Every finding on record at Pleasant Valley Nursing and Rehab Center

Based on interview and record review, it was determined that the facility failed to implement a comprehensive care plan for 1 of 3 residents reviewed for accidents in a final sample of 18 residents (Resident identifier is #26).Findings include:Review on 1/14/26 of Resident #26's care plan revealed a fall care plan with the following intervention: two person assist with all care, initiated on 12/15/25. Further review revealed an ADL (Activities of Daily Living) care plan with the following interventions for bed mobility: requires total assistance by two staff to turn and reposition in bed, initiated 12/13/25; and for dressing: total assistance of two staff to dress, initiated 12/13/25.Review on 1/14/26 or Resident #26's task notes for the last 30 days (12/16/25 to 1/14/26) revealed the following:Bed Mobility: Support Provided (how resident moves to and from lying position, turns side to side, and positions body while in bed). Resident #26 received 1 person assistance for 28 out of 30 days.Bathing: Support Provided (how resident takes full body bath/shower, sponge bath). Resident #26 received 1 person assistance for 6 out of 30 days.Personal Hygiene: Support Provided (how resident maintains personal hygiene). Resident #26 received 1 person assistance for 23 out of 30 days.Interview on 1/14/26 at approximately 2:30 p.m. with Staff F (Licensed Nursing Assistant) revealed that Staff F provided afternoon care on 1/14/26 to Resident #26 which included changing his/her brief and repositioning his/her in bed. Interview further revealed that Staff F completed the care alone.Interview on 1/14/26 at approximately 3:00 p.m. with Staff E (Director of Nursing) confirmed that Resident #26 is a 2-person assist with all care needs.Review on 1/14/26 of the facility's policy Activities of Daily Living (ADL), Supporting, revised April 2025, revealed: .5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting);.Review on 1/14/26 of the facility's policy Care Plans, Comprehensive Person-Centered, revised March 2022, revealed: .The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that expired medications were not administered for 1 medication in a total of 30 medication administrations observed. (Resident identifier is #89.)Findings include:Observation on 1/14/26 at approximately 7:20 a.m. of Staff A (Licensed Practical Nurse) administering Pataday 0.2% (percent) eye drops to Resident #89 revealed the eye drops were labeled with a open date of 10/29/25. Interview on 1/14/26 at approximately 7:20 a.m. with Staff A confirmed the above findings. Review on 1/14/26 of the manufacturer's instructions for Pataday Ophthalmic Solution 0.2%, Dated July 2020 revealed: . 6.3 Special Precautions for Storage . Discard 4 weeks after opening.Review on 1/14/26 of the facility policy titled, Administering Medications, Revision Date June 2024 revealed: . 13. The expiration/beyond use date on the medication label is checked prior to administering.Review on 1/14/26 of Drug Expiration Dates- Are Expired Drugs Still Safe to Take?, Drugs.com, Revision Date 8/1/24 revealed: . The expiration date is the final date that the manufacturer guarantees the full potency and safety of a medication. Eye drops should always be disposed of after their expiration date.

