an observation on 6/26/2024 at 8:47 AM, Staff G, CNA, opened the door from inside the room of Residents #154 and #96 and took a roll of clear bags from the housekeeper standing outside the room and closed the door from inside the room. Staff G was not wearing eye protection (a face shield or goggles). During an interview on 6/26/2024 at 8:48 AM, Staff G, CNA, stated, I should have had a face shield on. Both residents are on transmission-based precautions. They are both positive for COVID-19. During an interview on 6/26/2024 at 10:05 AM, the Director of Nursing stated, They [the staff] should be wearing goggles or a face shield when entering the COVID positive room. Review of Resident #154's medical record showed the resident was admitted on [DATE] with diagnoses including acute embolism and thrombosis of unspecified deep veins of the right extremity, dementia, mood disorder, and depression. Further review of the medical record showed Resident #154 tested positive for COVID-19 on 6/24/2024. Review of Resident #154's physician order dated 6/24/2024 read, Respiratory and droplet isolation r/t [related to] positive COVID 19 status. Review of Resident #96's medical record showed the resident was admitted on [DATE] with diagnoses including cognitive communication deficit, shortness of breath, history of falling, dependence on supplemental oxygen, anxiety disorder, major depressive disorder, and dementia. Further review of the medical record showed Resident #96 tested positive for COVID-19 on 6/23/2024. Review of Resident #96 physician order dated 6/23/2024 read, Droplet isolation r/t COVID. Review of the facility policy and procedure titled Response Phase Protocol for COVID-19 with an effective date of 3/13/2020 and last review date of 1/18/2024 read, d. Before entering resident room with an active case (or susceptive case), wear: 1. Gown (fluid resistant or impermeable), 2. Facemask, 3. Eye protection (goggles or face shield), 4. Gloves. 46523 2. During an observation on 6/26/2024 at 8:10 AM, Staff K, Licensed Practical Nurse (LPN), prepared Resident #110's medications and entered the resident's room. Resident #110 was lying in bed. Staff K took Resident #110's blood pressure. Staff K stated she would hold Resident #110's blood pressure medication due to the blood pressure parameters and placed blood pressure cuff on top of Resident #110's bedside table. Staff K gave Resident #110 a cup with water and administered the medications. Staff K placed blood pressure cuff in her pocket and exited the resident room. Staff K performed hand hygiene and began to pour Resident #133's medication. Staff K entered Resident #133's room. Without sanitizing the blood pressure cuff, Staff K used the medical device to take Resident #133's blood pressure. Staff K provided a cup with water to Resident #133 and administered medications. During an interview on 6/26/2024 at 8:30 AM, Staff K, LPN, stated, I should have sanitized the blood pressure cuff in between each resident use. I did not have wipes in my medication cart. During an observation on 6/26/2024 at 8:37 AM, Staff L, LPN, performed hand hygiene and poured all medications and removed a bottle of eye drops for Resident #101. Staff L donned gloves and grabbed two tissues. Staff L entered Resident #101's room and placed both tissues on top of the bedside table without sanitizing or placing a barrier on table. Table surface had areas of shining substance. Staff L moved tissues on top of the bedside table. Both pieces of tissue were in contact with the table surface. Staff L placed the medication cup on the table. Staff L applied eye drops into Resident #101's right eye and handed the resident the tissues resting on the bedside table to clean his eye. During an interview on 6/26/2024 at 8:44 AM, Staff L, LPN, stated, I should have handed the tissues to [Resident #101's name] or have sanitized the bedside table or placed a barrier on the table before placing the tissues down. During an observation on 6/26/2024 at 9:21 AM, Staff H, LPN, poured and crushed all of Resident #69's medications individually. Staff H donned gloves and gown to enter Resident #69's room. Staff H was administering medication and medication syringe fell on the floor. Staff H removed gloves and stood at the door and asked another staff member to bring her another syringe from her medication cart, giving them the medication cart keys. Staff H performed hand hygiene and donned a new pair of gloves. The staff member returned, gave Staff H the new syringe and the cart keys. Staff H put the keys into her pocket and returned to administer Resident #69's medications via gastric tube. Staff finished administering medications and placed medication syringe into a cup without cleaning syringe after administration. Staff H performed hand hygiene and proceeded to go assist another resident. During an interview on 6/26/2024 at 10:14 AM, Staff H, LPN, stated, I should have removed my gloves and performed hang hygiene after I was given the medication cart keys. I did not clean the syringe after I was done. I should have cleaned it. I was going to do that after going to get a zip lock bag for the syringe. During an interview on 6/26/2024 at 3:46 PM, the DON stated, Staff should run down with a wipe for all reusable medical equipment in between each resident use. If the bedside table is soiled, then staff should clean the surface of the table before placing the tissue on the table. The nursing staff should be cleaning the medication syringe after using them for medication administration. Review of the facility policy and procedure titled Blood Pressure Measurements with the last review date of 1/18/2024 read, Equipment Care: Clean the stethoscope and blood pressure cuff with a clean dampened cloth with disinfectant and water. Review of the facility policy and procedure titled General Dose Preparation and Medication Administration with the last review date of 1/18/2024 read, Procedure . 6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following . 6.4: Clean any reusable equipment or supplies. Review of the facility policy and procedure titled Medication Administered through an Enteral Tube with the last review date of 1/18/2024 read, Procedure . 19. Clean medication syringe and return to bedside.

