Every finding on record at Retreat at Wellmore of Lexington

Based on review of facility policy, record review, and interview, the facility failed to initiate cardiopulmonary resuscitation (CPR) and/or life saving measures for Resident (R)47, for 1 of 1 resident reviewed for a closed record review for death. Specifically, on [DATE] at approximately 5:50 AM, R47 was found to be unresponsive with shallow breathing. Despite R47's full code status, CPR was not initiated and upon EMS arrival R47 was pronounced deceased at approximately 6:05 AM. On [DATE] at 12:10 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.24 - Quality of Life. On [DATE] at 5:55 PM, the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team validated the facility's corrective actions and removed the IJ. The facility remained out of compliance at F678 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F678, constituting substandard quality of care.Findings Include: Review of the facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation last revised February 2018, revealed, Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. General Guidelines . 3. Victims of cardiac arrest may initially have gasping respirations or may appear to be having a seizure. Training in BLS includes recognizing presentations of SCA. 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse . 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) . If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events.Review of the facility policy titled Emergency Management Codes and Procedures last revised [DATE] revealed, Emergency management codes are used to notify employees of a crisis or disaster that may impact the facility. Codes are used to inform employees and begin mobilization of resources. The following code are utilized to notify the employees of the various crises. i. Medical Emergency (Code Blue), 2. All employees are trained to respond to emergency situations that may impact the facility.Review of R47's Face Sheet indicated the facility admitted R47 on [DATE], with diagnoses including but not limited to, Essential (Primary) hypertension (HTN), atherosclerotic heart disease of native coronary artery (CAD), chronic kidney disease, hyperlipidemia (HLD) and cognitive communication deficit.Review of R47's physician orders revealed, [DATE] Order summary: Full Code. Review of R47's Care Plan with an initiation date of [DATE] revealed the following:Code Status - Resident has voiced desire for a Full Code status with an intervention noted as; Code status will be respected through the next review.Cardiac: [R47] is at risk for alteration in cardiac activity [related to] r/t HTN, CAD, HLD with interventions that included but were not limited to, monitor for chest pain; s/s of heart attack and CVA and notify MD as needed and to Observe for physical signs of distress/fatigue (shortness of breath, pain, dizziness).Review of R47's Progress Note titled admission summary dated [DATE] at 3:51 PM, revealed, Reviewed code status with patient upon arrival. Patient voiced desire for a full code status. Chart updated accordingly.Review of R47's Health Status Progress Notes revealed the following:[DATE] 7:43 AM, Started rounds at 5:30am, resident pressed call out at 5:50am, CNA notified me that resident was breathing shallow with eyes open but not responding verbally when obtaining vital signs. I checked pulse and it was present. witnessed resident breathing shallow, called 911 at 5:53am. CNA changed resident because he had a bowel movement. Notified DON at 5:55am. CNA consistently checked on resident until and when EMS arrived. EMS arrived at 6:05am. They checked the resident and hooked him up to cardiac machine and it was flat lined. Called daughter at 6:00am and didn't receive a response. Daughter called back 645a.m and made aware of the death noticeXXX[DATE] 10:58 AM, Funeral home here now. Foley cath removed by DON and pt left floor at 10:35am.Review of R47's Vital Sign documentation revealed, [DATE] 3:22 AM, Blood Pressure 120/80mmHg, Temperature 98.7 F, Pulse 70, Respirations 18 Breaths/min. Further review of R47's vitals revealed there was no documented vital signs related to R47's medical emergency on [DATE].Review of a witness statement dated [DATE] signed by the Director of Nursing (DON) documented, Received a call at 6:07 am from the nurse that the resident [R47] in 4217 had passed away. At the time EMS was at bedside. Upon arrival at 6:30 resident was in the room. Resident did not have a pulse and was not breathing. The EMS company was there, a company called MED Trust. They reported that the patient had expired and that they had run out of EKG paper and could not print out a strip. I then called Lexington County Corner. Lexington County EMS showed up within 10 mins of me calling the corner office. They checked the resident also and determined that he had expired. Lexington county law enforcement arrived on the scene and also dispatched a call to the Lexington County corner office.During an interview on [DATE] at 9:50 AM, the DON reported that she received a call from Licensed Practical Nurse (LPN)4 notifying her of R47's situation. The DON stated she was on the phone with LPN4 when EMS was at the bedside. The DON reported that R47 had been deceased for a while prior to Lexington County EMS arriving.During an interview on [DATE] at 9:56 AM, LPN4 stated Certified Nursing Assistant (CNA)8 notified her that R47 was breathing shallowly and was not responding. LPN4 stated CNA8 was unable to obtain his vital signs. LPN4 stated she checked R47 for a pulse and felt a pulse that she described as thready. LPN4 stated she was aware R47 was a Full Code; however, she did not initiate CPR because R47 had a pulse. LPN4 stated that her most recent CPR certification was in February 2026. LPN4 stated she called Emergency Medical Services (EMS). LPN4 stated MedTrust initially responded to the facility, she noted they placed R47 on the monitor he was flat lined, however, they were not the critical care ambulance, and another ambulance was called to respond. When asked if an automated external defibrillator (AED) was available in the facility, LPN4 stated it was available; however, it was not used. When asked if she considered initiating CPR at any point, LPN4 paused and stated, uh no. LPN4 further stated R47's provider was not notified at the time, and she was aware of his full code status.During a follow-up interview on [DATE] at 11:12 AM, when asked if she had concerns about R47 not receiving CPR, the DON responded, yes. The DON stated that the day prior to the incident there had been discussion regarding R47 going on hospice; however, that had not yet occurred and R47 remained a Full Code. The DON stated she had concerns regarding R47 not receiving CPR and reported that education was subsequently provided to the staff who were working on the day of the incident.Attempted interview with CNA8 was unsuccessful as she is no longer employed by the facility. On [DATE] at 5:55 PM, the facility provided an acceptable IJ Removal Plan, which included the following: DISCLAIMER AND COMMITMENT TO RESIDENT SAFETY Wellmore of Lexington Skilled Nursing Facility takes resident safety, dignity, rights, and quality of care seriously. The facility is committed to responding promptly and thoroughly to all survey concerns and to protecting residents from the risk of serious injury, serious harm, impairment, or death. The facility respectfully submits this Immediate Jeopardy Removal Plan while acknowledging that the Immediate Jeopardy Template contains preliminary information and that Form CMS-2567 is the official document for survey findings. This Immediate Jeopardy Removal Plan is submitted solely in response to the alleged deficient practice identified by the survey agency and is intended to demonstrate the immediate actions taken by Wellmore of Lexington Skilled Nursing Facility to protect residents, address the concerns identified by surveyors, ensure ongoing resident safety, and remove any potential risk of serious injury, serious harm, impairment, or death. Submission of this removal plan should not be interpreted as an admission of noncompliance, wrongdoing, or agreement with the survey agency's allegations. Rather, the facility has proactively implemented the actions outlined below in the interest of resident safety and to demonstrate substantial compliance with federal requirements, CMS guidance, and applicable South Carolina nursing home regulations. This removal plan is submitted to demonstrate immediate resident protection, correction of the alleged deficient practice, systemic corrective actions, staff education, leadership oversight, monitoring, and QAPI follow-up. The facility alleges that Immediate Jeopardy has been removed upon implementation of the immediate corrective actions described below.REGULATORY BASIS CMS F678, Cardiopulmonary Resuscitation: faciity personnel must provide basic life support, including CPR, to a resident requiring emergency care prior to arrival of emergency medical personnel, subject to physician orders and the resident's advance directives. CMS State Operations Manual, Appendix Q: Immediate Jeopardy removal requires immediate action to address noncompliance that has caused or is likely to cause serious injury, serious harm, impairment, or death. South Carolina Standards for licensing Nursing Homes: the facility will maintain written policies and procedures, staff training, resident records, emergency procedures, and quality improvement processes consistent with applicable state nursing home requirements.BASIS FOR IMMEDIATE JEOPARDY The survey Immediate Jeopardy Template identified F678 - Cardiopulmonary Resuscitation. The preliminary fact analysis alleged that the facility failed to initiate CPR and/or life-saving measures for a resident with Full Code status who was found unresponsive with shallow breathing. The template further stated that immediate action was necessary because failure to initiate CPR and/or life-saving measures for Full Code residents places residents at risk for serious harm, injury, or death. FACILITY ALLEGATION OF IMMEDIATE JEOPARDY REMOVAL Wellmore of Lexington Skilled Nursing Facility alleges Immediate Jeopardy removal effective [DATE], following completion and implementation of immediate resident protection measures, facility-wide code status verification, emergency equipment checks, staff education, policy/procedure review, leadership oversight, and monitoring activities. The facility alleges that residents are no longer at risk for serious injury, serious harm, impairment, or death related to failure to initiate CPR or life-saving measures for residents identified as Full Code. I. IMMEDIATE ACTIONS TO PROTECT ALL RESIDENTS[DATE]-The Administrator, Director of Nursing, Medical Director, Regional Clinical Leadership, and Executive Leadership were notified of the Immediate Jeopardy concernXXX[DATE]-The Director of Nursing or designee initiated an immediate review with all nurses, certified nursing assistants, and agency personnel of the emergency response processes for Cardiopulmonary Resuscitation in the Skilled Nursing FacilityXXX[DATE]-A 100% audit of current resident code status documentation was completed, including physician orders, advance directives, CPR status, and electronic medical record documentationXXX[DATE]-Nursing leadership completed rounds and staff interviews to verify staff understanding of resident code status, Full Code response expectations, and emergency activation proceduresXXX[DATE]- Medical Director was notified[DATE]- The Director of Nursing or designee completed an additional audit of current resident code status documentation, including physician orders, full code response expectations, and emergency activation proceduresXXX[DATE]-The Director of Nursing or designee provided reeducation with all nurses, certified nursing assistants, and agency personnel of the emergency response processes for Cardiopulmonary Resuscitation in the Skilled Nursing FacilityXXX[DATE]-Emergency response equipment was checked for accessibility and readiness, including crash cart/emergency cart, oxygen supplies, suction equipment, ambu bag, and emergency calf procedures.Any discrepancy identified during the code status audit was immediately escalated to the Director of Nursing and corrected prior to continued reliance on the affected documentation.II. CORRECTIVE ACTION FOR THE ALLEGED DEFICIENT PRACTICE [DATE]-The facility completed an immediate clinical review of the alleged event and the related emergency response process. [DATE]-The Director of Nursing reviewed the facility policy and procedure for CPR, emergency response, code status verification, and resident change-in-condition response. [DATE]-The facility clarified that CPR and basic life support must be initiated immediately for residents identified as Full Code who require emergency [NAME]-saving measures. [DATE]-The facility reinforced that staff must activate EMS immediately and continue CPR/basic [NAME] support until relieved by EMS or other qualified responders, consistent with resident code status and accepted clinical standards.Ill. STAFF EDUCATION VALIDATIONBefore working independently with residents following the Immediate Jeopardy notification, nursing and direct care staff received immediate education. Education was provided by the Director of Nursing or qualified designee.Staff included will be educated on