Based on observation, interview, and record review, it was determined that the facility failed to ensure medications were appropriately labeled on 3 of 3 medication carts observed and 1 of 2 medication rooms observed. (Resident identifiers are #24, #50, #7, #35, #42, and #54.)Findings include:East 2 Medication Cart Observation on 1/13/26 at approximately 8:20 a.m. of the East 2 Medication Cart revealed the following medications, with no open/expiration dates: Resident #24's Latanoprost eye drops opened and not labeled with an open/open expiration date; Resident #50's Novolog 70/30 insulin pen opened and not labeled with an open/open expiration date; and Resident #7's Lantus insulin pen opened and not labeled with an open/open expiration date. Interview on 1/13/26 at approximately 8:20 a.m. with Staff B (Registered Nurse (RN)) confirmed the above findings. Further interview revealed that Resident #50 and Resident #7 both received the above insulin on 1/13/26. Review on 1/13/26 of Resident #50's January 2026's Medication Administration Record (MAR) confirmed that Lantus insulin was administered on 1/13/26 at 8:00 a.m. Review on 1/13/26 of Resident #7's January 2026's MAR confirmed that Novolog 70/30 insulin was administered on 1/13/26. [NAME] 1 Medication Cart Observation on 1/13/26 at approximately 8:25 a.m. of the [NAME] 1 Medication Cart revealed, with no open/expiration dates: Resident #35's Aspart insulin opened and not labeled with an open/open expiration date; and Resident #42's Lantus insulin pen opened and not labeled with an open/open expiration date. Interview on 1/13/26 at approximately 8:25 a.m. with Staff C (Licensed Practical Nurse (LPN)) confirmed the above findings. Medical/Surgical Unit (MSU) South Medication Cart Observation on 1/13/26 at approximately 8:30 a.m. of the MSU South Medication Cart revealed, with no open/expiration dates: Resident #54's Latanoprost eye drops opened and not labeled with an open/open expiration date. Interview on 1/13/26 at approximately 8:25 a.m. with Staff D (RN) confirmed the above findings. MSU Medication Room Observation on 1/13/26 at approximately 8:35 a.m. of the MSU Medication Room refrigerator revealed: A vial of Aplisol opened and not labeled with an open/open expiration date. Interview on 1/13/26 at approximately 8:35 a.m. with Staff D confirmed the above findings. Review on 1/13/26 of the manufacturer's instructions for Insulin Aspart Injection, Revision Date 2/2023 revealed: . Storage . After vials have been opened: . Throw away all opened Insulin Aspart vials after 28 days, even if they still have insulin left in them. Review on 1/13/26 of the manufacturer's instructions for Lantus (Glargine) Insulin, Revision Date 6/2023 revealed: . Storage . Lantus vial you are using should be thrown away after 28 days or if the expiration date has passed, even if it still has insulin left in it. Review on 1/13/26 of the manufacturer's instructions for Xalatan (Latanoprost Opthalmic Solution), Revision Date August 2011 revealed: . Once a bottle is opened for use, . for 6 weeks. Review on 1/13/26 of the manufacturer's instructions for Aplisol, Dated November 2013 revealed: . Storage . Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Review on 1/13/26 of the manufacturer's instructions for Novolog Mix 70/30 Insulin, Revision Date 12/2018 revealed: . The Novolog Mix 70/30 FLexPen you are using should be thrown away after 14 days, even if it still has insulin left in it. Review of the facility policy titled, Medication Labeling and Storage, Revision Date February 2023 revealed: . 5. Multi-dose vials that have been opened or accessed (e.g., needle puncture) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview, and policy review, it was determined that the facility failed to follow the facility's infection control policies and procedure for hand hygiene, linen handling, and enhanced barrier precautions. Findings Include: Observation on 11/19/24 at 10:33 a.m. of the Skilled Medical Unit (SMU) revealed a pile of soiled bed linens on the floor beside the bed where two Licensed Nursing Assistants (LNAs) were providing care. Interview on 11/19/24 at 10:35 a.m. with Staff F (Director of Nursing) confirmed that the linens were soiled and revealed they should have been put in a plastic bag for transport and not put on the floor. Observation on 11/20/24 at 11:48 a.m. of the SMU meal service revealed Staff G (LNA) exited a resident's room carrying a full clear trash bag. Staff G was not wearing gloves. Staff G disposed of the trash bag in the soiled utility room. After leaving the utility room, Staff G went directly to the drink cart without washing his/her hands and proceeded to grab a cup to pour drinks. Interview on 11/20/24 at 11:50 a.m. with Staff G confirmed the above findings that they did not wash their hands after handling a resident's trash. Review on 11/20/24 of the facility policy titled, Standard Precautions, (not dated), revealed: .Standard Precautions Include the Following Practices: 1 .b. Hand hygiene is performed with ABHR (Alcohol Based Hand Rub) or soap and water .4. after contact with items in the resident's room .7. Linen: a. Linen soiled with blood, body fluids, secretions, excretions are handled and processed in a manner that prevents skin and mucous membrane exposures, contamination of clothing and avoids transfer of microorganisms to other residents and environments . Review on 11/21/24 of the Center for Disease Control and Prevention guideline titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, retrieved from: https://www.cdc.gov/infection-control/hcp/core-practices/index.html, revealed: .Hand Hygiene .Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations. Use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient .After touching a patient or the patient's immediate environment .Immediately after glove removal . 49819 Resident #49 Observation on 11/19/24 at approximately 9:20 a.m. of Resident #49 revealed he/she had a urinary catheter. Further observation revealed no personal protective equipment available in or near the resident room and no indications he/she was on Enhanced Barrier Precautions (EBP). Review on 11/19/24 of Resident #49's physician orders revealed a current order for indwelling urinary catheter, dated 9/25/24. Interview on 11/19/24 at approximately 9:20 a.m. with Staff C (Licensed Practical Nurse) confirmed that Resident #49 had an indwelling urinary catheter. Review on 11/21/24 of facility policy titled, Enhanced Barrier Precautions, dated March 2024, revealed: .5. EBPs are indicated .b urinary catheters . Interview on 11/21/24 at approximately 8:30 a.m. with Staff D (Infection Preventionist) confirmed residents with indwelling urinary catheters should be on EBP. Further interview revealed that the facility follows the Centers for Disease Control (CDC) guidelines for EBP. Review on 11/21/24 of the CDC guideline titled, Implementation of Personal Protective Equipment Use in Nursing Homes to Prevent Spread of Multidrug Resistant Organisms (MDRO's), updated July 2022, revealed: .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. MDRO's may be indirectly transferred from resident-to-resident during these high-contact activities. Nursing home resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's. The use of gown and gloves for high-contact resident care activities is indicated, .Enhanced Barrier Precautions, Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: .Device care or use: central line, urinary catheter .

Based on observation, interview, and record review it was determined that the facility failed to ensure that licensed nursing staff had the competencies and skills necessary to care for residents with a Gastrostomy Tube (G-tube) for 4 of 4 contracted licensed staff reviewed for staffing (Staff Identifiers are E, I, J, and K). Finding include: Observation on 11/29/23 at 7:10 a.m. of Resident #71's G-tube medication administration with Staff E (Licensed Practical Nurse (LPN)) revealed that Staff E did not flush the G-tube prior to administering the first medication and did not flush between the medications. Interview on 11/29/23 at 10:00 a.m. with Staff E confirmed that he/she did not flush before administering medications or between the medications. Staff E revealed that he/she was a contracted nurse who had worked at the facility for approximately 1 month and had not had any orientation or training since starting at the facility. Review on 11/30/23 of the following contracted nurse employee files revealed that there was no on-site training or competencies documented as being completed; -Staff E (LPN) whose hire date was 10/30/23; -Staff I (Registered Nurse (RN)) hire date 3/7/23; -Staff J (LPN) hire date 2/8/23; -Staff K (RN) hire date 10/30/23. Interview on 11/30/23 at 1:08 p.m. with Staff F (Infection Preventionist/Staff Development) and Staff H (Human Resources) revealed that Staff H confirmed that no on-site training had occurred with the above 4 contracted staff. Staff F confirmed that contracted/agency staff did not have any onsite training or competencies related to the facility's policies and procedures. Review on 11/29/23 of the facility's Facility Assessment Tool updated 11/3/23 revealed, . 3.2 Staffing plan . nursing staffing plan will have sufficient staff with competencies and skill sets to provide nursing and related services to assure resident safety and obtain or maintain the higher practicable physical, mental and psychosocial well-being of each resident . Competencies completed for the facility staff members include are is not limited to Person-centered care . Activities of daily living . Disaster planning and procedures . Infection control . Medication administration . Measurements . Resident assessment and examinations . Caring for persons with Alzheimer's or other dementia . Specialized care - catheterization insertions/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post-op care, trach care/suctioning, ventilator care, tube feedings, wound care/dressings, dialysis care . Review on 11/30/23 of the facility's policy titled Orientation Program for Newly Hired Employees, Transfers, Volunteers revised May 2019, revealed, . An orientation program shall be conducted for all newly hired employees, transfers from other departments, those providing services under contractual arrangements, and volunteers . 1. All newly hired personnel/volunteers/transfers/contractors must attend a 10-hour orientation program within their first five (5) days of hire . Review on 11/30/23 of the facility's policy titled Staffing, Sufficient and Competent Nursing revised August 2022, revealed, .Our facility provides . competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment .Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: a. programming for staff training results in nursing competency; b. gaps in education are identified and addressed; c. education topics and skills needed are determined based on the resident population; d. tracking or other mechanisms are in place to evaluate effectiveness of training .