Based on observation, interview, and record review, the facility failed to ensure medical records were accurate for 2 of 10 residents reviewed for medication administration, Residents #12, and #39. Findings include: 1. Review of Resident #12's admission record showed the resident was admitted on [DATE] with diagnosis including but not limited to chronic pain syndrome. During an interview on 6/24/2024 at 9:46 AM, Resident #12 stated, I have pain in my legs and take pain medication for the pain. Review of Resident #12's physician order dated 5/13/2024 read, Acetaminophen 325 mg [milligrams] tablet: Administer 2 tablet(s) to equal 650 mg by mouth every 4 hours as needed As Needed, for mild pain. Review of Resident #12's physician order dated 5/13/2024 read, Morphine 20 mg/1 ml [milliliters] syringe administer 0.5 ml by mouth once every 4 hours as needed for pain management. Review of Resident #12's physician order dated 5/13/2024 read, Pain Assessment chart highest degree of pain by scale 0-10 for your shift. Chart q [every] shift. Review of Resident #12's Medication Administration Record (MAR) for Acetaminophen 325 mg for June 2024 showed the resident received the medication on 6/18/2024 at 8:26 PM. Review of Resident #12's MAR for administration of Morphine 0.5 ml for June 2024 documented the resident received the medication on 6/1/2024 at 3:05 AM, 9:32 AM, and 4:56 PM, on 6/2/2024 at 9:38 AM and 4:55 PM, on 6/7/2024 at 6:44 PM, on 6/10/2024 at 1:27 PM and 5:42 PM, on 6/11/2024 at 6:09 AM, on 6/12/2024 at 10:36 AM, on 6/13/2024 at 4:35 AM, on 6/14/2024 at 4:58 AM, on 6/15/2024 at 11:11 AM, on 6/16/2024 at 9:10 AM and 9:16 PM, 6/17/2024 at 4:42 AM, on 6/18/2024 at 8:26 PM, on 6/19/2024 at 5:36 AM, on 6/20/2024 at 11:48 AM and 7:28 PM, and on 6/24/2024 at 1:01 PM. Review of Resident #12's MAR for pain assessment for June 2024 showed the resident's pain level was documented as zero on 6/1/2024 through 6/25/2024 at 6:30 AM and 2:30 PM. Review of Resident #12's progress note dated 6/10/2024 read, Res [resident] on hospice, c/o [complain of] pain in afternoon, morphine given prn [as needed] per MAR and was effective. CNA [certified nursing assistant] attempted 2 times to go RES OOB [out of bed] and RES refused, this nurse attempted 1x [times] and RES refused, PT [Physical Therapist] attempted and RES refused. During an interview on 6/26/2024 at 3:55 PM, the Director of Nursing stated, The nursing staff should chart the pain level at the end of shift and follow what the order says. The staff should accurately document the highest level of pain at the end of the shift. Review of the facility policy and procedure titled Pain Management and Assessment with the last review date of 1/18/2024 read, Purpose: The detection of the presence of pain, determining the frequency and intensity of pain, and identification of effective pain management interventions can help to avoid adverse outcomes that impact the resident/guest(s) functional status and quality of life. Standard . An on-going assessment of pain utilizing either a numeric scale of 0-10 or a verbal descriptor scale will be conducted daily and with evidence of new or worsening pain . Process . II. On-going Pain Assessment . e. Document Pain (1-10), or use verbal descriptors scale, or staff observation for documentation on MAR. 49289 2. Review of Resident #39's admission record showed the resident was most recently admitted on [DATE] with diagnoses including type 2 diabetes mellitus, chronic kidney disease (stage 4), hypokalemia, hypothyroidism, and adult failure to thrive. Review Resident #39's physician order dated 2/13/2024 read, Accu-checks [Blood glucose testing] AC/HS [before meals and at bedtime] cover w/ [with] Novolog [short acting insulin] 100 unit/ml vial . > [greater than] 399 mg /DL [deciliter] 7 U [units] & Call MD [medical doctor]. Special Requirement Brief Instructions . Notify MD for BG [blood glucose] less than 60 mg/dl or greater than 399 mg/dl. Review of Resident #39's physician order dated 5/22/2024 read, Novolin R [regular, human short acting insulin] 100 unit/ml vial. Administer 12 U subcutaneous if BS is > 399. Review of Resident #39's MAR for May and June 2024 for subcutaneous administration of 12 units of Novolin R of blood sugar is greater than 399 showed the resident received the medication on 5/25/2024 at 8:03 PM, on 5/27/2024 at 10:57 AM, on 5/28/2024 at 11:01 AM, on 5/29/2024 at 11:44 AM, on 5/31/2024 at 11:45 AM and 5:04 PM, on 6/1/2024 at 7:50 PM, on 6/2/2024 at 1:31 PM, on 6/4/2024 at 12:55 PM, on 6/11/2024 at 11:33 AM, on 6/12/2024 at 3:07 PM, on 6/14/2024 at 12:59 PM and 3:07 PM, on 6/15/2024 at 10:53 AM, on 6/16/2024 at 12:00 PM, on 6/17/2024 at 3:58 PM and 9:28 PM, on 6/18/2024 at 12:32 PM and 4:33 PM, on 6/19/2024 at 3:12 PM, on 6/20/2024 at 12:47 PM, on 6/22/2024 at 3:12 PM and 7:56 PM, on 6/24/2024 at 11:35 AM, on 6/25/2024 at 10:41 AM, and on 6/26/2024 at 11:07 AM, with no documentation of the blood glucose reading. Review of Resident #39's MAR for May and June 2024 for the order Accu-checks AC/HS cover w/ Novolog 100 unit/ml vial . > 399 mg/DL 7 U & Call MD showed N (Not Administered) documented for 5/25/2024 at 11:30 AM with no BG reading documented, on 5/25/24 at 9:00 PM with BG of 425, on 5/27/2024 at 11:30 AM with BG of 426, on 5/28/2024 at 11:30 AM with BG of 451, on 5/29/2024 at 11:30 AM with BG of 433, on 5/31/2024 at 11:30 AM with BG of 439, on 5/31/2024 