or before their next shift: Licensed nurses, Certified Nursing Assistants Agency Personnel, Nursing leadership and supervisory staffEducation topics included:CMS F678 CPR requirements and resident right to care consistent with physician orders and advance directives. Recognition of cardiac arrest, respiratory arrest, and unresponsive resident emergencies. Immediate verification of code status and initiation of CPR for Full Code residents. Immediate activation of EMS and internal emergency response/chain of command. Use and location of emergency response equipment. Documentation requirements following emergency events. Reporting requirements to nursing leadership and the physician/provider.IV. SYSTEMIC CHANGES IMPLEMENTEDA. Emergency Response Protocol1. Immediately assess the resident for responsiveness, breathing, and pulse as appropriate to staff role and training.2. Immediately activate EMS and the facility emergency response process.3. Immediately verify code status using the designated code status source and communication tool.4. Immediately initiate CPR/basic life support for Full Code residents requiring emergency life-saving measures.5. Continue CPR/basic life support until relieved by EMS or qualified responders, or until directed by an authorized provider consistent with applicable orders and law.6. Notify the Director of Nursing, Administrator, physician/provider, and resident representative consistent with facility policy.B. Code Status Verification Process Code status will be verified at admission, readmission, significant change, and upon any code status update. Code status will be reviewed during shift-to-shift report and communicated to appropriate direct care staff. The Director of Nursing or designee will audit code status documentation for current residents and new admissions. Any inconsistency between physician orders, advance directives, EMR documentation, care plan/service plan, will be corrected immediately.C. Mock Code and Emergency Readiness Program Monthly mock code drills will be completed on varied shifts for the first three months. Quarterly mock code drills will continue thereafter or more frequently if audit results indicate need. New hire orientation will include CPR/emergency response expectations and location/use of emergency equipment. Annual CPR/emergency response validation will be completed for applicable staff for active BLS Certification Card.D. Leadership Review The Director of Nursing or designee will review all code events, EMS activations, unresponsive resident events, and resident deaths within 24 hours. The Administrator and Medical Director will be notified of findings requiring additional review or corrective action. Findings will be trended through QAPI to determine whether additional system revisions, education, or monitoring are needed.V. IDENTIFICATION OF OTHER RESIDENTS WITH POTENTIAL TO BE AFFECTEDBecause the alleged deficient practice had the potential to affect any resident requiring emergency life-saving measures, the facility reviewed all current residents for code status accuracy and emergency response readiness.The facility also reviewed recent emergency events, EMS transfers, code events, and resident deaths to determine whether any additional concerns existed related to failure to initiate CPR for a resident identified as Full Code. No additional failures to initiate CPR for a resident identified as Full Code were identified during the facility review. If any additional concern is identified through ongoing review, the Director of Nursing and Administrator will implement immediate corrective action and report through QAPI.VI. MONITORING AND SUSTAINABILITY PLANTimeframe/ Monitorning Activity: Week 1-4 , Week 1--week of 8/12 , Week 2- week of8/19 , Week 3- week of 8/26 , Week 4- week of 9/4: Emergency response readiness audits weekly; 10 code status documentation audits weekly; mock code observation weekly on varied shifts. Completed by the Director of Nursing or Designee. Administrator to review weekly and a Monthly QAPI summary report. Months 2-3, Month 2- 10/4 , Month 3-11/4 , Months 4-6: Weekly emergency response documentation audits; weekl code status verification audits; monthly CPR/mock code. Completed by the Director of Nursing or Designee. and will be reported to QAPI Committee. Month 4- 12/4 , Month 5-[DATE] , Month 6- [DATE]: Monthly emergency response audits; monthly code status audits: review of all code events, EMS activations, unresponsive resident events, and deaths. Completed by the Director of Nursing or Designee. and will be reported to QAPI Committee and Medical Director as indicated. Ongoing: Immediate leadership review of any adverse findings, trends, or emergency response concerns with additional education/corrective action as needed. Completed by admin/DON. reporting to QAPI and governing body as applicable. VII. QAPI OVERSIGHTAudit findings, mock code results, code status audit results, and emergency event reviews will be reported to the Quality Assurance and Performance Improvement Committee. The QAPI Committee will review trends, determine whether corrective actions are sustained, and direct additional interventions when audit results identify opportunities for improvement. The Medical Director, Administrator, Director of Nursing, and applicable interdisciplinary leaders will participate in review of clinical trends and corrective action effectiveness. Monitoring will continue until sustained compliance is demonstrated and the QAPI Committee determines that the corrective actions are effective. VIII. DOCUMENTS AVAILABLE FOR SURVEYOR REVIEW Resident code status audit tool and completed audit results. Emergency equipment audit/checklist and completed verification. Staff education sign-in sheets. Updated CPR/emergency response policy and procedure review documentation. Mock code drill forms and results. Leadership review forms for EMS activations, code events, unresponsive resident events, and deaths. QAPI meeting documentation and action tracking. X. FINAL FACILITY STATEMENTWellmore of Lexington Skilled Nursing Facility respectfully alleges that Immediate Jeopardy related to F678 Cardiopulmonary Resuscitation has been removed. The facility has implemented immediate resident protection, corrected the alleged deficient practice, educated and validated staff, strengthened emergency response and code status verification systems, and established ongoing monitoring through leadership and QAPI oversight. The facility remains committed to resident safety, regulatory compliance, and sustained quality improvement. All immediate and corrective actions related to this alleged violation were corrected evident of full compliance on [DATE].

Based on review of facility policy, record review, and interview, the facility failed to appropriately document Resident (R)5's provided one on one's to include resident centered activities. Findings include: Review of the facility policy titled, Activity Programs, with revision date of June 2018, revealed, Policy Statement: Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation: I. The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. 2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 3. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. 4. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. 5. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. 7. Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident. Activity programs include activities that promote: a. self-esteem; b. comfort; c. pleasure; d. education; e. creativity; f. success; and g. independence . 9. All activities are documented in the resident's medical record. 10. Activities participation for each resident is approved by the attending physician based on information in the resident's comprehensive assessment. 11. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g., bed bound or visually impaired residents). 12. Individualized and group activities are provided that: reflect the schedules, choices and rights of the residents; are offered at hours convenient to the residents, including evenings, holidays and weekends; reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents; appeal to men and women, as well as those of various age groups residing in the facility; and incorporate family, visitor and resident ideas of desired appropriate activities. Review of R5's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses including, but not limited to, Acute Osteomyelitis, right ankle and foot, bacteremia, Paroxysmal ATRIAL Fibrillation, type 2 diabetes mellitus, and hyperlipidemia. Review of R5's care plan revealed, no care plan for activities. Review of R5's Quarterly Assessment Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/28/26 revealed a Brief Interview of Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. Review of Section F of the Quarterly MDS with an ARD date of 05/28/26 revealed that going outside and getting fresh air is very important to R5.Review of Lexington LLC Attendance Report PDF and the Wellmore Senior living Communities Activity Participation Sheet for May 2026, June 2026, and July 2026, revealed that R5 attended no documented activities in May 2026, R5 participated in one activity in June 2026, and four activities in July 2026.During an interview on 08/11/26 at 11:14 AM, revealed R5 is not informed of what activities are occurring or when they are occurring. R5 stated, I am never invited to activities. R5 revealed that she has only been outside once since she has been at Wellmore During an interview on 08/13/26 at 11:36 AM, the Administrator stated, It would probably be better if you talked to the social director about activities when she comes back. I cannot answer your questions. I would not be much help.During an interview with the Social Director (SD) on 08/13/26 at 2:30 PM, revealed, I am over all activities for the independent residents, assisted living residents and residents in skilled care. I am also over concierge, transportation, and wellness. I have worked here for two years. The SD revealed that there are Life Enrichment Leaders that work with her that are involved in every area of care for activities. The SD stated that she was not as familiar with R5. The SD stated, I enter all of the resident care plans. We do not have many residents participating in activities right now in rehab. I did not go to [R5's] care plan. I do not go to all of the care plan meetings. Another member of the activity staff attends when she can. Activity attendance is documented in our [NAME] computer system. The SD further stated, Right now [NAME] and Point Click Care do not talk to each other. We have been working with Point Click Care since April of this year . refusals should be put in the system. I do not know if refusals show up on the attendance record. Residents that are participating in rehabilitation do not in the [NAME] system. Rehab rollouts are something we do 2 or 3 times a week to touch base with the rehab residents. Rehab rollouts are in another binder. I go to all of the morning meetings and I hear if a resident needs an activity care plan.During an interview with a Life Enrichment Leader on 08/13/26 at 3:04 PM revealed, R5 came to the facility on [DATE] on her birthday. She participated in our anniversary celebration. She has participated in other activities. She prefers activities in her room.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure staff followed appropriate hand hygiene during medication administration for Resident (R)53, for 1 of 4 residents reviewed for medication administration.Findings include:Review of the facility policy titled, Instillation of Eye Drops, with a revision date of January 2014 revealed, Purpose: The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes. Steps in the Procedure: 1. Place the equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Put on gloves. 13. Remove gloves and discard into designated container. Wash and dry your hands thoroughly.Review of R53's Face Sheet revealed R53 had an admission date of 08/05/26, with diagnoses including, but not limited to, urinary tract infection, hyperlipidemia, hypertension, hypothyroidism, and tubulo-interstitial nephritis, depression, and anxiety disorder.Review of R53's active physician orders revealed, Timolol Maleate Ophthalmic Solution 0.25 % (Timolol Maleate (Ophth) Instill 1 drop in both eyes one time a day for Glaucoma-Start Date 08/06/2026 0900.Review of R53's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/26, revealed the resident's Brief Interview for Mental Status (BIMS) score was 7 out of 15, indicating severe cognitive impairment.During an observation on 08/12/26 at approximately 8:25 AM, of medication administration, Licensed Practical Nurse (LPN)1 failed to sanitize her hands, LPN1 then donned gloves in R53's room. As LPN1 entered R53's room, LPN1 touched the resident's door and then touched his bedside table. LPN1 then administered an eye drop in both of R53's eyes. LPN1 then administered resident's oral medication. LPN1 then removed her gloves and failed to perform hand hygiene.During an interview on 08/12/26 at 9:50 AM, LPN1 stated, I cannot believe I did that. I know better. That is going to worry me all afternoon.During an interview on 08/12/26 at approximately 10:27 AM, the Director of Nursing (DON) revealed that her expectation is that the nurses wash or sanitize there hands before and after the administration of eye drops.