Based on interview and record review, it was determined that the facility failed to provide documentation of performance reviews and regular in-service education for 2 of 2 Licensed Nursing Assistants (LNAs) reviewed for staffing (Staff Identifiers are Q and R). Findings include: Interview on 11/30/23 at 2:51 p.m. with Staff O (Administrator) revealed that the facility was aware that staff performance reviews and in-service education had not been done. Review on 12/1/23 of the facility's Active Employee list revealed that Staff Q and Staff R had been employees since 2019. Review on 12/1/23 of Staff Q's employee file revealed that there was no annual performance review completed in the past 12 months and no in-service training. Review on 12/1/23 of Staff R's employee file revealed that there was no annual performance review completed in the past 12 months and no in-service training for abuse or dementia care since 2021. Interview on 12/1/23 with Staff H (Human Resources) confirmed the above findings. Review on 12/1/23 of the facility's policy titled Staffing, Sufficient and Competent Nursing revised August 2022 revealed, . Our facility provides . nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment . Review on 12/1/23 of the facility's policy titled In-Service Training, All Staff revised August 2022, revealed, . Completed training is documented by the staff development coordinator, or his or her designee and includes: a. the date and time of the training; b. the topic of the training; c. the method used for training; d. a summary of the competency assessment; and e. the hours of training completed.

Based on interview and record review, it was determined that the facility failed to implement and monitor corrective actions for identified gaps in systems. Findings include: Review on 11/30/23 of 5 residents for influenza and pneumococcal vaccination revealed that 3 of 5 medical records did not contain documentation that residents were offered and received education for influenza and pneumococcal vaccination. Cross reference F883 Influenza and Pneumococcal Immunizations. Interview on 11/30/23 at 2:51 p.m. with Staff O (Administrator) revealed that the facility had identified issues offering and educating residents for influenza and pneumococcal vaccinations and the issue was in Quality Assurance. Staff O was not able to provide documentation of any audits or monitoring to ensure that corrective actions were effective. Review on 11/30/23 of 4 of 4 contracted nursing staff revealed that all 4 had not had training or competencies. Cross reference F726 Competent Nursing Staff. Review on 11/30/23 of 2 of 3 Licensed Nursing Assistants revealed that there was no documentation of annual performance reviews and regular in-service education for the staff. Cross reference F730 Nurse Aide Perm Review - 12 Hr/yr In-Service. Interview on 11/30/23 at 2:51 p.m. with Staff O revealed that the facility was aware that staff training and competencies for contracted nursing staff, annual performance reviews, and regular in-service education were not being done. Staff O was not able to provide documentation of any audits or monitoring to ensure that corrective actions were effective. Review on 12/1/23 of the facility's Performace Improvement Project titled New Hire Orientation and Annual Education for all Staff dated 9/5/23 revealed that there was no education system in place.

Based on record review, observation, interview, and policy review it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP) for 6 of 8 residents reviewed for infection control (Resident Identifiers are #36, #79, #88, #71, #91, and #9). Findings Include: Resident #88 Review on 11/28/23 of Resident #88's medical record revealed they had a Foley catheter since admission on 10/30/23. Observation on 11/28/23 at approximately 12:15 p.m. of Resident #88 revealed no EBP signage or PPE available outside of the resident's room. Interview on 11/29/23 at approximately 9:35 a.m. with Staff A (Licensed Practical Nurse (LPN)) confirmed the above finding. Resident #36 Review on 11/30/23 of Resident #36's medical record revealed they had a wound and a Foley catheter since admission on 10/13/23. Observation on 11/30/23 at approximately 7:50 a.m. of Resident #36 revealed no EPB signage outside the resident's room. Interview on 11/30/23 at approximately 8:18 a.m. with Staff A confirmed the above finding. Resident #79 Review on 11/30/23 of Resident #79's medical record revealed they had a Foley catheter since admission on 4/6/23. Observation on 11/30/23 at approximately 8:00 a.m. of Resident #79 revealed no EBP signage or PPE available outside resident room for catheter care. Further observation at this time revealed an uncovered catheter bag and part of the tubing resting on the floor. Interview on 11/30/23 at approximately 8:20 a.m. with Staff A confirmed the above finding. Resident #9 Review on 11/30/23 of Resident #9's medical record revealed they were positive for COVID-19 since 11/23/23 and on TBPs. Observation on 11/30/23 at approximately 10:20 a.m. of Resident #9's room revealed Staff E (LPN) entered Resident #9's room without donning gloves, gown, and eye protection. Interview on 11/30/23 at approximately 10:25 a.m. with Resident #9 revealed that staff sometimes don gloves, gowns, and eye protection when entering the room, but not always while on precaution. Interview on 11/30/23 at approximately 10:30 a.m. with Staff E revealed they were running behind on medication pass, did not don PPE prior to entry into Resident #9's room, and confirmed the above findings. Review on 12/1/23 of the facility policy titled, Isolation - Categories of Transmission-Based Precautions, last revised September 2022, revealed: 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. Review on 12/1/23 of the facility policy titled, Enhanced Barrier Precautions, last revised August 2022, revealed: 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and wound care (any skin opening requiring a dressing). Review on 12/1/23 of Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) on the CDC website, found at https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html updated 7/12/22, revealed .Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing [11-15]. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs [3,5,6]. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization . Review on 12/1/23 of the CDC website titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, update date of May 8, 2023, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .Personal Protective Equipment HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) . 26364 Resident #91 Review on 11/30/23 of Resident #91's medical record reviewed they had wound care every day on the right foot and ankle. Observation on 11/30/23 at approximately 8:00 a.m. of Resident #91 revealed no EBP signage or PPE available outside resident room for wound care. Observation on 11/30/23 at approximately 7:10 a.m. of Resident #91's room revealed Staff P (Registered Nurse/MSU Unit Manager (RN)) and Staff I (RN) entered Resident #91's room without donning gloves and gown protection to provide wound care to two open wounds on the mid-shin area and scabbed areas to the toes on the right foot. Interview on 11/30/23 at approximately 7:45 a.m. with Staff I and Staff P confirmed no EBPs were used only gloves. 43002 Resident #71 Review on 11/28/23 of Resident #71's medical record revealed that Resident #71 received all medications through a Gastronomy tube (G-tube). Observation on 11/29/23 at 7:10 a.m. of Resident #71 receiving medications via G-tube by Staff E (LPN) revealed that Staff E wore a face mask and gloves to perform the medication administration, but no gown. There was no EBP signage or PPE available outside or inside the room other than gloves. Interview on 11/29/23 at 10:00 a.m. with Staff E confirmed the above. Staff E revealed that he/she was unaware of any precautions for Resident #71. Resident #91 Review on 11/29/23 of Resident #91's medical record revealed that Resident #91 was receiving an antibiotic via an intravenous (IV) catheter. Observation on 11/29/23 at approximately 8:30 a.m. of Resident #91 receiving IV medication by Staff I (RN) who was wearing gloves and a face mask, but no gown. There was no EBP signage or PPE available outside or inside the room other than gloves. Interview on 11/29/23 at approximately 8:30 a.m. with Staff I confirmed the above. Interview on 11/30/23 at 10:24 a.m. with Staff F (Infection Preventionist) revealed that the facility followed CDC guidelines for infection control guidance.