at 4:30 PM with BG of 450, on 6/1/2024 with BG of 408, on 6/2/2024 at 11:30 AM with BG of 514, on 6/14/2024 at 11:30 AM with BG of 453, on 6/15/2024 at 11:30 AM with BG of 466, on 6/16/2024 at 11:30 AM with BG of 464, on 6/17/2024 at 4:30 PM with BG of 571 and at 9:00 PM with BG of 412, on 6/18/2024 at 11:30 AM with BG documented as high and at 4:30 PM with BG of 421, on 6/19/2024 at 4:30 PM with BG of 492, on 6/20/2024 at 11:30 AM with BG documented as high, on 6/21/2024 at 4:30 PM with BG of 463, on 6/22/2024 at 4:30 PM with BG of 486 and at 9:00 PM with BG of 500, on 6/24/2024 at 11:30 AM with BG of 433, and on 6/25/2024 at 11:30 AM with BG of 400. Review of Resident #39's progress notes showed no documentation from the nurses or the Advanced Practice Registered Nurse (APRN) #1 to defer from the active order for administration of 7 units of Novolog for blood glucose over 399 and call MD to the active order for administration of 12 units of Novolin R for blood glucose over 399 and not call the MD. Review of Resident #39's progress note dated 5/29/2024 showed the APRN #1 documented, History of present illness . Has been eating more lately with multiple hyperglycemic episodes reported and blood sugars as high as 451 . Plan . Continue medication, MAR reviewed. Review of Resident #39's progress note dated 6/20/2024 showed the APRN #1 documented, History of present illness . Unfortunately continues with hyperglycemic episodes and blood sugars trending between 154 and high will increase with multiple readings in the 400s . Plan . Continue medication, MAR reviewed. During an interview on 6/25/2024 at 2:51 PM while reviewing the two insulin orders on the MAR for June 2024 with the Director of Nursing (DON), the DON stated, The doctor was sick of the nurses calling so they put that order (referring to the Novolin R insulin order to give 12 units of insulin for blood sugars over 399). The nurses will put 'N' [Not administered] for the Novolog sliding scale order if the BS is over 399 and defer to the Novolin R order. Right now, it's confusing and the orders need to be more clear. During an interview on 6/27/2024 at 9:46 AM, the APRN #1 stated, The resident [Resident #39] is very hard to manage for her blood sugars. She will either be hypoglycemic or hyperglycemic. She is very fragile. She is not supposed to be on two insulin orders. I don't know why the pharmacy did that. I have so many medication orders for reconciliation. It's hard to keep up with. The staff communicates her elevated blood sugars with me every day, throughout the day. I am there [at the facility] five days a week. We communicate verbally throughout the day and there is a communication log at the desk that the nursing staff use if I'm not there for any non-critical blood sugar concerns and actions. The nurses and I have agreed that they should follow the orders for insulin and do not need to call me unless the blood sugar is over 450. During an interview on 6/27/2024 at 10:38 AM, Staff H, Licensed Practical Nurse (LPN), stated, I am familiar with the resident [Resident #39] and have administered insulin to her. It's kind of common knowledge to give 12 units of insulin if the blood sugar is over 399. Typically, we use the sliding scale for blood sugars and give the insulin dose according to the blood sugar range. We usually will give 7 units and call the doctor for blood sugars over 399, and then the doctor may order an additional 5 units. We never go over 12 units. There is a separate PRN [as needed] order for this resident to just give the 12 units due to her labile sugars. I don't know why there are to orders, but we just know to go to the PRN order. During an interview on 6/27/2024 at 10:55 AM, Staff I, LPN, stated, I am here each day and am the rounding nurse. I work directly with [the APRN #1's name] and gather the resident information from the communication call log printed sheets in the book here at the nursing station [pointing to the empty call book on the desk]. I am very familiar with the resident [Resident #39] and her labile blood sugars. I don't know why she has two insulin orders. Typically the standard order is to give 7 units of insulin for blood sugars over 399. I think the insulin order to give her 12 units of insulin was supposed to be a one-time order as needed. I am here Monday through Friday, and the nurses communicate her blood sugars to either me or [the APRN #1's name] throughout the day if there are concerns. At night, they would call the on-call provider. During an interview on 6/27/2024 at 11:05 AM, Staff J, Registered Nurse (RN), stated, I am very familiar with the resident [Resident #39]. If the nurses have questions about the elevated blood sugars during the day, [the APRN #1's name] is here every day, but if she is not here, we call the on-call doctor. It's a standard for this resident to give her 12 units of insulin if her blood sugar levels are over 399. It is confusing, it's common knowledge for the nurses caring for her. It could be confusing for a new nurse or a nurse not familiar with her to have two orders. Review of the facility policy and procedure titled Charting and Documentation Guidelines with the last review date of 1/18/2024 read, Purpose: Documentation in medical records of residents, by the interdisciplinary team, should provide: Communication of the resident's care, treatment, response to care, signs, symptoms and progress of the resident to providers of care . Process: I. Rules for charting and documentation: a) Chart all pertinent changes in the resident's condition, reaction to treatments, medications, as well as routine observations . IX. Miscellaneous Documentation: Documentation of various events occurs in the nursing notes and may include . e) Whenever a prn medication is given; the reasons for its use along with the resident's response.