Based on review of facility policy, record review and interview, the facility failed to ensure Resident (R)43 was free from significant medication error. Specifically, the facility failed to ensure that R43 received the correct medication order for Bupropion/Wellbutrin, which led to the resident being hospitalized . On 05/21/25 at 1:00 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 03/04/25. The IJ was related to 42 CFR 483.25 - Pharmacy Services. On 05/22/25 the facility provided an acceptable IJ Removal Plan. On 05/22/25 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 03/13/25. An extended survey was conducted in conjunction with the Recertification and Complaint Survey, for non-compliance at F760, constituting substandard quality of care. Findings include: Review of the facility policy titled Reconciliation of Medications on Admission with a last revision date of July 2017, revealed, General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over-the-counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. Review of the facility policy titled Medication Regimen Review with a last revision date of May 2019, revealed, Policy Interpretation and Implementation . 4. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. 9. An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. 10. If the identified irregularity represents a risk to a person's life, health, or safety, the Consultant Pharmacist contacts the physician immediately (within one hour) to report the information to the physician verbally and documents the notification. Review of the facility policy titled Admission Assessment and Follow Up: Role of the Nurse with a revision date of September 2012, revealed, Steps in the Procedure: 11. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from previous institution, according to established procedures. Review of R43's Face Sheet revealed R43 was admitted to the facility on [DATE], with diagnoses including but not limited to: cerebral infarction, depression, and anxiety. Review of R43's unspecified Minimum Data Set, dated dated dated [DATE], revealed the resident had an active diagnoses of depression and anxiety disorder. Further review of the MDS indicated R43 was receiving antianxiety and antidepressant medications. Review of R43's Discharge Summary from a (local hospital) dated 03/04/25, revealed R43's discharge medications from the hospital included: Bupropion (Wellbutrin) 300 mg (milligram) 24 hour ER (extended release) tablet, take 1 tablet (300 mg total) by mouth daily. Review of the Pharmacy Orders for R43 revealed that on 02/28/25 and on 03/11/25, R43 had an order for Bupropion 300 mg tablet that was coded T1T1D. According to the key, T1T1D indicates, take 1 tablet by mouth daily. This was confirmed by the Director of Pharmacy Operations (DPO). Review of R43's Physician Orders dated 03/04/25 at 5:52 PM, revealed the following order, Bupropion 300 mg 24 hour tablet, extended release every 8 hours at 06:00 AM, 02:00 PM, and 10:00 PM. Review of R43's Medication Administration Record (MAR) revealed, Bupropion 300 mg 24 hour tablet, extended release every 8 hours was administered to R43 on the following dates: on 03/04/25-R43 received 1 dose of medication at 10:00 PM. On 03/05/25-R43 received 1 dose of medication at 6:00 AM, 2:00 PM, and 10:00 PM. On 03/06/25-R43 received 1 dose of medication at 6:00 AM, 2:00 PM, and 10:00 PM. On 03/07/25-R43 received 1 dose of medication at 6:00 AM, 2:00 PM, and 10:00 PM. On 03/08/25-R43 received 1 dose of medication at 6:00 AM. Review of R43's Treatment Administration Record (TAR) did not reveal an order or documentation for antidepressant side effect monitoring. During an interview with R43's Resident Representative (RP) on 05/20/25 at 4:47 PM, revealed R43 was admitted on [DATE]th, and over the following days the family noticed that R43 was more groggy and sleepier than normal. The RP stated that he reported the new finding to the Nurse Practitioner (NP)1 and asked if maybe her medications is causing R43 excessive sedation. NP1 told the RP that the medications were correct in the system. The RP revealed NP1 provided the RP with a copy of the current medications R43 was taking. The RP then went to R43's Primary Care Provider (PCP) and requested a copy of R43's medication list prior to her admission to the nursing home. After comparing the two-medication lists, the RP discovered that there was a discrepancy in R43's Wellbutrin dose. The RP revealed that while in the facility, the resident was receiving Wellbutrin 300 mg every 8 hours, on the other hand, the medication list from the PCP revealed R43 should have only been receiving Wellbutrin 300 mg 1 time every 24 hours. After the discovery was made, the RP revealed he called NP1 immediately. The RP stated NP1 called poison control to report the incident and that poison control recommended they send the resident out to the hospital for further evaluation and monitoring. The RP further stated R43 spent a few days at the hospital for close monitoring. The RP concluded R43's medication has since been corrected and R43's mentation was drastically improved. During an interview with Licensed Practical Nurse (LPN)1 on 05/20/25 at 5:36 PM, revealed her role during medication reconciliation process during admission is as follows: If a resident is coming in from another facility or hospital, the pharmacy team will put the residents' medication orders into the system and the floor nurse will verify and activate the orders. LPN1 stated the pharmacy team only puts the name and dosage of the drug, and the floor nurses verify the medication orders and will put in the medication frequency, times, and route. LPN1 further stated that she does not remember putting in R43's Wellbutrin orders, as the incident happened in March and that she is only PRN (as needed). LPN1 revealed if the system states that she was the one who input the order on the resident chart, then it was possible that she may have put in the incorrect order. LPN1 stated that she does not just pull random orders out of thin air and that if she put in the order incorrectly, then the must have gotten the order from somewhere. LPN1 concluded that she was not in the facility when R43 went out to the hospital, nor did she know of R43's hospitalization regarding the resident's level of consciousness change. During an interview with the Director of Pharmacy Operations (DPO) on 05/20/25 at 5:50 PM, revealed that the pharmacy's role regarding the medication reconciliation process during admission is as follows: If the facility is admitting a resident from another facility or the hospital, a staff member from the facility will send over the discharge summary to pharmacy team. The pharmacy team will then have a data entry specialist input the medication orders outlined by the provider who wrote the resident's discharge instructions into the system. A Pharmacist will then review the medication orders and verify that the medication orders on the resident chart matches the orders on the resident discharge instructions. A pharmacy technician will then print the medication label and fill the prescription. Lastly, a second pharmacist will verify that the information printed on the medication label matches the resident order. Once the checks have been completed, then the medications will be sent out to the facility. The DPO stated the pharmacy team is only able to put the name of medication and the dose in the resident system, although the pharmacy team cannot put the frequency, time, and route of medication in the system, the pharmacy team then will leave a note on the order with the aforementioned details. The nurse who will activate the orders are the ones ultimately responsible for inputting the frequency, times, and route of administration. The DPO revealed that the order for R43's Wellbutrin was for 300 mg once daily, per the discharge instruction from the (local hospital). The DPO revealed that the order they placed for R43 was for the resident to receive Wellbutrin 300 mg once daily. The DPO continued, the disconnect occurred with whomever the nurse was that activated the orders. The DPO stated that the order for Wellbutrin 300 mg every 8 hours was an error, and that the resident was supposed to receive the Wellbutrin 300 mg once a day. The DPO further stated that when the error was brought to the pharmacy teams' attention, a change in the process was made. During an interview with the Director of Nursing (DON) on 05/20/25 at 6:10 PM, revealed medication orders are typically placed by pharmacy team on draft. Medications being on draft means, a medication order is not active until a nurse verifies the orders and activates them. The nurse primarily responsible for this role is the nurse caring for the resident. This is a way of providing a second check/verification. The DON stated the resident discharge summary from where they are admitting from is what the facility uses to input and verify resident medication orders. The DON further stated on this particular incident, LPN1 did not follow protocol when reviewing R43's Wellbutrin order on draft. LPN1 placed the medication order on active without following the necessary steps to verify the correct medication order matches the resident discharge summary and medication. During an interview with NP1 on 05/21/25 at 9:50 AM, revealed her role in the medication reconciliation process is to review the medication orders from the hospital and compare it to the resident facility Medication Administration Record (MAR) and ensure the orders match within a 72-hour window. NP1 revealed that she was with R43 and family in the resident's room trying to figure out what was making R43 drowsy. NP1 revealed she told the RP that she has not gotten to review the resident's MAR. NP1 stated the RP then asked NP1 if they could provide the family with the current medication list at the facility. The RP then compared the list to the resident home medication list and that is when the discrepancy was found. NP1 stated because of this, she and the family worked together to determine the cause of R43's increased drowsiness. Once NP1 was made aware of the discrepancy, NP1 immediately called the poison control center, and poison control recommended to send R43 to the hospital for close monitoring of cardiac arrhythmia. NP1 stated she called the floor nurse and notified her of the situation, and the nurse went through their process of reporting and following up with the NP1's orders. When R43 came back from the hospital, the resident was still slightly confused but mentation was improved. NP1 further stated during R43's time in the hospital, they completed a CT scan and determined the resident had a Cerebrovascular Accident (a medical condition characterized by the sudden interruption of blood flow to the brain, leading to brain damage), the hospital provider was not able to make a determination of when the CVA had occurred. With the newly found CVA and resident was still a little bit confused on re-admission, but her mentation has improved. NP1 revealed the pharmacy team was to put in the orders as outlined by the discharge instructions and the floor nurses are the ones who accept and activate the orders after verifying that the draft orders match the discharge instructions. The process broke down when the nurse failed verify the orders as evidenced by order being placed incorrectly. NP1 concluded the nurse failed at meeting her expectations regarding following safe procedure when inputting medication orders. During an interview with the Administrator (LNHA) on 05/21/25 at 11:34 AM, revealed on 03/08/25, R43 was sent to the hospital for altered mental status. Upon investigation, the LNHA and management team conducted an internal investigation where they determined after review of hospital discharge and R43's current medication order, R43 was receiving too many doses of Wellbutrin. The LNHA stated the breakdown that occurred was human error with LPN1. The LNHA revealed LPN1 went out of her way to input the orders on draft and activated the orders herself without having another nurse verify the order. The LNHA noticed that on the Hospital Discharge Summary 2 (two) medications were listed on top of one another which may have attributed to LPN1's error. The Hospital discharge medication list had the medication BUPROPRION (Wellbutrin) 300 mg 24 hour ER Tablet Daily above the medication BUSPIRONE (Buspar) 10 MG tablet 3 (three) times daily. During an interview with the Medical Director (MD) on 05/21/25 at 12:50 PM, revealed when a newly admitted patient arrives from the hospital, the process was for the nurse to reconcile medication from the discharge summary and put the orders into the system. The NP, MD and Pharmacy team will then serve as another layer of safety to reconcile the medications to ensure the resident is receiving the correct medication outlined by the discharge summary. The MD stated that he was made aware of the incident with R43, when it was reported to the MD that R43 was receiving an excessive dose of Wellbutrin. The MD stated R43 was receiving Wellbutrin 300 mg 3 times a day instead of Wellbutrin 300 mg 1 time a day. The resident was sent out to the hospital for 3 days for close monitoring. After facility investigation, the MD revealed that the error was made by a member of the nursing staff, where the nurse may have confused the Bupropion/Wellbutrin 300 mg 1 tablet 1-time daily order with the Buspirone 10 mg 3 times daily. The MD stated that due to the similarity of the medications the nurse incorrectly placed the wrong order for Bupropion/Wellbutrin. On 05/22/25 the facility provided an acceptable IJ Removal Plan, which included the following: I. Ensuring Harm Will Not Occur or Recur. To prevent the recurrence of pharmacy services medication error incidents, our facility has taken immediate and ongoing actions to eliminate the risk associated with medication errors. These steps include the reassessment of all residents at risk, reinforcement of security measures, and staff education to ensure proper monitoring and response. All actions taken are designed to provide an accident-free environment while ensuring adequate supervision for all at-risk residents. II. Date of Implementation. While all corrective actions were initiated immediately upon the discovery of the deficiency, the official implementation dates for specific actions are listed below: 3.13.2025 - Facility was in full compliance. 1. March 8, 2025 - Resident was sent to the hospital for evaluation due to altered mental status. 2. March 9, 2025-Review of the incident by the community revealed the resident was receiving wrong dosage of medication. 3. March 12, 2025- Incident review with medical director, contracted pharmacy and nursing staff; new admission procedure implemented. 4. March 12, 2025 - Re-education provided to nurses regarding admission medication order procedures. 5. March 12, 2025 - Nursing staff reviewed all orders for current patients. Nurses enter medications in draft status to review, while a second nurse will verify accuracy and activate orders. 6. March 13, 2025- DON, ADON, RCC or designee review all new admission medication orders after pharmacy and nurse enter. 7. Ongoing- Upon admission, each resident medication list is entered by trained pharmacy staff. Receiving nurses will review profiled medications by pharmacy as second check, reconciling with physician order and activating. DON, ADON, RCC or designee review all new admission medication orders after pharmacy and nurse enter. III. Identifying Those Affected or at Risk The resident involved in the medication error incident, along with all residents receiving medications have been identified as at risk. Immediate interventions were implemented for these residents, including reassessment and reinforcement of monitoring protocols to prevent further occurrences. IV. Systemic Process Changes to Prevent Recurrence The facility has taken the following steps to alter systemic failures and prevent future adverse outcomes: 1. Increased Monitoring and Audits: a 3.12.2025-DON, ADON, RCC or designee review all new admission medication orders after pharmacy and nurse enter. o 5.21.2025: CSA, DON, and/or Designee will conduct audits daily for two weeks, weekly for eight weeks, and monthly for three months or longer until I00% compliance is met to ensure all new med orders are accurate. All negative findings will be corrected immediately. Involved Team Members will be reeducated immediately. o 5.21.2025: Audit results will be reviewed in monthly Quality Assurance (QA) meetings for further recommendations. 2. Enhanced Staff Training and Education: o 3.12.2025: Nursing staff re-educated on medication admission policies, including the proper use of pharmacy integration and verifying order read back and correctness. o 5.21.2025: New nurse hires will receive training on proper medication during orientation, and annual refresher training will be conducted for all nurses. 3. Family and Resident Engagement: o 5.21.2025: Families and residents will be provided education by the facility on the potential of medication errors and facility safety measures. o 5.21.2025: Family input will be incorporated into individualized care plans to enhance medication error prevention strategies.