Based on interview and record review it was determined that the facility failed to ensure a resident was offered and/or provided education on the risks and benefits of the Pneumococcal or Influenza vaccination for 3 of 5 residents reviewed for vaccinations (Resident Identifiers are #49, #85, and #91). Findings include: Resident #91 Review on 11/30/23 of Resident #91 medical record revealed that Resident #91 was admitted to the facility in October 2023, discharged to the hospital on 10/30/23, and returned on 11/10/23. Review on 11/30/23 of Resident #91's medical record revealed the following; -Under the immunization tab there was no record that the pneumococcal or influenza vaccination had been given or refused; -The consent form titled Pneumococcal/Influenza Immunization Consent was not filled out except for Resident #91's name at the bottom; -The hospital discharge summary dated 11/9/23 revealed There is no immunization history on file for this patient. Further review of Resident #91's medical record revealed that in the front of Resident #91's paper chart was an Admission Checklist dated 11/10/23 under All consents including Flu and pneumonia vaccines to be completed was initialed as completed, but the 2nd check initials had no initials that it had been done. The form read To be completed by nursing within 72 hours. Complete then given to UM [Unit Manager] or 11-7 supervisor for the second check. Interview on 11/30/23 at 9:35 a.m. with Staff P (Unit Manager (UM)) confirmed the above. Review on 12/1/23 of Resident #91's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) revealed under Section O the following; -Did the resident receive the influenza vaccine in this facility for this year's influenza season was answered No and Not offered; -Is the resident's Pneumococcal vaccination up to date was coded No' and Not offered. Resident #85 Review on 11/30/23 of Resident #85's medical record revealed that Resident #85 was admitted to the facility in August 2023. Further review on 11/30/23 of Resident #85's medical record revealed the following; -The Pneumococcal/Influenza Immunization Consent form revealed under the pneumococcal immunization was written Had already date?'; -The immunization tab did not have anything documented for a pneumonia vaccine. Interview on 11/30/23 at 11:00 a.m. with Staff B (UM) confirmed the above. Interview on 11/30/23 at 11:18 a.m. with Staff F (Infection Preventionist) confirmed the above. Review on 12/1/23 of Resident #85 Significant Change in Status MDS with an ARD of 9/29/23 revealed under Section O Is the resident's Pneumococcal vaccination up to date was coded No' and Not offered. Resident #49 Review on 11/30/23 of Resident #49's medical record revealed that Resident #49 was admitted to the facility in February 2021. Further review on 11/30/23 of Resident #49's medical record revealed that a pneumococcal Prevnar 13 (PCV (pneumococcal conjugate vaccine)) vaccine had been administered on 2/24/22. No additional documentation of offering or refusing any additional pneumonia vaccines was noted in the record. Interview on 12/1/23 at 8:50 a.m. and 10:40 a.m. with Staff A (UM) confirmed the above. Review on 12/1/23 of Resident #49's Quarterly MDS with an ARD of 9/14/23 revealed under Section O Is the resident's Pneumococcal vaccination up to date was coded No' and Not offered. Interview on 12/1/23 at 11:05 a.m. with Staff F confirmed the facility uses the Centers for Disease Control and Prevention guidance for vaccination administration guidance. Review on 12/1/23 of the facility's policy titled Pneumococcal Vaccine revised March 2022, revealed, .All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections . 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . 2. Assessments of pneumococcal vaccination status are conducted within five (5) working days of the resident's admission if not conducted prior to admission .5. Residents/representative have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination .7. Administration of the pneumococcal vaccines are made in accordance with Current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination . Review on 12/1/23 of the facility's policy titled Influenza Vaccine revised October 2023, revealed, .All residents . who have no medical contraindication to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza .2 residents admitted between October 1st and March 31st shall be offered the vaccine within five (5) working days of . the resident's admission to the facility . Review on 12/1/23 of the CDC's Pneumococcal Vaccine Timing for Adults, provided by the facility, revealed that if an adult [AGE] years or older had had a PCV13 pneumonia vaccine, then after 1 year they had the option of a PCV20 or PPSV23 (Pneumococcal polysaccharide vaccine) vaccine to be up to date.