Based on interview and record review, the facility failed to ensure residents received blood pressure medication as ordered by the physician for 1 of 7 residents reviewed for medication administration, Resident #43. Findings include: Review of Resident #43's physician order dated 11/16/2022 read, Midodrine HCL 5 mg [milligrams] tablet. 1 tablet by mouth daily. Hold for SBP [Systolic Blood Pressure] >110 Dx [Diagnosis]: Hypotension. Review of Resident #43's Medication Administration Record (MAR) for June 2024 documented the resident received Midodrine 5 mg on 6/9/2024 at 9:00 AM for a blood pressure of 120/80, 6/10/2024 at 9:00 AM for a blood pressure of 122/80, 6/17/2024 at 9:00 AM for a blood pressure of 120/80, 6/18/2024 at 9:00 AM for blood pressure of 120/78 and 6/24/2024 for a blood pressure of 122/74. During an interview on 6/26/2024 at 3:56 PM, the Director of Nursing stated, Nursing staff should follow the physician order and hold the medication when it is ordered to do so. During an interview on 6/26/2024 at 5:08 PM, the Advance Practice Registered Nurse (APRN) #1 stated, Normally staff would check the blood pressure and follow the parameters given. For Midodrine, some guidelines for the systolic are greater than 120 or 110. [Resident #43's name] has not had any problems receiving the medication. I wanted to be conservative due to the resident's age. The parameters of 110 is on the lower side and the medication dosage is minimal. The whole point of parameters is for staff to follow them. Review of the facility policy and procedure titled General Dose Preparation and Medication Administration with the last review date of 1/18/2024 read, Procedure . 3. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but no limiting to the following: 3.1 Verify each time a medication is administered that is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was completed for 1 of 3 residents reviewed for PASRR, Resident #90. Findings include: Review of Resident #90's medical chart showed the resident was admitted to the facility on [DATE] for respite care for one month with diagnoses including unspecified dementia, depression, brief psychotic disorder, and mood disorder due to known physiological condition. Review of Resident #90's progress note authored by Staff C, Social Worker, on 3/23/2023 showed Resident #90's spouse was unsure about the resident's status regarding respite. Review of Resident #90's progress note authored by Staff C, Social Worker, on 4/24/2023 showed the facility educated Resident #90's spouse on the extension process and would send clinicals to the insurance company. Review of Resident #90's progress note authored by Staff C, Social Worker, on 5/2/2023 showed the facility inquired with insurance company if the resident was eligible for long term care and confirmation was obtained. Review of Resident #90's progress note authored by Staff C, Social Worker, on 5/29/2023 showed the late entry for 5/26/2024 indicating that the facility has met with Resident #90's spouse on 5/26/2024 to review overall status. Resident #90's spouse was unable to manage resident at home and requested assistance to apply for long term rehab contract. Review of Resident #90's insurance records showed the resident was authorized for contract nursing home services for respite effective 3/17/2024 through 4/17/2023, and upon expiration of the initial respite stay, an extension was authorized until 6/4/2023 for rehabilitation services. On 5/31/2023, the resident was approved for long term care effective 6/4/2023 to 6/4/2024. Review of PASRR Evaluation Request for Resident #90 showed the request was completed on 3/6/202. Review of Section II showed the resident was admitted for a respite stay. Review of Resident #90's medical chart revealed no results for level I screen for serious mental illness and/or intellectual disability or related conditions. During an interview on 6/26/2024 at 2:22 PM, Staff C, Social Worker, stated, [Resident #90's name] was here only for respite care. After the respite stay, the spouse decided to leave [Resident #90's name] for long term care. The resident's PASRR should have been updated. During an interview on 6/27/2024 at 7:39 AM, the Director of Nursing stated, I was told about [Resident #90's name] PASRR wasn't correct. It should have been caught. Review of the facility policy and procedure titled Social Service Manual with an effective date of 7/15/2009 and the last review date of 1/18/2024 read, Process: Level I Determinations must be signed and dated by an RN [Registered Nurse] at the admitting nursing facility on or before the date of admission. The nursing facility is responsible for ensuring that a Level I screening is completed, submitted and has a Level I Determination and/or a Level II if indicated, on or before nursing home admission and regardless of payment source . The Original documents for the Level I and/or Level II determinations will be retained the medical chart behind the Social Services tab.