Based on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the refrigerator and dry storage were labeled and discarded after the manufacturer's expiration date. Findings Include: Review of the facility's policy titled, Food Receiving and Storage, with a revised date of [DATE], reveals, Food shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage: 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated. Such foods are rotated using a first in-first out system. Refrigerated/Frozen Storage: 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. During an initial tour observation on [DATE] at 12:24PM, in the walk-in refrigerator and dry storage area revealed: 1. One unopened five-pound bag of Mozzarella cheese labeled with a received date of [DATE], had a manufactured expiration date of [DATE], which also contained mold. 2. A blue bucket that did not contain any label of the contents, an opened or expiration date. The Dining Service Manager (DSM) confirmed that the contents were mushrooms. 3. A box containing approximately twelve squash that were molded, had a received date of [DATE]. 4. A box containing single packs of Mayonnaise had a manufactured expiration date of [DATE]. 5. A five-pound container of baking powder, that was half full, had a manufactured expiration date of [DATE]. 6. An unopened eight-ounce jar of Pad Thai Sauce had a manufactured expiration date of [DATE]. An interview on [DATE] at 12:35 PM with the DSM, revealed that they check the food contents on a weekly basis, and they use a first in and first out method. He included that the stock they have usually does not last beyond two weeks as they are constantly using the items that they have ordered, and they replenish about every week. An interview on [DATE] at 2:02 PM with the Certified Dietary Manager (CDM), revealed that he is primarily responsible for ensuring that all items that are stored are labeled and dated and are within the manufactured expiration date. He stated that he is responsible for all the kitchen areas to include the main and satellite. He also is responsible for providing in- services to staff when there is an area that needs to be revisited or just general information/guidelines, as well as performing bi-weekly audits. The CDM stated he was unaware of any expired items, and they use the first in- first out method to ensure expired items are discarded.

Based on review of the facility policy, observations, interviews, and record review, the facility failed to provide respiratory care in accordance with professional standards. The facility failed to ensure 2 of 2 residents (R) 34 and R195's, continuous positive airway pressure (CPAP), were properly cleaned and stored after each use. This failure has the potential to cause respiratory and other communicable infections/complications. Findings Include: Review of the facility policy titled, CPAP/BiPAP Support, with a revised date of March 2015, states, 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. Review of R34's face sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to hypertension and obstructive sleep apnea. Review of R34's treatment orders revealed an order dated 01/11/24, which indicated, continuous positive airway pressure (CPAP), hour of sleep starting, resident should have on at bedtime, the settings are set on the machine and the patient is able to apply head mask. Review of R34's care plan revealed, R34 has periods of breathing difficulty at night related to a diagnosis of sleep apnea. The goal is for R34 to have no difficulties with breathing at night through the next review, with an intervention of using a CPAP machine and O2 at night per medical doctor orders. During an observation on 01/29/24 at approximately 3:00 PM, R34's face mask was observed uncovered, lying on his bedside table. During an observation on 01/31/24 at approximately 12:30 PM, R34's face mask was observed uncovered, lying on his bedside table. Review of R195's face sheet revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, nonrheumatic aortic stenosis, hypertension, and obstructive sleep apnea. Review of R195's treatment orders revealed an order dated 01/24/24, indicating, continuous positive airway pressure (CPAP), hour of sleep starting, resident may use own CPAP. Review of R195's care plan revealed that, R195 has periods of breathing difficulty at night related to a diagnosis of sleep apnea. The goal is for R195 to have no difficulties with breathing at night through the next review, with an intervention of using a CPAP machine at night per medical doctor orders. During an observation on 01/29/24 at approximately 2:00 PM R195's face mask was observed uncovered, lying on his bedside table. During an interview on 01/31/24 at 4:00 PM with the Director of Nursing (DON), she stated that she has not had any notification of the resident refusing to wear a CPAP machine, and the resident is self-compliant with donning/doffing the apparatus. She also stated that the device should be air dried and if it is put in a bag, bacteria would grow if it was enclosed in a bag. She said she was unaware of their policy that indicated that they should be storing the face mask a specific way. During an interview on 01/31/24 at 4:10 PM with the facility Administrator, revealed that the policy that was provided, is the only policy that they have in reference to storing and caring for respiratory devices. During an interview on 01/31/24 at 4:13 PM, Certified Nursing Assistant (CNA)1, revealed they use bags with oxygen tubing or a mask that is not in use, so they are not sitting out in the open. She stated the bags are located at the nurse's station and we (CNAs) carry them in our pockets. CNA1 stated they use clear trash bags and put the date on the outside of the bag. CNA1 stated if she witnessed oxygen tubing or a mask on the floor, she will pick it up and discard.

Based on review of the facility policy, observations, interviews, and manufacturer package inserts, the facility failed to maintain clean medication carts for 2 of 7 med carts and failed to prevent expired and/or improper storage of medications in 2 of 4 med rooms. Findings include: Review of the facility's policy titled, Storage of Medications, revised [DATE], stated that the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of the facility's policy titled, Medication Labeling and Storage, dated February 2023, stated that if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. On [DATE] at approximately 1:08 PM inspection of the 100-hall south medication cart revealed sticky substances on bottles of Pro-stat and bottom of third (3rd) drawer on left side of cart. On [DATE] at approximately 1:13 PM, during an interview, Licensed Practical Nurse (LPN)1 acknowledged that the medication storage drawer and bottles of Pro-Stats were dirty and needed to be cleaned. On [DATE] at approximately 9:28 AM inspection of the 200-hall north medication room revealed an open approximately half (,d+[DATE]) full tube of MediHoney labeled Sterile and Single-use by the manufacturer stored in an upper cabinet. The MediHoney instructions state that it should only be used once; instead, it was used continuously. The inspection also revealed one (1) Povidone-Iodine Prep Pad with an ,d+[DATE] expiration date and 1 Povidone-Iodine Prep Pad with an ,d+[DATE] expiration date. On [DATE] at approximately 9:35 AM, LPN2 acknowledged, during an interview, that the Medi-Honey was being used for Resident(R)18 and she was unaware that the medication was designated for single sterile use. LPN2 also acknowledged that she was unaware of the expiration dates on the Povidone Iodine Prep-Pads. On [DATE] at approximately 2:07 PM inspection of the 200-hall north medication cart revealed sticky substances on the bottom of the 3rd drawer on the left side of medication cart. This finding was acknowledged during an interview with LPN2 in the presence of the Assistant Director of Nursing. On [DATE] at approximately 10:35 AM inspection of 100-hall north medication room revealed a container of True Metrix 50 count test strips expired on [DATE] stored in top cabinet. On [DATE] at approximately 10:40 AM, LPN3 stated, during an interview, that the test strips were used on night shift to check residents blood sugar levels and she advised she was unaware of the expiration date.

Based on review of the facility policy, observation, and interview, the facility failed to establish and maintain an infection prevention and control program to prevent the development and transmission of communicable disease and infections related to influenza for one of one, Resident (R)1. Findings include: Review of the facility policy titled Influenza, Prevention and Control of Seasonal, revised March 2022 states, This facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. Influenza Control, 6. Visits to residents on precautions for influenza are scheduled and controlled to allow for: a. screening visitors for symptoms of acute respiratory illness before entering the facility; and b. providing instruction before visitors enter residents' rooms, on hand hygiene, limiting surfaces touched, and use of personal protective equipment (PPE) while in resident's room. Infection Precautions: 1. Contact and droplet precautions are implemented for residents with suspected or confirmed influenza for seven (7) days after illness onset or until 24 hours after resolution of fever and respiratory symptoms, whichever is longer. Precautions may be applied for longer periods based on clinical judgement. 2. Information about residents with suspected, probable, or confirmed influenza is communicated to appropriate personnel before transferring them to other departments in the facility or to other facilities. During an interview on 01/30/24 at 3:15 PM with the Certified Occupational Therapist, (COTA)1 revealed he was waiting for a few more residents to have a group therapy session. He has two group sessions a week, Tues/Thursday. He said, Right now, we have 2-3 residents that have the flu. He pointed to R1's room, and said she has the flu. When asked if there should be precautions?, he said, I don't know why she doesn't, she should have them. I walked into her room a few days ago and didn't even know it. During an interview on 01/30/24 at 3:37 PM with the Infection Control Preventionist (ICP), revealed precautionary measures were used for R1, with the flu. She revealed the facility uses present Centers for Disease Control (CDC) guidelines, and log residents' temperature that lasts for over 24 hours. In order to confirm a resident has the flu, the facility uses the swab method. The ICP revealed R1 never had a temperature and there are no precautions used for newly flu diagnosed residents. She stated, Resident just self-isolate and staff do not wear full PPE, just masks. The ICP revealed staff are made aware of a resident who has the flu via a report and per CDC guidelines, residents with no signs and symptoms do not have to isolate. During an interview on 1/31/24 at 10:06 AM with Licensed Practical Nurse (LPN)1 revealed the signage on the door of R1's room is because she has the flu. She stated, R1 tested for Influenza on Friday, 01/26/24, and we got the results back on Saturday. She's been having a runny nose and cough for a while. During an interview on 01/31/24 at 10:10 AM with the ICP, she stated, I wanted to tell you I was incorrect on the flu precautions. I checked the CDC and learned that a resident who has tested positive for influenza should be on contact precautions for seven days. We put isolation precautions in place yesterday for R1 because she has tested positive and today is the seventh day. The ICP also stated, The staff who pass trays to the residents should sanitize before they begin delivering trays. She said, If they require meal setup, you make sure you do not touch the straw in a way that your hands actually touch the straw itself, only the paper. When unwrapping the silverware, they should not actually touch the silverware with their bare hands. An observation on 01/31/24 at 10:05 AM of R1's room revealed droplet signage and a cart outside the door containing face masks, N95s, face shields, gloves, etc.