Based on record review, and interview it was determined that the facility failed to inform the resident's activated durable power of attorney for healthcare (DPOA-H) of a change in medication for 1 of 1 resident reviewed for notification of change in a final sample of 25 residents (Resident identifier is #16). Findings include: Review on 11/30/23 at approximately 9:30 a.m. of Resident #16's current physician's orders revealed an order dated 10/28/22 to activate Resident #16's DPOA-H. Review on 11/30/23 of Resident #16's physician's orders revealed an order on 8/2/22 for Methenamine Hippurate Tabled 1 GM [gram] Give 1 tablet by mouth one time a day for UTI [urinary tract infection] prophylactic. Review on 12/01/23 of Resident #16's care plan meeting nursing notes dated 11/7/23 revealed that Resident #16's activated DPOA-H questioned if Resident #16 was still taking HIPREX [Methenamine Hippurate]. Staff B (Unit Manager) replied that Resident #16 had not been taking HIPREX since 6/23/23. Resident #16's activated DPOA-H wanted to know why the medication was stopped and they were not informed. Interview on 12/01/23 at approximately 1:34 p.m. with Staff N (Licensed Practical Nurse) confirmed that there was a physician's order dated 6/9/23 to discontinue Resident #16's HIPREX and the activated DPOA-H was not informed.

Based on interview, observation, and record review it was determined that the facility failed to follow physician's orders for 2 residents in a final sample of 25 residents (Resident Identifiers are #71 and #91). Finds include: Professional reference: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009. Chapter 23 Legal Implications Page 336-Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Chapter 35 Medication Administration Page 699-Prescriber's Role Prescriber must document the diagnosis, condition, or need for use for each medication ordered Page 706-709-Standards The prescriber often gives specific instructions about when to administer a medication Resident #91 Review on 12/01/23 of Resident #91's November 2023 Medication Administration Record (MAR) revealed the following: Acetaminophen oral Tablet 325 mg [milligram] 2 tablets by mouth every 4 hours as ordered for pain 1-5/10 NTE [not to exceed] 3 g [grams] APAP [Acetaminophen] in [a] 24 [hour] period, with an order date of 11/12/2023. This was administered on the following dates: 11/18/23, for a pain level of 8, effective; 11/19/23, for a pain level of 8, effective; 11/25/23 for a pain level of 7, effective; 11/27/23, for a pain level of 9, effective. Further review of Resident #91's November MAR revealed an order for oxycodone HCL [Hydrochloride] 5 mg 1 tablet by mouth every 6 hours as needed for severe pain 8-10, with an order date of 11/12/23. This was administered on 11/26/23 for a pain level of 5, effective, 11/28/23, twice, no assessment of pain was noted or NA [not assessed]. Interview on 11/29/23 at 10:00 a.m. with Staff P (Registered Nurse) confirmed the above findings. 43002 Resident #71 Observation on 11/29/23 at 7:10 a.m. of Resident #71's Gastrostomy-tube (G-Tube) medication administration with Staff E (Licensed Practical Nurse) revealed that Staff E did not flush the G-tube prior to administering the first medication and did not flush between the following medications; Levetracintin 15 milliliters (mL); Amantadine 5 mL; Docosate 10 mL; Valproic acid 20 mL. Interview on 11/29/23 at 10:00 a.m. with Staff E confirmed the above. Review on 11/29/23 of Resident #71's active physician's order list revealed an order dated 7/21/23 to flush with 5 to 10 mL of water between each medication. Review on 11/29/23 of Resident #71's November 2023 Enteral Orders MAR revealed the above physician's order was noted for 7:00 a.m., 3:00 p.m., and 11:00 p.m., but had not been signed as completed for the month (28 days). Interview on 11/29/23 at 10:30 a.m. with Staff B (Unit Manager) confirmed that a G-tube should be flushed with water prior to administering medications and between each medication. Staff B confirmed that Resident #71's November 2023 MAR for the above flushes were not documented as being completed. Review on 11/29/23 of the facilities policy revised November 2018, titled Administering Medications through an Enternal Tube, revealed, .The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . General Guidelines . 3. Administer each medication separately and flush between medications . Steps in the Procedure . 7. Stop feeding and flush tubing with at least 15 mL warm purified water (or prescribed amount) . 13. If administering more than one medication, flush with 15 mL warm purified water (or prescribed amount) between medications .

Based on observations, interviews, and record review, it failed to establish policies for Oxygen (O2) services to include cleaning of O2 equipment for 2 of 2 residents reviewed for respiratory care in a final survey sample of 25 residents (Resident Identifiers are # 41 and #87). Finds include: Resident #41 Observation on 11/28/23 at 9:30 a.m. revealed that there was an O2 concentrator next to Resident #41's bed with a nasal cannula attached to it. The O2 tubing had no marking indicating the date the tubing was put into use. O2 was in use at this time by Resident #41 and the tubing was clear and appeared clean and not soiled. Observation on 11/29/23 at 12:16 p.m. revealed Resident #41's O2 tubing with no date for initiation of tubing. O2 was in use at this time by Resident #41. Review on 11/29/23 at approximately 12:45 p.m. of Resident #41's current Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no orders for O2 tubing changes. Interview on 11/29/23 with Resident #41 at approximately 10:30 a.m. revealed that he/she does not remember when the O2 tubing was changed. Review on 11/30/23 of Resident 41's current care plan reveled that there were no interventions for Resident #41's use of O2. Interview on 11/30/23 at approximately 1:00 p.m. with Staff P (Registered Nurse) confirmed there was no date on Resident #41's O2 tubing and that there were no current orders for Resident #41's O2 tubing to be changed. Interview on 11/30/23 at approximately 1:10 p.m. with Staff P confirmed that the facility's policy Oxygen Administration with a revised date of October 2010 did not have any policies or procedures for when or how often to change the O2 tubing. Resident #87 Observation on 11/28/23 at 10:30 a.m. revealed that there was an O2 concentrator next to Resident #87's bed with a nasal cannula attached to it. The O2 tubing had no marking indicating the date the tubing was put into use. O2 was in use at this time by Resident #87. The O2 tubing appeared clear and not soiled. Interview on 11/29/23 with Resident #41 at approximately 10:45 a.m. revealed that he/she does not remember when the O2 tubing was changed. Observation on 11/29/23 at 12:16 p.m. revealed Resident #87's O2 tubing with no date for initiation of tubing. O2 was in use at this time by Resident #87. Review on 11/30/23 of Resident # 87's current care plan revealed that there were no interventions for Resident #87 use of O2. Review on 11/30/20 at approximately 12:45 p.m. of Resident #87's current MAR and TAR revealed no orders for O2 tubing changes. Interview on 11/30/23 at approximately 1:00 p.m. with Staff P confirmed there was no date on Resident #87's O2 tubing. Interview on 11/30/23 at approximately 1:10 p.m. with Staff P confirmed that the facility's policy Oxygen Administration with a revised date of October 2010 did not have any policies or procedures for when or how often to change the O2 tubing.