Based on observation, interview, and record review, the facility failed to ensure restriction of the use of assistive devices for fluids was implemented for 1 of 8 residents reviewed for nutrition, Resident #26. Findings include: During an observation of Resident #26's lunch tray on 6/24/2024 at 1:30 PM, there were one plastic glass with an opaque lid containing a brown liquid and one white Styrofoam cup with an opaque lid. Both glasses contained drinking straws (photographic evidence obtained). Staff D, Registered Nurse (RN), entered the room, picked up the Styrofoam cup and stated, I'll go get you more water. Review of Resident #26's lunch ticket dated Monday 6/24/2024 read, Mech [mechanical] Soft Rancher's Chicken- 3 Oz [ounces]; Seasoned Mashed Potatoes- 1/2 Cup; Seasoned Collard Greens- 1/2 Cup; Dinner Roll- 1 Ind [individual]; Margarine- 1 Ea [each]; Pumpkin Pie- 1/2 Pc [piece]; Iced tea- 8 Oz; No Straws. During an observation on 6/24/2024 at 1:40 PM in the 100/North Hallway outside of Resident #26's room, Staff D, RN, was holding a Styrofoam cup with a lid and a straw with the Resident #26's room number on it. During an interview on 6/24/2024 at 1:40 PM regarding restrictions of the use of straws for Resident #26, Staff D, RN, stated, I will have to check her meal ticket about straws. During an interview on 6/26/2024 at 11:55 AM, Staff D, RN, stated, We expect CNAs [Certified Nursing Assistants] to read the meal tickets. We are the last line of defense for the residents. I should have known better than to get [Resident #26's name] water and put a straw in it. Review of Resident #26's physician order dated 5/30/2024 read, CCD [Carbohydrate Controlled Diet]/CCHO [Consistent Controlled Carbohydrate] Mechanical Soft thin liquid, no straws. Review of Resident #26's Communication Form completed by the Speech Language Pathologist on 5/30/2024, read, To: Nursing . From: Rehab [rehabilitation services] . Recommendation: Discontinue Reg [regular]/ thin diet consistency. Change to mechanical soft/thin diet consistency . Comments: No straws. Please provide bowl of gravy w/ [with] every lunch [and] dinner. During an interview on 6/26/2024 at 2:45 PM, the Speech Language Pathologist, stated, She [Resident #26] coughs when she drinks with straws. It seems to be related to facial weakness and really poor dentition. There is a possible risk for choking and aspiration pneumonia, but she does pretty well. After my clinical evaluation, watching her, and a swallow study, as a precaution, I said not to use straws. It is more as a precaution. It is better to air at the side of caution than not to do it. It is not a hard absolute, more as a precaution. If it was something we consider harmful, we would do a FMP [Functional Maintenance Plan] where we would have a meeting and train as much staff as possible and involve restorative CNA. For [Resident #26's name], we did not find it necessary to do a FMP. Some of the residents are on the edge and it was really more of a precaution than anything. Review of Resident #26's Fiberoptic Endoscopic Evaluation of Swallowing [FEES] dated 5/30/2024, read, Consistencies Administered: Thin liquids- cup, straw . Aspiration: no aspiration visualized w/ thin liquids, mech soft, regular or mixed consistencies. During an interview on 6/26/2024 at 3:20 PM, the Director of Nursing (DON) stated, Therapy communication goes to the unit manager and the unit manager updates the care plan within a couple of days. If it is serious, we put it on the resident care manager [section of the electronic medical record] for the CNAs. There is an order in the system [regarding Resident #26]. During an interview on 6/27/2024 at 9:25 AM, the DON stated, The order [for Resident #26 not to have straws] goes to dietary and it goes on the [meal] ticket. They [the CNAs] need to check the tickets when they are passing trays.

Based on record review and interview, the facility failed to ensure resident assessment were completed accurately to reflect the resident discharge status for 1 of 3 residents reviewed for discharge, Resident #158. Findings include: Review of Resident #158's physician order dated 3/29/2024 read, Discharge Resident 4/2/24 at 2:00 PM via Medical Transport to [Name of the facility] SNF [Skilled Nursing Facility]. Review of Resident #158's Planned Discharge to Home Instructions dated 4/2/2024 read, Resident moving to [Name of the State]- Follow up with SNF physician. Review of Resident #158's Minimum Data Set (MDS) dated [DATE] under Section A2105 read, 4. Short Term General Hospital. During an interview on 6/26/2024 at 11:10 AM, Staff A, Long Term Care MDS Coordinator, stated that Section A 2105 was entered as a 4. Short term- General Hospital and should have been entered as 3. Skilled Nursing Facility. Resident #158 was sent to a skilled nursing facility out of state. During an interview on 6/26/2024 at 11:16 AM, Staff B, MDS Coordinator, stated that Resident #158 was discharged to a SNF out of state and MDS discharge status was coded in error as discharged to short term- General Hospital and should have been coded as discharged to SNF.