Based on observations, staff interviews, and record review, the facility failed to ensure foods stored in the kitchen were labeled, dated, and not expired. These failures had the potential to increase the prevalence and spread of foodborne illness and infection to all facility residents. Findings include: Review of the [NAME] Baker Quality Control Checklist for Cleaning of Exhaust System dated [DATE], [DATE], [DATE], and a [DATE] email and on [DATE], cleaning was canceled and rescheduled for [DATE]. During a review of the facility's policy and procedures the following was revealed: The Refrigerators and Freezers policy stated .#7 All food shall be appropriately dated to ensure proper rotation by expiration dates . Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage . Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened . #8 Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes . Review of the Food Receiving and Storage policy stated .#1 Food Services, or other designated staff, will maintain clean food storage areas at all times.#7 Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first-in first out system. #8 All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date).#14. b. Food items and snacks kept on the nursing units must be maintained as indicated below: All foods belonging to residents must be labeled with the resident's name, the item and the use by date. #14. d. Beverages must be dated when opened and discarded after twenty-four (24) hours. #14. e. Other opened containers must be dated and sealed or covered during storage . On [DATE] at 11:01 AM, during the initial kitchen tour, the following was observed: In the main kitchen, a bag of opened carrots was observed in the refrigerator not dated, a bag of opened cooked Italian sausage was observed in the freezer not dated, and four Ziploc bags of ham hocks was observed in the freezer not labeled or dated. On the shelf in the main kitchen, the following was observed: eight bottles of expired Nepro (a nutritional supplement) with an expiration date of [DATE], 23 bottles of expired Vital HP (a nutritional supplement) with an expiration date of [DATE], and one can of dented apple pears was on the shelf in the dry storage area. Debris on the side of the kitchen hood in the main was observed. In the Rehab North Nourishment Room, three bottles of expired [MEDICATION(S)] (a nutritional liquid meal) were observed in the refrigerator with an expiration date of [DATE]. In the South Rehab Nourishment Room, two white containers were observed in the refrigerator without a label and open date. One container said, No name no date. In the South Skilled Nourishment Room, one bottle of Med Pass Fortified Nutritional Shake Vanilla was observed opened without an opened date. The directions on the shake stated, Discard four days after opening. During an interview with the Dining Room Manger (DRM), Assistant Administrator (AA), and the Certified Dietary Manager (CDM) about the facility's expectation on sanitation practices and date marking and labeling revealed: on [DATE] at 11:26 AM, the DRM stated Staff checks dates daily. There's a new system they are piloting about food safety training where the chef and sous-chef checks labels daily. If an item is found unlabeled and the opened date is unknown they throw it out. The kitchen is audited monthly. During an interview on [DATE] at 12:09 PM, the AA stated All food in the refrigerator should be marked with the date it was opened, expiration date, and resident's name when applicable. Kitchen equipment is cleaned a few times a week if not every day when cleaning the kitchen. During an inteview on [DATE] at 12:12 PM, the CDM stated Food items in the kitchen should have the date its used, item name, use by date, and initials. Staff are trained to discard items when they are not labeled. Appliances are cleaned every day at the end of every shift.

Based on observations, record review, staff interviews, review of the manufacturer's guidelines for medication use, and review of the facility's policy and procedures, the facility failed to ensure that three of five residents (Resident (R) R30, R41, and R42) reviewed for unnecessary medication use did not receive psychoactive medications without an appropriate assessment and indication for use, monitoring of adverse effects, attempting gradual dose reductions when appropriate, reducing or discontinuing as needed psychotropics past the 14 day criteria, identifying and routinely monitoring specific target behaviors, and developing and implementing resident specific non-pharmacological interventions. This deficient practice had the potential for serious harm and/or death for all residents who reside in the facility. Findings include: Review of the facility's policy dated April 2018 titled, Medication Utilization and Prescribing- Clinical Protocol stated Assessment and Recognition:2. As part of the overall review, the physician and staff will evaluate the rationale for existing medications that lack a clear indication or are being used intermittently on a PRN (as needed basis). Monitoring: 1. The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications . Review of the facility's policy dated January 2018 tilted, Medication Monitoring and Management stated .6. As needed (PRN) orders include an indication for use. A. If the PRN medication is used to modify behavior, the indication(s) for use is clearly defined in objective terms, e.g., what specific symptom(s) is being addressed. B. The resident is monitored for the effectiveness of the medication or possible adverse consequence. Results are documented in the resident's active record 8. The medication regimen is re-evaluated periodically to determine whether prolonged or indefinite use of a medication is indicated. A. Prescribers, facility staff, and consultants document progress towards, maintenance of, or regression from therapeutic goals . According to the manufacturer's box warning dated 02/2021, revealed .WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA RELATED [CONDITION(S)] Elderly patients with dementia-related [CONDITION(S)] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION(S)] is not approved for use in patients with dementia-related [CONDITION(S)]. INDICATION AND USAGE for prescribing [MEDICATION(S)] is an atypical antipsychotic indicated for: Treatment of [CONDITION(S)], as monotherapy or adjunctive therapy with [MEDICATION(S)] or valproate, for the treatment of acute manic or mixed episodes associated with [CONDITION(S)], and treatment of irritability associated with autistic disorder . Review of the Review of the Diagnostic Criteria for [CONDITION(S)] in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) provided the following information regarding psychotic disorder due to general medical condition: .A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by a mental disorder. D. The disturbance does not occur exclusively during the occurrence of [CONDITION(S)] .The hallmark features of psychotic disorders such as [CONDITION(S)] are hallucinations, delusions, and disordered thinking . Review of the National Institute of Mental Health booklet titled, [CONDITION(S)], (NIH Publication No. 15-3517), indicated, Symptoms [of [CONDITION(S)]] such as hallucinations and delusions usually start between ages 16 and 30 .Most commonly, [CONDITION(S)] occurs in late adolescence and early adulthood. It is uncommon to be diagnosed with [CONDITION(S)] after age 45. Review of the facility's policy titled Antipsychotic Medication Use, dated December 2016, stated .Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. 3. The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic episodes, and will differentiate them from enduring psychiatric conditions. 4. The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions. 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will: a. Complete PASARR screening (preadmission screening for mentally ill and intellectually disable individuals), if appropriate; or b. Re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduces, tapered, or discontinued. c. Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication. 6. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident . 1. Review of R30's electronic medical record (EMR), Face Sheet stated, R30 was admitted on [DATE] with diagnoses of but not limited to [CONDITION(S)], history of anxiety disorder, a single episode of [CONDITION(S)] and psychotic disorder. R30 received a diagnosis of [CONDITION(S)] on 08/30/21. Review of R30's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/19/21 revealed R30 scored a 14 out of 15 on the Brief Instrument for Mental Status (BIMS) assessment which meant R30 was cognitively intact. It was documented R30 had a progressive neurological condition. It was documented R30 had an active diagnosis of psychoactive disorder (other than [CONDITION(S)]) with no behaviors, hallucinations, or delusions present. Review of R30's significant change in status MDS with an ARD of 01/04/22, documented in the PASARR section of the assessment that R30 was not evaluated for a level two PASARR. It was documented R30 declined in cognition and scored a 02 out of 15 on the BIMS assessment. R30 was documented with changes in mood and exhibited no change in behavior. It was documented R30 had an active diagnosis of anxiety, depression, psychoactive disorder (other than [CONDITION(S)]), and [CONDITION(S)] with no behaviors, hallucinations, or delusions present. R30's functional status indicated no change and documented R30 required supervision to extensive assistance from staff with activities of daily living (ADL). Review of R30's Care Area Assessment (CAA) Summary, dated 01/13/22, for care area Cognitive Loss/Dementia, Psychosocial Well-Being and [CONDITION(S)] Drug Use, revealed R30 had [CONDITION(S)] induced hallucinations, and [CONDITION(S)] disorder with confusion. R30 was at risk for cognitive impairment related to the progression of R30's disease process. Will proceed to care plan. Review of R30's Non-PRN Treatment Notes, where the facility documented target behaviors dated from November 2021 through February 2022, had documented one incident of hitting and kicking, on the evening of 01/24/22. All other documentation was documented that R30 had no behaviors. Review of R30's Recommendation to MD from Pharmacist dated 12/12/21, and the Summary of Recommendations to MD and Nursing dated 12/21/21, revealed R30 was prescribed [MEDICATION(S)] (antipsychotic medication) 1 mg (milligram) bid (twice daily) routinely with no indication for use. 2. Review of the Admission Record, located on the Face Sheet in the EMR, indicated R41 was admitted to the facility on [DATE] with diagnoses of acute pulmonary [CONDITION(S)], major depressive disorder, unspecified dementia, repeated falls, and anxiety disorder. Review of the EMR admission MDS with an ARD of 01/14/22, revealed R41 was moderately cognitively impaired and was documented to have a diagnosis of dementia. The MDS documented R41 as exhibiting disorganized thinking, but indicated R41 did not exhibit behaviors of hallucination or delusions. Section N: Medications of the MDS documented R41 as receiving the following types of medications: Antipsychotic 0 days; Antianxiety 6 days; Antidepressant 7 days; Hypnotic 0 days; Anticoagulant 0 days; Antibiotic 0 days; Diuretic 0 days; Opioid 6 days. Section V: Care Area Assessment (CAA) Summary of the MDS documented R41 triggered the following care areas: Cognitive Loss/Dementia, Communication, Urinary Incontinence, and Indwelling Catheter, Falls, Nutritional Status, Pressure Ulcer, and [CONDITION(S)] Drug Use. Review of the Physician Order Sheet for the month of January 2022 located under the tab Physicians Orders in the EMR dated for 01/07/22 revealed an order for R41 to receive [MEDICATION(S)] (an antianxiety medication) 0.5 mg (milligram) tablet as needed every six hours. The notes stated Indication: anxiety, agitation, Instructions: Therapeutic Range There were no orders to monitor for medication adverse side effects or resident specific target behaviors for the use of the medication [MEDICATION(S)]. Review of the Physician Order Sheet for the month of January 2022 located under the tab Physicians Orders in the EMR dated for 01/13/22, revealed an order for R41 to receive [MEDICATION(S)] 0.5 mg tablet every evening starting 01/13/22 Review of the pharmacy recommendations titled, Recommendation to MD From Pharmacist dated 01/15/22 stated .Updated F758 regulation states: Residents do not receive PRN [CONDITION(S)] drugs unless med is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for [CONDITION(S)] drugs are limited to 14 days. If order needs to be extended, physician should document their rationale in the medical record and indicate the duration. PRN orders for antipsychotic drugs are limited to 14 days. Orders cannot be renewed unless physician evaluates the resident for continued appropriateness of med. In order to comply with updated psychoactive PRN medication regulation, please evaluate the following PRN medications: [MEDICATION(S)] .5 mg q (every) 6 hr [sic] (hours) PRN (as needed) initiated in hospital. Please continue x (times) 14 days from admission (01/07/22) and then reevaluate for d/c (discontinue). She also receives .5 mg q hs [sic] (hours of sleep) . Review of the pharmacy recommendations titled, Summary of Recommendations to MD and Nursing dated 01/15/22 stated .This resident receives psych meds which should have physical monitors attached to med orders so behaviors and side effects can be monitored. Non-pharmacological methods should be attempted before giving the PRN [MEDICATION(S)]. Please add an entry so side effects can (be) monitored daily and behaviors can be monitored every shift. Please add non-pharmacological entry so nurses can document before giving PRN [MEDICATION(S)] . Further review of the resident's EMR revealed there was no clinical rationale for the continued use of the PRN [MEDICATION(S)] beyond the standard 14 days. Review of R41's behavioral monitoring documentation located on the Medication Administration Record (MAR) dated 02/02/22 through 02/03/22 revealed .Action: antianxiety side effects and behaviors . with no resident specific target behaviors listed. There was no consistent daily behavior documentation showing what target behavior was exhibited and what non-pharmacological intervention was attempted with the outcome prior to administering the PRN [CONDITION(S)] medication for the month of January 2022, however, there was documentation to show the resident was re-directed successfully with non-pharmacological interventions. Review of the nursing progress notes titled, Progress Notes in the EMR located under the tab Progress Notes dated from 01/30/22 to 02/02/22 revealed there was documentation of R41 becoming agitated at times however, staff interviews indicated that R41 was easily re-directed without pharmacological intervention. Progress note dated 01/30/22 stated .