Based on record review, interview, and observation, it was determined that the facility failed to limit psychotropic medication to 14 days for 1 of 5 residents reviewed for unnecessary medications in a final sample of 25 residents (Resident Identifier is #77). Findings include: Resident #77 Review on 11/30/23 at approximately 10:36 a.m. of Resident #77's pharmacy recommendations revealed a recommendation on 8/28/23 to consider discontinuing Resident #77's active order for Haloperidol PRN [as needed] without a specified stop date. Review on 11/30/23 of Resident #77's physician's orders revealed the following: Haloperidol Lactate Oral Concentrate dated 8/7/23 Give 0.25 ml [milliliter] by mouth every 12 hours as needed for agitation and increased behaviors with a discontinue date of 9/6/23. Resident #77 received this medication on 8/9, 8/14, 8/16, 8/17, 8/21, 8/22, 8/25, 8/26, 8/29, 9/1, 9/2, 9/3, and 9/4, Interview on 12/1/23 at approximately 2:28 p.m. with Staff B (Unit Manager) confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to label medication with open expiration dates when applicable in 1 of 3 medication carts reviewed (Resident Identifiers are #20 and #56). Findings include: Observation on 11/28/23 at approximately 11:00 a.m. of the South Side Medication Cart revealed the following: One Humalog Lispro Insulin vial for Resident #20 with no open or open expiration date; One Levemir Flex Pen for Resident #56 with no open or open expiration date; and One Lantus Solostar Insulin Pen for Resident #56 with no open or open expiration date. Interview on 11/28/23 at 11:03 a.m. with Staff D (Licensed Practical Nurse) confirmed the above findings. Review on 11/28/23 of facility policy titled Vials and Ampules of Injectable Medications, dated 08-2020, revealed. the following: 2. The date opened and this triggered expiration date are both important to record on multi-dose vials. At a minimum, the date opened must be recorded .Triggered expiration dates may be found in the manufacturer's package insert, or on the package provided, or on a referenced chart by the pharmacy, or by contacting the pharmacist. Review on 11/28/2023 of manufacturer's instructions for Humalog Lispro Insulin, dated 11/2019, revealed the following: 16.2 Storage and Handling .In-use Insulin Lispro Injection vials . must be used within 28 days or be discarded, even if they still contain Insulin Lispro Injection . Review on 11/28/2023 of manufacturer's instructions for Levemir solution for subcutaneous injection dated 3/2012 revealed the following: Unrefrigerated Levemir should be discarded 42 days after it is first kept out of the refrigerator. LevemirFlex Pen: .Unrefrigerated Levemir FlexPens should be discarded 42 days after they are kept out of the refrigerator . Review on 11/28/2023 of manufacturer's instructions for Lantus dated 7/2021 revealed the following: Once you take your Lantus out of cool storage, for use or as a spare, you can use it for up to 28 days . Do not use it after this time . 43002

Based on observation and interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety in 1 of 3 kitchenettes reviewed. Findings include: Observation on 11/28/23 at 9:30 a.m. with Staff G (Food Service Manager) of the [NAME] Kitchenette refrigerator revealed a refrigerator temperature of 50 degrees ( ) Fahrenheit (F). Interview on 11/28/23 at 9:30 a.m. with Staff G confirmed the above and revealed that the refrigerator should be below 45 F. Observation on 11/28/23 at 12:45 p.m. of the [NAME] Kitchenette refrigerator revealed a temperature of 46 F. Interview on 11/28/23 at 12:46 p.m. with Staff G confirmed the above. Observation on 11/28/23 at approximately 2:26 p.m. of the [NAME] Kitchenette refrigerator revealed a temperature of 50 F. Review on 11/28/23 of [NAME] Kitchenette's October 2023 Refrigerator logs revealed the following: -October 7, 2023 temperature was 42 F (note stating uncommon will watch) -October 15, 2023 temperature was 42 F (note stating alerted maintenance temp is fluctuating) -October 20, 2023 temperature was 43 F -October 21, 2023 temperature was 42 F -October 22, 2023 temperature was 46 F -October 28, 2023 temperature was 43 F The top of the form read Thermometer must read 41 F or below and Corrective Action: Immediately notify dietary manager if refrigerator or food temperature above 40 F for fridge. Review on 11/28/23 of November 2023 [NAME] Kitchenette Refrigerator logs revealed the following: -November 4, 2023 temperature was 43 F -November 20, 2023 temperature was 42 F -November 23, 2023 temperature was 44 F -November 24, 2023 temperature was 42 F -November 25, 2023 temperature was 43 F -November 26, 2023 temperature was 42 F -November 28, 2023 temperature was 42 F The top of the form read Thermometer must read 41 F or below and Corrective Action: Immediately notify dietary manager if refrigerator or food temperature above 40 F for fridge. Interview on 11/28/23 at 1:00 p.m. with Staff L (Director of Maintenance) revealed that he/she was not notified of temperatures being out of range since 10/7/2023. Interview on 11/28/23 at 1:28 p.m. with Staff M (Maintenance Assistant) revealed that on 11/18/2023 he/she received a text message at 6:10 p.m. that the [NAME] Wing refrigerator was up to 50 F. Staff M was not aware of any other temperatures being out of range. Staff M also stated this was the only issue he/she was aware of regarding the [NAME] Kitchenette refrigerator. Staff M reviewed refrigerator temperature logs for October 2023 and November 2023 and confirmed that the temperatures were inconsistent. Review on 11/28/23 of facility policy titled Food Storage: Cold Foods dated 9/2017 revealed . 2. All perishable foods will be maintained at a temperature of 41 degrees F or below, except during necessary periods of preparation and service . Review on 11/28/23 of facility policy titled Refrigerators and Freezers dated 11/2022 revealed . 1. Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41 degrees F . Review on 12/04/2023 of FDA Are You Storing Food Safely? Current as of 1/18/2023 revealed . -Keep your appliances at the proper temperatures. Keep the refrigerator temperature at or below 40 degrees F . 43002