Based on observation, interview, and record review, the facility failed to ensure foods were stored in a safe manner in 3 of 3 nourishment rooms. Findings include: During a tour of the East Hall nourishment room on 6/24/2024 beginning at 9:30 AM with the Certified Dietary Manager, there was no thermometer in the freezer compartment of the refrigerator. There was an ice buildup in the freezer compartment and there was a wire dangling from the ice. During a tour of the North Hall nourishment room on 6/24/2024 beginning at 9:35 AM with the Certified Dietary Manager, there was no thermometer in the freezer compartment of the refrigerator. During a tour of the South Hall nourishment room on 6/24/2024 beginning at 9:38 AM with the Certified Dietary Manager, there was no thermometer in the freezer compartment of the refrigerator. There was an ice buildup in the freezer compartment. There was one undated individual pizza serving in the freezer. There was no thermometer in the cooling compartment of the refrigerator. During an interview on 6/24/2024 beginning at 9:30 AM, the Certified Dietary Manager confirmed there should be thermometers in the nourishment room refrigerators. He acknowledged the freezer compartments of the refrigerators in the East and South Hall needed defrosting. He indicated the individual serving of pizza stored in the freezer compartment of the South Hall refrigerator was undated. Review of the facility policy and procedure titled Leftover Food Storage and Use last reviewed on 1/18/2024, showed the policy read, Process . b. Leftover foods should be covered, labeled and dated. c. Refrigerated leftover foods should be used within 72 hours (three days). If not used within 72 hours, refrigerated foods should be discarded. These foods should be monitored for proper cooling, with times and temperatures recorded on a cooling log. Review of the facility policy and procedure titled Food Storage Temperature Logs last reviewed on 1/18/2024, showed the policy read, Process: In order to prevent food borne illnesses, foods should be stored at proper temperatures. Standard . Temperatures should be monitored and recorded on a food temperature log.

Based on observation, interview, and record review, the facility failed to ensure all foods were stored, covered, labeled, and discarded in accordance with professional standards for food service safety in the main kitchen and 2 of 3 nourishment rooms and failed to ensure sanitary standards were maintained in the walk-in cooler, walk-in freezer, and the stock/storage room. Findings include: During an initial tour of the kitchen on [DATE] at 09:10 AM with the Certified Dietary Manager (CDM) and the Administrator, the walk-in cooler had a large container labeled Pureed Meat dated ,d+[DATE], three unlabeled clear containers of food, one half gallon container of milk with approximately 16 ounces remaining that did not have an opened date on the container. The walk-in freezer had several opened boxes that exposed the food to the elements and the potential for freezer burn, a large buildup of ice under the sprinkler head on the left wall, two breadsticks and a piece of raw fish on the floor, and multiple pieces of trash and debris on the floor under the food racks. The reach-in cooler had one thickened sweetened tea with lemon and one thickened flavored water with no opened date. During an interview on [DATE] at 9:30 AM, the CDM confirmed that pureed foods should be discarded after each meal and not saved as a leftover per policy, all boxes in the freezer should be closed to protect the integrity of the food products, the walk-in freezer should not have food product and debris left on the floor and under the food racks and all products should be labeled and dated for storage, or an open date placed on bulk products that had been opened for use in the kitchen and in the nourishment rooms. During a tour of the kitchen on [DATE] at 9:20 AM with the Administrator, there were 36 clean fruit dishes and 124 clean dessert plates stored on an open cart that were not inverted or covered, four hood lights that were not working, a flat of 20 raw shell eggs left on the grill top, the clean robot coupe blender with water around the blade and bottom of the bowl, and the test strips for the 3-compartment sink with an expiration date of 2019. No other test strips were available. During an interview on [DATE] at approximately 9:45 AM, the CDM confirmed that raw shell eggs should have been stored in an ice bath when pulled from the cooler and returned to the cooler immediately after meal service, the expiration date on the test strips was 2019 and that expired strips may not be reliable for accurate readings for the sanitization of pots and pans. The CDM acknowledged that clean dishes should be either inverted or the top dish covered completely, verified that 4 lights were not working under the stove hood and that the robot coupe blender should be left to completely air dry after being washed, rinsed, and sanitized and not placed back on the base creating a potential wet nesting or allowing potential microorganisms to grow. During a tour of three nourishment rooms with the Administrator on [DATE] at 11:30 AM, the east nourishment room had an opened undated container of thickened cranberry cocktail, and the south nourishment room had an opened undated and unlabeled container of Red Bull drink, Pepsi soda, and a bottle of juice stored in the refrigerator. During an interview on [DATE] at 11:30 AM, the Administrator confirmed that 2 of 3 nourishment room refrigerators had opened products that did not have an opened date or labeled with a name. Review of the policy titled Leftover Food Storage and Use last reviewed [DATE], read, Purpose. To assure that food borne illnesses are avoided. Process. b. Leftover foods should be covered, labeled and dated. c. Refrigerated leftover