[MEDICATION(S)] PRN given at 8:30 am. Patient yells and grimaces and grabs left hip during repositioning and incontinent care .PRN [MEDICATION(S)] given at 8:30 am for agitation not resolved by redirection or other attempts. Patient will attempt to hit staff during dressing changes, incontinent care, and transfers. Patient has a purple hat that can be very calming for her to wear . Review of the Progress Note dated 02/01/22 stated .PRN [MEDICATION(S)] continues for anxiety with good effect when used. Purple hat also helpful with calming pt [sic] (patient) An observation on 02/03/22 at 9:13 AM R41 was in in her room smiling, lying in bed, and listening to music. R41 stated, She was feeling fine, and she was happy. In an interview with the Physical Therapist (PT) on 02/02/22 at 11:54 AM, she stated R41's agitation fluctuates throughout the day. When she verbally gets frustrated and gets loud, staff redirects and speaks with her calmly. She follows commands with extra time and reminders. Her frustration is due to dementia and when she gets tired. When this happens, staff repositions her in the bed and she calms down. In an interview with LPN 3 on 02/02/22 at 11:58 AM, she stated When staff tries to get R41 out of the bed, her agitation stems from confusion, she doesn't know where she is and why she's here. Staff redirects her and speaks with her calmly and answers her questions (e.g., Where she is? Where are her kids?). Other than redirection, she is taken out of stimulating areas, staff will dim the lights in her room, etc. In an interview with the Social Worker (SW) on 02/02/22 at 2:44 PM, she stated R41's agitation depends, she has her moments. You cannot put chocolate in front of her and she likes staff to write down what they are doing today. She naturally speaks loudly and will repeat herself at least 3 or 4 times. She wants everything explained to her. She likes the engagement stations (e.g., folding clothes) she does not like big social groups, she likes listening to music, but Frank Sinatra sets her off because that is her and her husband's song and she will get upset when she hears it. She likes the concerts, one-to-one activities, and she likes crafts, but it has to be one or two steps. If agitated staff would ask her what she wants, sometimes she gets frustrated because she cannot communicate what she wants. Staff would redirect or relocate the resident and try to find the solution and determine if she is upset because of the location or if it is too much stimulation. The facility's certified dementia training tells you how to approach the situation to determine why the residents are upset and how to resolve the issue. The resident was in memory care but now that she's in rehab and sometimes she doesn't want to participate. During a phone interview with LPN 4 on 02/03/22 at 9:58 AM, she stated At night R41 gets agitated, and she tries to get out of bed, but she isn't aggressive. If she gets agitated, I do one to one, hold the resident's hand, and then she calms down. If a PRN is given for 14 days, the resident should be reevaluated because she may need to have it routinely if that is going to be used to get her anxiety under control. When they receive training, they are introduced to residents that have a diagnosis of dementia, informed of the care plan which tells them how to proceed with providing care for the resident. 3. Review of the EMR Face Sheet for R42, revealed that R42 was admitted on [DATE] with diagnoses of but not limited to vascular dementia with behavioral disturbance, [CONDITION(S)] disorder (unspecified), anxiety disorder (unspecified), and cognitive communication deficit. Review of the MDS with an ARD of 01/16/22 revealed R42 was assessed to have short- and long-term memory deficit. Further review of the MDS assessment revealed R42 was rarely or never understood. R42 exhibited behaviors and received seven days of antipsychotics routinely. Review of R42's Physician Orders, dated from 01/13/21 through 02/01/22 located in the EMR revealed R42 had been prescribed [MEDICATION(S)] (an antipsychotic medication) 25 mg (milligrams) daily for the of vascular dementia with hallucinations, starting on 02/23/21. Review of R42's EMR Progress Notes dated 02/23/21 documented that the chief complaint and reason for the visit was hallucinations and medication review. The description of health present illness related to the visit stated that the patient .has dementia and is alert and only oriented to self and does follow some commands at times. She has been having hallucinations. She is a bit more anxious then normal . R42's active medical problems were listed as dementia, muscle wasting, at risk for malnutrition, closed fracture of right femur, sick sinus syndrome, and anxiety. The documented assessment and plan were: .dementia: chronic-worsening anxiety and hallucinations. [MEDICATION(S)] 25 mg daily started, and she was to continue [MEDICATION(S)] and Trazadone . The diagnosis was vascular dementia without behavioral disturbance, anxiety disorder (unspecified), and hallucinations (unspecified). Review of R42's EMR Progress Notes dated 03/18/21 documented that the chief complaint and reason for the physician visit was a follow up on the hallucinations and anxiety. The description of health present illness related to the visit stated that the patient .has dementia and is alert and oriented to self and does follow some commands at times. She was started on [MEDICATION(S)] at her last visit for hallucinations and anxiety, which is improved. She is calm on exam. No acute concerns voiced by staff . The assessment and plan were .dementia: chronic-anxiety and hallucinations improved. Continue [MEDICATION(S)] 25 mg daily. She will continue on this likely indefinitely . The diagnosis was vascular dementia without behavioral disturbance, anxiety disorder (unspecified), and hallucinations (unspecified). Review of R42's EMR Progress Notes dated 05/12/21 documented that the chief complaint and reason for the physician visit was a follow up on [CONDITION(S)] disorder and dementia. The description of health present illness related to the visit stated that the patient .is alert but not oriented. She has dementia. She is on [MEDICATION(S)] for [CONDITION(S)] disorder. Unable to GDR current medication given this was tried in the past and she did not tolerate .The assessment and plan was [CONDITION(S)] disorder with dementia. Continue [MEDICATION(S)] for [CONDITION(S)] disorder without dose change today. Unable to Gradual Dose Reduce (GDR) current medication given this was tried in the past and she did not tolerate. Continue to monitor for behavior changes. Psychiatric consult placed. The diagnosis was [CONDITION(S)] disorder (unspecified). Review of R42's EMR Progress Notes dated 07/14/21 documented that the chief complaint and reason for the physician visit was the follow up on the multiple medical concerns. The description of health present illness related to the visit stated that the patient .is alert but not oriented due to dementia .The assessment and plan is .dementia: chronic baseline .[CONDITION(S)]: chronic trazadone, agitation: stable on [MEDICATION(S)] . Review of R42's EMR Progress Notes dated 07/30/21 documented that the chief complaint and reason for the physician visit was the follow up on dementia. The description of health present illness related to the visit stated that the patient .she is alert but confused secondary to dementia which appears to be at baseline without behavior disturbance noted today on exam. She is on [MEDICATION(S)] for behaviors secondary to dementia. GDR (Gradual Dose Reduction) attempted in the past but unsuccessful given she became agitated and anxious. She remains stable on current dose .The assessment and plan is dementia with behavioral disturbance: chronic, remains stable. Continue [MEDICATION(S)] and [MEDICATION(S)] as ordered for now. She is on [MEDICATION(S)] for behaviors secondary to dementia. GDR attempted in the past but unsuccessful given she became agitated and anxious. Will get psychiatric consult. Continue to monitor . Review of the Medication Administration Record (MAR) for December 2021 revealed that R42 had behavioral symptoms 18 days (1, 5, 6, 7, 10, 12, 13, 14, 17, 18, 21, 22, 24, 26, 27, 28, 30, 31) of 31. Notes stated R42 was crying out/yelling/screaming for all days except for the 6th which documented R42 had delusions, on the 7th R42 was striking out, on the 12th it was documented R42 had hallucinations, and on the 24th it was documented R42 was refusing care. Review of the MAR for January 2022 revealed that R42 had behavioral symptoms 17 days (1, 2, 3, 4, 5, 7, 8, 10, 11, 12, 16, 20, 21, 24, 28, 29, 31) of 31. The notes stated that R42 was crying out/yelling/screaming on those days. Review of the EMR current comprehensive Care Plan for R42 revealed interventions as: .monitor and record mood or behavior problems; monitor for adverse effects associated with antidepressants ([CONDITION(S)], restlessness, weakness, fatigue, headache, nausea/vomiting, anorexia, diarrhea, delusions, disorientation, etc.; monitor for adverse effects of medications and report to charge nurse/MD; encourage appropriate behavior and praise efforts; monitor for opportunity to decrease [CONDITION(S)] medications quarterly; monitor for appetite and weight changes; remove from stressful situations as needed; encourage and assist to attend group activities or to do independent activities of choice, provide soothing type pm [sic] activities . In an interview with the Director of Nursing (DON) on 02/03/22 at 11:48 AM, she stated The facility has a functional wellness program for skilled and assistant living. Activities does weekly exercise and mobility program. Nurses and Certified Nursing Assistants (CNAs) monitor daily range of motion (ROM) for upper and lower extremities. There is not an order to document this information. The Nurses and Nurse managers, monitor psychotropics, behavioral health and psychiatric services. The Care Manager, the Nurses, and the Nurse managers monitor effectiveness of care plan. This is ongoing if something needs to be added or changed. IDT have meetings Monday-Friday (stand -up meetings), Medicare meetings are Thursdays for rehab, and they discuss LTC if anyone needs to be added to therapy, psychotropics are discussed, newly and existing psychotropics. The Nurse practitioner attends these meetings daily when things are added or discontinued. The Nurse Practitioner works under the Medical Director. The Medical Director or Nurse Practitioner can send a referral for psychiatric services for evaluation. The facility utilizes Life Source. The facility asks agency staff to come an hour before their assigned shift to have orientation to the floor. The facility utilizes shift key for online modules and testing. The staff receive yearly training on Dementia and behavior training. The facility provides a list of requirements with the agency, and they only assign staff to a shift if they meet those requirements. The facility emails these requirements to the agency. In an interview with the Pharmacist on 02/03/22 at 11:58 AM, she stated I visit the facility once a month or when needed. Monthly pharmacy review, inhouse pharmacist does initial Monthly Review Reports (MRR). I attend the Quality Assurance (QA) meetings and follow a template that asks general questions like number of prescriptions, and how many residents are on psychotropics. If the doctor does not respond to the MRR recommendation, then I will follow up the next month or two months. The facility does not consistently respond to MRR recommendations and sometimes the medical staff will document on the progress notes if they do not document on the recommendation. I review nurses' notes as far as behaviors, if meds were given and the reason, PRN medication usage, pulling up the MAR to see how often PRN medications are given. For hospice residents I use the care plan as the rationale when no evaluation or rationale to continue medication are provided. When brought up in the QA meetings the MD states that they are aware. Ideally, I would like to see on admission the MD write the order for 14 days which will discontinue the use of it if it is not reevaluated. Box warnings are placed on antipsychotic medications related to contraindications in the elderly. If a resident is on antipsychotic medication on admission, I try to find out if there are notes of a psychiatric evaluation. I haven't completed my review to see if I received any responses from the MD for the pharmacy recommendations from last month (January 2022) yet. In an interview with the Medical Director on 02/03/22 at 3:04 PM, she stated I have been with Wellmore since June/ July 2021. Primary care for over 60 residents, 20 of them are in Assisted Living (AL), and some residents are in Long Term Care (LTC) and rehab. I visit the facility once a week and am reachable by phone every day. I am involved with the Quality Assurance/Process Improvement (QAPI) meetings, every Thursday . She stated she overseen the behavioral health treatment and services for the residents in collaboration with psych services. She further stated that the management of mental health for psychotropics use was a collaborative effort with psych services. She stated the facility had overused antianxiety medications. She stated PRN medication were evaluated after 14 days to determine if they should be continued. She stated when pharmacy made their review, they usually had something in their notes and there was a form that was signed and scanned into the facility and EMR. She further stated a target behavior would be considered as yelling. If the resident were yelling once in a while that would be fine however, if it were multiple times the underlying issue should be assessed. She stated they would collaborate with the psych group to determine if a medication was appropriate for use.