Based on record review and interview, it was determined the facility failed to develop a comprehensive care plan which included a resident's need for Oxygen (O2) for 2 of 2 residents reviewed for O2 use in a final sample of 25 residents (Residents Identifiers are #41 and #87). Findings include: Resident #41 Observation on 11/28/23 at approximately 9:30 a.m. of Resident #41 revealed that Resident #41 was receiving oxygen through a nasal cannula (NC). Review of 11/28/23 of Resident 41's current physician orders revealed an order for Oxygen at 0-4 L /min [Liters/per minute] O2 via NC to maintain O2 saturation of 91% [percent] and greater with O2 concentrator while in room and portable O2 tank while out of the room. Review on 11/30/23 of Resident 41's current care plan revealed that there were no interventions for Resident #41's use of O2. Interview on 11/30/23 at approximately 10:00 a.m. with Staff P (Registered Nurse) confirmed that there were no interventions for Resident #41's O2 use in their current care plan. Resident #87 Observation on 11/28/23 at approximately 10:30 a.m. of Resident #87 revealed that Resident #87 was receiving O2 through a nasal cannula. Review of 11/28/23 of Resident 87's current physician orders revealed an order for O2 at 0-4 L /min via O2 concentrator while in room and O2 when out of the room. Review on 11/30/23 of Resident # 87's current care plan revealed that there were no interventions for Resident #87 use of O2. Interview on 11/30/23 at approximately 10:00 a.m. with Staff P confirmed that there were no interventions for O2 use on Resident #87's current care plan. Review on 12/1/23 of the facility's policy titled Oxygen Administration policy, revisioned October 2010, revealed the following: Preparation .2. Review the resident's care plan to assess for any special needs of the resident.

Based on record review and interview, it was determined that the facility failed to ensure that the resident or resident's Durable Power of Attorney (DPOA) was fully informed of the risk of treatment from antipsychotic medications for 4 of 5 residents reviewed for antipsychotic use (Resident identifiers are #29, #55, #67 and #72). Findings include: Resident #55 Review on 12/2/22 of Resident #55's physician's orders revealed an order for Seroquel (an antipsychotic medication) tablet 25 milligrams (mg) to be given 1 tablet by mouth two times a day for agitation/behavioral outbursts with a start date of 10/6/22. Resident #55 was initially admitted to the facility 2/11/20. Review on 12/2/22 of Resident #55's paper and electronic medical record revealed no documentation that the facility informed Resident #55 or Resident #55's representative of Seroquel's use and side effects. Resident #67 Review on 12/2/22 of Resident #67's physician's orders revealed an order for Risperdal tablet 1 mg give 2 mg by mouth two times a day for agitation, which the Resident was admitted on , with a start date of 11/1/22. Review on 12/2/22 of Resident #67's paper and electronic medical record revealed no documentation that the facility informed Resident #67 or Resident #67's representative of Risperdal's use and side effects. Interview on 12/2/22 at 1:30 p.m. with Staff B (Director of Nursing) and Staff C (Interim Director of Nursing) confirmed that residents #55 and #67 were on antipsychotic medication and did not have signed or verbal consents. 43002 Resident #72 Review on 12/2/22 of Resident #72's physician's orders revealed on 9/11/22 a new order for Seroquel 12.5 mg twice daily. Further review revealed on 9/28/22 a new order to change the Seroquel to 12.5 mg in the morning and 25 mg at bedtime. Review on 12/2/22 of Resident #72's Medication Administration Record for September, October, November, and through December 2, 2022 revealed that Resident #72 had received Seroquel as per the physician's orders. Review on 12/2/22 of Resident #72's medical record (both paper and electronic) revealed no documentation that Resident #72 or his/her representative consented the use of this medication and potential side effects. Interview on 12/2/22 at 12:38 p.m. with Staff C confirmed that there was no verbal or signed consent for Resident #72's Seroquel. 46510 Resident #29 Review on 12/1/22 of Resident #29's active physician's orders revealed an order for Haloperidol lactate concentrate 2 milligrams (mg) / millilitres (ml) give 0.5ml by mouth at bedtime related to Schizoaffective Disorder with an order date of 10/20/22. Review on 12/2/22 of Resident #29's paper and electronic medical records including scanned documents revealed no documentation that the facility informed Resident #29 or Resident #29's representative of Haloperidol's uses and side effects. Interview on 12/2/22 at approximately 12:48 p.m. with Staff B confirmed that Resident #29 was on Haloperidol and did not have a verbal or signed antipsychotic consent. Review on 12/5/22 of the facility's policy titled Psychotropic Management, revised January 2022, revealed, .1. Upon receipt of new orders for psychotropic medication, the licensed nurse will implement the following . b. Complete the appropriate psychotropic medication consent form; c. Education of the resident and/or the resident representative is conducted to communicate the risk and benefits of the medication . 5. The licensed nurse will complete the Abnormal Involuntary Movement Scale (AIMS) . upon initiation and/or change of medication and every six (6) months thereafter for residents receiving antipsychotic medications .