food should be used within 72 hours (three days). If not used within 72 hours, refrigerated foods should be discarded. h. Pureed foods should not be re-used. Review of the policy titled Food Receipt and Storage last reviewed [DATE], read, k. Open food items should be covered, labeled, and dated; opened dry goods should be kept in tightly sealed containers. p. If food items with expiration dates are removed from the original containers, the expiration date should be transferred to the food item and identified as the expiration date. Review of the policy titled Three Compartment Sink Sanitization last reviewed [DATE], read, Process. The final rinse should be monitored for the proper temperature, if hot water sanitization is used, and for proper chemical concentration if chemical sanitization is used. Review of the policy titled Cleaning of Miscellaneous Equipment and Utensils last reviewed [DATE], read, 16. Food Processor: (after each use) Air dry on clean surface or use clean paper towels or cloth to dry. 18. Freezer: b. Walk-In Type (weekly). Mop floor, Shelves should be pulled out and washed as needed. 35. Refrigerator: (weekly) a. Reach In Type. 3. Check with the supervisor and sort and throw away food not usable or past the storage period.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 4 of 6 medication carts (south hall, north back hall, north hall, east hall) and failed to ensure medications were secured (photographic evidence obtained). Findings include: 1.) During an observation of south hall medication cart on [DATE] at 9:15 AM with Staff A, Licensed Practical Nurse (LPN), there was an opened bottle of Latanoprost ophthalmic solution with no open or expiration date and one expired bottle of Dorzolamide HCI ophthalmic solution with open dates [DATE] and [DATE] noted on the same bottle. During an interview on [DATE] at 9:25M Staff A, Licensed Practical Nurse (LPN) stated that the medication should be dated when opened and forgo the expiration date in box. During an observation of the north back hallway medication cart on [DATE] at 9:27 AM with Staff B, LPN, there were five medication cups containing unlabeled medications, one opened Toujeo Solostar insulin pen with no open or expiration date, one opened Novolin insulin pen with no open or expire date, and one open bottle of Pro-stat with no open date. During an interview on [DATE] at 9:36 AM, Staff B, LPN, stated that the medication should be immediately dated and initial when opened. She confirmed medication should be stored in their original bottle. During an observation of the north hall medication cart on [DATE] at 9:38 AM with Staff C, Registered Nurse (RN), there was one expired bottle of Azopt 1% eye drops with an open date [DATE], one expired bottle of Latanoprost 0.005% ophthalmic solution with an open date of [DATE] with instructions to discard after 42 days, one expired bottle of Travoprost 0.004% eye drops with an open date of [DATE], one expired bottle of artificial tears with an opened date of [DATE] and one expired bottle of artificial tears with an open date [DATE]. During an interview on [DATE] at 9:44 AM, Staff C, RN, stated that the expired medication should be removed from the active section of the cart, and they will either go back to pharmacy or the Director of Nursing will destroy them. During an observation of the east hall medication cart on [DATE] at 9:50 AM with Staff D, LPN, there was one expired bottle of Pro-stat with an open date of [DATE], one bottle of fungi care with no original pharmacy packing and no open date, one opened bottle of Timolol with no open date, and a closed package of cookies. During an interview on [DATE] at 9:55 AM, Staff D, LPN, stated that the medication should be dated when opened and the bottle of fungi care should not be in the cart because the treatment was discontinued. During an interview on [DATE] at 12:39 PM the Director of Nursing stated, Medication should be opened and dated. If the medication is expired, staff should reorder and check stock in house. The staff should discard expired medication. 2.) During an observation on [DATE] at 10:14 AM Resident #81 was lying in bed. A bottle of antacid tablets were on the bedside table next to the resident. During an interview on [DATE] at 10:15 AM Resident # 81 stated I don't really know how to take one. During an observation on [DATE] at 10:45 AM, Resident #52 was lying in her bed watching television. An inhaler was observed on Resident #52's bedside table next to resident. During an interview on [DATE] at 10:46 AM, Resident #52 stated I take the inhaler on my own. During an observation on [DATE] at 8:23 AM, Resident #81 was lying in bed having breakfast. A bottle of antacid tablets was observed on the resident's bedside table next to resident. During an observation on [DATE] at 9:10 AM, Resident #81 was lying in bed. A bottle of antacid tablets was observed on the resident's bedside table next to resident. During an interview on [DATE] at 9:14 AM, the Director of Nursing stated, medications should be kept in medication cart. Review of the policy titled Storage and Expiration Dating of Medications, Biologicals last reviewed on [DATE] read Procedure. 4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or return to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for open medication. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. 5.4 When an ophthalmic solution or suspension has a manufacturers shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container. 9. Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. 13. Bedside Medication Storage. 13.2. Facility should store bedside medications or biologicals in a locked compartment within the resident's room. 16. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law, and in accordance with Policy 8.2 (Disposal/Destruction of Expired or Discontinued Medication.)

Based on observation, interview, and record review the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 4 out of 7 residents reviewed for respiratory care. (Resident #15, Resident #129, Resident #156, Resident #9) Findings Include: 1.) During an observation on 2/13/23 at 11:53 AM Resident #15 was observed sitting in bed receiving oxygen through a nasal cannula. The oxygen concentrator was observed set on 2.5 liters of oxygen. Review of the physician orders for Resident #15 dated 8/30/22 read Oxygen @ 2 L/Min [at 2 liters per minute] per nasal cannula PRN (as needed) for short of breath and low oxygen saturations. During an interview on 2/13/23 at 11:30 AM Staff E, South Hall Unit Manager, Registered Nurse (RN), confirmed Resident #15's oxygen was running at 2.5L [liters per minute] and Resident #15 has physician's orders to receive oxygen at 2 liters per minute. During an observation on 2/13/23 at 11:56 AM, Resident #129 was observed sitting in bed receiving oxygen through a nasal cannula. The oxygen concentrator was observed set on 1.5 liters of oxygen. Review of the physician orders for Resident #129 dated 2/12/23 read Apply oxygen at 2 liters per minute via NC [nasal cannula] if O2 Sat [oxygen saturation] was less than 92% or SOB [shortness of breath]. During an interview on 2/13/23 at 11:30 AM Staff E, South Hall Unit Manager, RN, confirmed Resident #129's oxygen was running at 1.5L and the physician's order read 2 liters per minute for oxygen administration. During an observation on 2/12/23 at 10:30 AM, Resident #156 was observed sitting in bed receiving oxygen through a nasal cannula. The oxygen concentrator was observed set on 1.5 liters of oxygen. Review of the physician orders for Resident #156 dated 11/10/22 read Oxygen @ 3 L/Min [liters per minute] per nasal cannula continuous. During an interview on 2/13/23 at 11:40 AM Staff E, South Hall Unit Manager, RN, confirmed Resident #156's oxygen was running at 1.5L [liters per minute] and the physician's orders read 3 liters per minute. During an interview on 2/14/23 at 11:49 AM the Director of Nursing stated, If patients need more or less oxygen a doctor should be called, and orders changed. My expectation of my staff is to follow the doctors' orders. Review of the policy titled Oxygen Administration last review 1/19/23, read Standard. Oxygen should be administered under orders of the attending physician, except in the case of an emergency. In an emergency, oxygen may be administered without physician's orders, however, the order should be obtained immediately after the crisis is under control. Process. 1. Obtain physician's orders for the rate of flow and route of administration of oxygen (i.e. by tank, concentrator, nasal cannula, mask, etc.) 5. Attach the oxygen delivery device ordered by the physician to the oxygen unit (mask, cannula). 8 Check oxygen flowmeter for correct liter flow. 46523 2. ) During an observation on 2/12/23 at 10:25 AM Resident #9, was lying in bed resting calmly with eyes closed, oxygen being administer at 2.5 liters per minute via nasal cannula with humidifier. During an observation on 2/13/23 at 8:28 AM Resident #9, was eating breakfast in her room, oxygen being administer at 2.5 liters per minute via nasal cannula with humidifier. During an observation on 2/13/23 at 11:20 AM Resident #9, was lying in bed resting calmly with eyes closed, oxygen being administer at 2.5 liters per minute via nasal cannula with humidifier. Review of the face sheet for Resident #9 documented the resident was admitted on [DATE] with diagnosis that included shortness of breath, obstructive pulmonary disease, and dependence on supplemental oxygen. Review of the physician order dated 12/14/22 reads, O2 (Oxygen) On 2LT /Min [2 liters per minute] Via NC [nasal cannula] with Humidifier DX [diagnosis]: SOB [shortness of breath] During an interview on 2/13/23 at 11:47 AM Staff C, RN/Unit Manager, confirmed Resident #9's oxygen was running at 2.5 Liters and Resident #9 has orders for oxygen at 2 Liters with humidifier.

Based on observation, interview, and record review the facility failed to post daily nurse staffing information on 1 of 5 days of the survey. Findings include: An observation was made of the posted daily nurse staffing information on Sunday, 2/12/23, at 9:00 AM at the time of the entrance into the facility. The posted daily nurse staffing information was dated Friday, 2/10/23 and only the day shift was completed on the form. During an interview on 2/14/23 at 1:30 PM, the Executive Director stated that the nurse staffing information is a continuous working schedule and the Staff Development Coordinator is responsible for updating the posted nurse staffing. During an interview on 2/15/23 at 11:00 AM, the Staff Development Coordinator stated it is her responsibility to maintain the daily nurse staffing posting and in her absence, there is an Registered Nurse in the facility that is responsible for the staff posting. Review of policy number NM.I-5, last reviewed 1/19/23 read Each facility shall post daily at the beginning of the shift the number of direct-care staff on duty for each shift.