Based on interview and record review, it was determined that the facility failed to ensure that a resident with a mental disorder received a PASRR (Pre Admission Screening and Resident Review) for 2 of 4 residents reviewed for PASRR in a final survey sample of 25 residents (Resident identifiers are #25 and #66). Findings include: Resident #25 Review on 11/30/22 of Resident #25's medical record revealed that Resident #25 was admitted to the facility on [DATE]. Review on 11/30/22 of Resident #25's diagnosis list in the electronic medical record revealed that Resident #25 had a diagnosis of Schizophrenia. Review on 12/2/22 of Resident #25's PASRR dated 11/8/18 revealed . The PASRR [sic] (Pre-Admission Screening and Resident Review) office for New Hampshire has completed a review of need for services and agrees that has a need for short-term nursing facility services. Therefore we find that a 180 day stay from 11/5/2018 through 5/3/2019 is appropriate pursuant to He-M 1302. A month or so before the end of 's[sic] stay at the nursing facility, if continues to need nursing facility services, please have the nursing facility contact the PASRR [sic] Office . Interview on 12/2/22 at 9:11 a.m. with Staff A (Social Worker) confirmed that Resident #25's PASRR was only good for a 180 day stay and should have been re-done. 38218 Resident #66 Review on 12/1/22 of Resident #66's PASRR (Pre Admission Screening and Resident Review) dated, 4/13/21 revealed: . 2. A. Suspected Diagnosis: Has the individual been diagnosed with or is suspected of having MI (Mental Illness), (box checked for yes) Please check all that apply: Major depression, Anxiety (box checked) . Section 7. Categorical Determinations Hospital Discharge Exemption Convalescent stay (box checked) Direct admit from hospital for same acute condition treated for at hospital based on physician's order, the maximum length of stay is 90 days. Interview on 12/2/22 at approximately 9:15 a.m. with Staff A revealed I don't know why that would have been checked for a 90 day stay. Further interview revealed that Staff A didn't request another PASSR be completed. Review on 12/5/22 of the facility's policy titled Pre-admission Screening and Resident Review (PASRR) dated November 2017, revealed, .Pre-admission screening is coordinated for residents identified to have a mental disorder and/or an intellectual disability in accordance with Federal and State law. Recommendations from the PASRR level II determination and the PASRR evaluation report are incorporated in the resident's assessment, care planning and transitions of care. Residents currently diagnosed or with newly evident or possible mental disorders, intellectual disability, or a related condition are referred for level II PASRR review upon significant change in status assessment . 7. Upon a significant change in status assessment, Nursing will refer residents currently diagnosed with or residents with newly evident or possible mental disorder, intellectual disability, or a related condition for a PASRR level II review .

Based on interview, record review, facility assessment, and policy review, it was determined that the facility failed to provide behavioral health/psychiatry consults for 1 of 5 residents reviewed for unnecessary medications in a final survey sample of 25 residents (Resident identifier is #29). Findings include: Resident #29 Review on 12/2/22 of Resident #29's active diagnosis revealed the following diagnoses: 1. Schizoaffective Disorder, Unspecified, Date 6/27/22 2. Major Depressive Disorder, Recurrent Unspecified, Date 10/6/20 3. Anxiety Disorder, Unspecified, Date 10/6/20 4. Cognitive Communication Deficit, Date 10/8/21 5. Expressive Language Disorder, Date 7/14/21 Review on 12/2/22 of Resident #29's current orders revealed the following orders: 1. Haloperidol Lactate Concentrate 2 mg (milligrams)/ml (milliliters), Give 0.5 ml by mouth at bedtime related to Schizoaffective Disorder, Unspecified, Start Date 10/21/22. 2. Consult: may be seen and treated by a Mental Health Worker, Order Status: Active, Order Date 10/28/21. Interview on 12/5/22 at approximately 11:19 a.m. with Staff C (Interim Director of Nurses) confirmed that there was an active order for a psychiatric referral. Further interview revealed that there was no documented evidence of Resident #29 being offered treatment by a Mental Health Worker. Review on 12/5/22 of the facility policy titled, Behavioral Health Management, Revision Date January 2022 revealed: Policy Residents receive behavioral health care and services, including those residents diagnosed with mental disorder or psychosocial adjustment difficulty, to attain or maintain their highest practicable physical, mental, and psychosocial well-being in accordance with the resident's comprehensive assessment and care plan. Review on 12/5/22 of the facility assessment dated , 2021-2022 revealed: .3.B. Staffing Plan . [pronoun omitted] has behavioral health practitioner that have competencies and skill sets to care for many behavioral diagnoses. These clinicians have appropriate training and supervision in caring for residents with mental and psychosocial disorders

Based on observation, interview, and policy review it was determined that the facility failed to ensure a medication cart was locked and failed to store medication in its original container on 1 of 5 medication carts (West Unit Low Medication Cart). Findings include: 38218 West Unit Low Medication Cart Observation on 11/30/22 at approximately 11:40 a.m. revealed that the medication cart was unlocked. The nurse was not near the medication cart. Further observation inside the medication cart revealed the following: 1 white pill in a medication cup in the top drawer with no identifying markings. 2 pills in a medication cup in the top drawer with no identifying markings. Interview on 11/30/22 at approximately 11:45 a.m. with Staff E (Licensed Practical Nurse) revealed that the medications that were in the 2 medication cups in the top drawer were poured for 2 different residents to be given prior to lunch. Staff E confirmed that he/she left the medication cart unlocked and unattended. Review on 11/30/22 of the facility policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, Revision Date 10/28/19 revealed: Procedure . Policy Title: 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles .4. Facility should ensure that medications and biologicals that: (1) have an expiration date on the label; (2) have been retained longer than recommended by the manufacturer or supplier guidelines; (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely locked in a locked cabinet/cart or locked in the medication room that is inaccessible by residents and visitors 10. Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received.