Based on record reviews, interviews and review of the facility policy titled, Advance Directives, the facility failed to ensure Resident (R)19 and R42 were afforded the right to formulate an advance directive for 2 of 4 residents reviewed for Advance Directives. Findings Include: The facility admitted R19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on [DATE] at 1:22 PM of the medical record for R19 revealed no documentation to ensure R19 was afforded the right to formulate an Advance Directive. Further review on [DATE] at 1:25 PM of the medical record for R19 revealed no assessments and signatures of 2 physician's indicating that R19 was not able to make her own healthcare decisions. During an interview on [DATE] at 3:35 PM with the Director of Nursing (DON), she confirmed that R19 was not afforded the right to formulate her choices for an Advance Directive. Review on [DATE] at 9:14 AM of the facility policy titled, Advance Directives, states, Advance directives will be respected in accordance with state law and facility policy. The Policy Interpretation and Implementation states under #1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medial or surgical treatment and to formulate an advance directive if he or she chooses to do so. Number 6 states, Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, or his/her family members and/or his or her legal representative, about the existence of any written advance directives. Number 7 states, Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Number 8 states, If the resident indicates that he or she has no established advance directives, the facility staff will offer assistance in establishing advance directives: a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Number 9 states, The attending physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan. Review of the electronic medical record (EMR) Face Sheet revealed R42 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R42's clinical EMR revealed there was no documentation of an Advanced Directive. Review of R42's comprehensive Care Plan revealed the resident was a Full Code (Direction to perform Cardiopulmonary Resuscitation (CPR) in the event the heart stops) . In an interview with the DON on [DATE] at 12:00 PM, it was confirmed that there was no documentation to show Advanced Directives information provided to R42. She further stated that there were some family dynamic issues surrounding R42, and the facility was working to get them resolved.

Based on observation and interview, the facility failed to maintain a homelike environment for one of two residents (Resident (R) R42) reviewed for environment. Specifically, R42 had food crumbs, paper trash, and other particles on the floor. This had the potential to affect all 47 residents residing in the facility. Findings Include: During initial tour of the facility on 01/31/22 at 12:43 PM, observation of food crumbs and paper trash were noted lying on the floor in R42's room. Observation on 02/01/22 at 8:54 AM , food crumbs and paper trash were observed on the floor in R42's room located in the same place as observed on the previous day. Observation on 02/02/22 at 8:59 AM, food crumbs and paper trash were observed on the floor in R42's room located in the same place as observed on the previous dates of 01/31/22 and 02/01/22. Observation on 02/02/22 at 8:59 AM, during a wound care observation with R42, it was noted the floor had a large amount of food crumbs and other non-identified dirt particles, a smashed brown food substance, a dried red liquid substance, gauze, and paper debris (under the bed), and pink plastic caps from nebulizer medication solution containers. The food and unidentified dirt particles were scattered throughout the room floor and on of the overbed tables. There was no liner in the trash can in the room. In an interview with the Housekeeper on 02/02/22 at 3:45 PM, she stated the skilled unit was normally her assigned unit, however, since she was the only housekeeper, she covered the entire facility at this time. She stated the routine procedure was to clean every resident room daily. She stated because of her being the only housekeeper, she was unable to get to every resident's room every day. She stated she would start on one day at one end of the hallway and then the next day the other end of the hallway. She stated she had not cleaned R42's room today (02/02/22). She confirmed the R42's floor was dirty, and she would get to it the next day. She confirmed the smashed in substance on the floor was food and the red substance was some type of liquid. She stated when asked if R42 had kept her room messy with food and paper products, Not too much, she doesn't get out of bed most days. The Housekeeper stated she thought she had cleaned R42's room, at least swept it the day before, but wasn't sure.

Based on interview and record review, the facility failed to ensure two of two sampled residents (Residents (R) R30 and R42), who were given mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, R30 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R42 was admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure placed the residents at risk for unmet care needs, unnecessary medication/s, and at risk for not receiving appropriate mental health treatment and support/services needed. This had the potential to affect all residents with a mental health diagnosis. Findings Include: Review of the Review of the Diagnostic Criteria for [CONDITION(S)] in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) provided the following information regarding [CONDITION(S)] due to general medical condition: .A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by a mental disorder. D. The disturbance does not occur exclusively during the occurrence of [CONDITION(S)] .The hallmark features of psychotic disorders such as [CONDITION(S)] are hallucinations, delusions, and disordered thinking . Review of the National Institute of Mental Health booklet titled, [CONDITION(S)], (NIH Publication No. 15-3517), indicated, Symptoms [of [CONDITION(S)]] such as hallucinations and delusions usually start between ages 16 and 30 .Most commonly, [CONDITION(S)] occurs in late adolescence and early adulthood. It is uncommon to be diagnosed with [CONDITION(S)] after age 45. Review of the Behavioral Assessment, Intervention and Monitoring Policy dated March 2019 stated: .1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder. a. All residents will receive a Level I PASARR screen prior to admission, b. If the Level I screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability, or related condition he or she will be referred to the state PASARR representative for the Level II (evaluation and determination) screening process. c. The Level II evaluation report will be used when conducting the resident assessment and developing the care plan . 1 . Review of R30's electronic medical record (EMR), Face Sheet stated, R30 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R30 received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R30's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/19/21 revealed R30 scored a 14 out of 15 on the Brief Instrument for Mental Status (BIMS) assessment, indicating R30 was cognitively intact. It was documented R30 had a progressive neurological condition. It was documented R30 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R30's significant change in status MDS with an ARD of 01/04/22, documented in the PASARR section of the assessment that R30 was not evaluated for a level two PASARR. It was documented R30 declined in cognition and scored a 02 out of 15 on the BIMS assessment. R30 was documented with changes in mood and exhibited no change in behavior. It was documented R30 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R30's functional status indicated no change and documented R30 required supervision to extensive assistance from staff with activities of daily living (ADL). Review of the PASARR level one screening for R30 dated 10/24/19, documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no mention of the psychiatric disorder diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2 . Review of R42's EMR face sheet stated, R42 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PASARR level one dated 01/13/21 for R42 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation indicating R42 had a mental diagnosis. Review of the admission MDS with an ARD of 01/20/21 for R42 revealed in the PASARR and condition assessment, it was documented R42 had not had a PASARR level two referral completed. It was documented R42 had no behaviors. Review of the quarterly MDS with an ARD of 10/16/21 for R42 revealed active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented mood or behaviors. It was documented R42 received seven days of antipsychotic and antidepressant medications. There were no psychological therapy minutes documented. Review of the annual MDS with an ARD of 01/16/22 for R42 revealed active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It was documented R42 was assessed to be severely cognitively impaired and unable to make decisions. R42 was assessed to have disorganized thinking, difficulty focusing, and altered level of consciousness. It was documented R42 received six days of antipsychotic medications and seven days of antidepressants. There were no psychological therapy minutes documented. An interview on 02/03/22 at 9:30 AM, with the Social Worker (SW), confirmed the PASARR process was not done correctly, and the facility should have referred a PASARR level two for R30 and R42 for the newly diagnosed mental illness. She confirmed she was aware of the regulation.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement the comprehensive care plan interventions for two residents (Resident (R) 30 and 41) of five reviewed for [CONDITION(S)] medication care plan/s. These failures had the potential to affect all residents prescribed [CONDITION(S)] medications with target behaviors by increasing the potential for harm due to the facility failing to implement nonpharmacological methods that were identified on the care plan with the usage of unnecessary medications. Findings include: Review of the Admission Record, located on the Face Sheet in the electronic medical record (EMR), indicated R41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the EMR admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/14/22, revealed R41 was moderately cognitively impaired and was documented to have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The notes stated Indication: anxiety, agitation, Instructions: Therapeutic Range. There were no orders to monitor adverse side effects or identified target behavior/s for the use of the medication. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R41's comprehensive care plan titled Care Plan Report with the problem .R41 has behavior symptoms AEB (As evidenced by) yelling, agitation, episodes of hitting/slapping her arm, prefers to not use utensils at times . dated 01/07/22 revealed the goal was to decrease the resident ' s behavior symptoms over the next review AEB the nursing documentation of the episodes. The interventions listed were .Encourage caregivers to participate in activities with resident to promote positive interactions. Document behaviors in clinical record. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Respond in a calm voice; maintain eye contact. Remove from area if resident is agitated. Resident has a purple hat she wears at times to help calm her. Tv on with soft music channel on may also calm her. Resident has a favorite quilt that she likes to be put over her legs . Review of R41's behavioral monitoring documentation located on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Action: antianxiety side effects and behaviors however, there were no specific target behaviors listed. The daily documentation for the month of January 2022 had not been documented. Further review revealed the two days where there were behavioral symptoms noted the documentation had not specified what type of target behavior was exhibited. However, there was documentation to show the resident was re-directed successfully with non-pharmacological interventions with no specific documentation to show which intervention was implemented. The documentation revealed that the facility had not consistently monitored and implemented the plan of care related to the use of [CONDITION(S)] medication and the correlated identified target behavior/s. Progress note dated 02/01/22 stated PRN [MEDICATION(S)] continues for anxiety with good effect when used. Purple hat also helpful with calming pt. In an interview with the Physical Therapist on 02/02/22 at 11:54 AM, she stated The resident ' s agitation fluctuates throughout the day. When she verbally gets frustrated and gets loud, staff redirects and speaks with her calmly. She follows commands with extra time and reminders. Her frustration is due to dementia and when she gets tired. When this happens, staff repositions her in the bed and she calms down. In an interview with Licensed Practical Nurse (LPN) 3 on 02/02/22 at 11:58 AM, she stated When staff tries to get the resident out of the bed, her agitation stems from confusion, she doesn't know where she is and why she's here. Staff redirects her and speaks with her calmly and answers her questions (e.g., Where she is? Where are her kids?). Other than redirection, she is taken out of stimulating areas, staff will dim the lights in her room, etc. In an interview with the Social Services Director on 02/02/22 at 2:44 PM, she stated The resident's agitation depends, she has her moments. You cannot put chocolate in front of her and she likes staff to write down what they are doing today. She naturally speaks loudly and will repeat herself at least 3 or 4 times. She wants everything explained to her. She likes the engagement stations (e.g., folding clothes) she does not like big social groups, she likes listening to music, but Frank Sinatra sets her off because that is her and her husband ' s song and she will get upset when she hears it. She likes the concerts, one-to-one activities, and she likes crafts, but it has to be one or two steps. If agitated staff would ask her what she wants, sometimes she gets frustrated because she cannot communicate what she wants. Staff would redirect or relocate the resident and try to find the solution and determine if she is upset because of the location or if it is too much stimulation. The facility's certified dementia training tells you how to approach the situation to determine why the residents are upset and how to resolve the issue. The resident was in memory care, but now that she's in rehab and sometimes she doesn't want to participate. During a phone interview with LPN 4 on 02/03/22 at 9:58 AM, she stated At night the resident gets agitated, and she tries to get out of bed, but she isn't aggressive. If she gets agitated, I do one to one, hold the resident ' s hand, and then she calms down. If a PRN is given for 14 days, the resident should be reevaluated because she may need to have it routinely if that is going to be used to get her anxiety under control. When they receive training, they are introduced to residents that have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff indicated in interviews that R41 was easily redirected by utilizing non-pharmacological interventions however, according to review of R41's MAR, the PRN [MEDICATION(S)] was administered on the following dates: 01/07/22, 01/08/22, 01/09/22, 01/10/22, 01/11/22, 01/15/22, 01/16/22, 01/18/22, 01/20/22, 01/21/22, 01/22/22, 01/23/22, 01/24/22, 01/25/22, 01/28/22, and 01/29/222 without complete documentation of what behavior was targeted, what non-pharmacological intervention was implemented prior to administering the medication, and how successful was that intervention. Review of R30's EMR, Face Sheet indicated, R30 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R30 received a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R30's admission MDS with an ARD date of 02/19/21 revealed R30 scored 14 out of 15 on the Brief Instrument for Mental Status (BIMS) assessment which meant R30 was cognitively intact. It was documented R30 had a progressive neurological condition. It was documented R30 had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R30's Quarterly MDS dated [DATE] revealed BIMS score of 08 out of 15; showed no evidence of an acute change in mental status from the resident's baseline; Section D-Mood, showed no change from resident's baseline, with a severity score of 00; Section E-Behavior showed no change from resident's baseline; I- Active Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .g., [CONDITION(S)] and schizophreniform disorders). Section N-Medications - Medications revealed antipsychotics were received on a routine basis only, GDR has not been documented by a physician as clinically contraindicated. Section Q-Participation in Assessment and Goal Setting- resident participated along with family member. Review of R30's Quarterly MDS dated [DATE] revealed BIMS score of 08 out of 15, Section D- Mood - no change since last quarter; Section E-Behavior -no change since last quarter Section N- revealed antipsychotics were received on a routine basis only, GDR has not been documented by a physician as clinically contraindicated. Review of R30's MDS - Significant Change in Status Assessment, dated 01/04/22, documented re-entry from an acute hospital on 12/21/21. Section C- Cognitive Patterns R30 declined to a BIMS score of 02. Section D - Mood R30 showed some change with mood scored 04 on the Resident Mood Interview. Section E - Behaviors it was documented R30 exhibited no change in behavior. Review of Psychoactive Utilization records for 07/20/21 and 08/13/21, 08/20/21 and 09/09/21, and 11/20/21 and 12/12/21, document [MEDICATION(S)] (for [CONDITION(S)]) Tab 1 MG q 12 hrs., [MEDICATION(S)] (for hallucinations) 34 mg qd, and [MEDICATION(S)] (for depression anxiety) bid - depr, are being prescribed by orders dated 02/12/21, with the next evaluation date shown as 06/21. Review of Progress notes dated 02/12/21 through 01/31/22. There were no documented notes from the physician or the Interdisciplinary Team indicating that R30's medications had been reviewed. Review of Non-PRN Treatment Notes, (which monitor the behaviors and side effects of the medications), from 11/21 - 02/22 documented one incident of hitting and kicking, on the evening of 01/24/22. Clinical Notes documented by the Pharmacist show on 12/12/21: Note to MD regarding psych meds; 01/15/21: Resident is now Hospice status. NP c/I GDRs 12/15/21. No irregularities found. Review of the Recommendation to MD from Pharmacist letter, dated 12/12/21, and the Summary of Recommendations to MD and Nursing letter, dated 12/21/21, document the Pharmacist sent letters to the physician and the facility, regarding R30's [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no signed documents of these two forms. During an interview with the Pharmacist on 2/3/22 at 11:59 AM, she stated she has worked for the facility for four years, and visits once a month, or more if needed. She conducts monthly pharmacy reviews, and the inhouse pharmacist conducts the initial Medication Regimen Review (MRR). If the doctor does not respond to the MRR, she will follow up within two months. The facility doesn't consistently respond to the MRR. Sometimes the medical staff will document on the progress notes. She reviews the nurses' notes for behaviors, medications given and the reason, PRN medication usage and will check the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Pharmacist reviews the care plan of hospice residents to evaluate the continuation of medications. She attends the Quality Assurance meetings and follows a template that ask general questions about the number of residents on [CONDITION(S)] medications. When she brings up her concerns in the QA meetings, the MD states they are aware of the issue. The Pharmacist confirmed that she knows that the regulation states antipsychotics must be written every 14 days and it has been discussed with medical staff. Ideally, she would like to see on admission, the MD write the order for 14 days which will discontinue the use of the antipsychotic, if not reevaluated. Box warnings are placed on antipsychotics. She confirmed that [CONDITION(S)] is unlikely to be diagnosed after the age of 30.

Based on observations, record review, interview and review of the facility's policy titled, Wound Care, and Handwashing/Hand Hygiene, the facility failed to ensure proper wound care for Resident (R)1 for 1 of 3 residents reviewed for Pressure Ulcers. Findings Include: The facility admitted R1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 2/2/22 at 12:05 PM of the medical record for R1 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Clean the left and right buttocks and perineum with wound cleanser and pat dry. Apply collagen powder and calcium alginate to the wound bed and cover with a dry dressing and secure with tape. An observation on 2/2/22 at 12:10 PM of wound care for R1 went as follows: Registered Nurse (RN)1 and Licensed Practical Nurse (LPN)1 began preparing R1 for the wound care. RN1 applied gloves to her hands and removed the top cover from the resident and raised the bed for better access to R1's wounds. Using the same gloved hands, RN1 mixed the collagen powder with normal saline making a paste like consistency. The LPN assisting applied gloves and aided R1 in removing his pants, and removing the brief. Using the same gloved hands, RN1 then sprayed wound cleanser on 4x4s and the open area and began wiping back and forth across the wounds. Then taking clean 4x4s in hand, she patted the area dry. Never changing her gloves and never washing or sanitizing her hands. RN1 then applied the collagen powder paste using a wooden applicator and then applied a full sheet of calcium alginate over R1's entire bottom, not applying it to only the wound beds. RN1 then, using the same gloved hands, peeled the back off a large piece of clear tape and applied this over the entire dressing. Using the same gloved hands, RN1 cleaned the paper off the bed and placed it in a trash bag and removed her gloves that she had used during the entire procedure, washed her hands and charted the treatment. During an interview on 2/2/22 at 4:30 PM with RN1, she confirmed that she had not washed her hands, changed her gloves nor had she used hand sanitizer during the entire dressing change. RN1 also confirmed that she had used the entire sheet of calcium alginate and placed it over R1's entire bottom and not just the wound beds as ordered. Review on 2/3/22 at 7:45 AM of the facility policy titled, Wound Care, states under, Purpose, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Under, Steps in the Procedure, number 2 states, Wash and dry your hands thoroughly. The wound are policy also states after removing a soiled dressing, Wash and dry your hands thoroughly. Review on 2/3/22 at 7:50 AM of the facility policy titled, Handwashing/Hand Hygiene, states under the policy statement, The facility considers hand hygiene the primary means to prevent the spread of infections. Under the Policy Interpretation and Implementation states under number 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Number 9 states, The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation and interviews, the facility failed to ensure there was sufficient nursing staff available to respond to call lights and assist residents as needed for five of the 12 residents (Residents (R) R32, R10, R22, R29, R39) attending the Resident group and one of two residents reviewed for environment (R32). This failure has the potential to affect all residents who resided in the facility. The census was 43. Findings include: On 01/31/22 at 12:47 PM, R32 was observed eating while in bed. R32 was leaning to her right side while eating her food with her left hand. When asked if she was ok, R32 stated she was concerned about her position because she couldn't see her food. When asked if R32 had activated the call light to request for assistance in positioning, R32 stated she didn't know where the call light was. Further observation revealed after activating the call light it was approximately 15 minutes later, staff had not come to assist the R32. Observation of the nurse ' s station revealed no one was at the nurse's station at the time R32's call light was activated. During an interview on 01/31/22 at 3:20 PM with R10, it was revealed R10 stated that they (meaning the facility) don't have enough staff. R10 stated when he rings his call light; staff do not come in a timely manner. During an observation and interview with R32 on 02/02/22 at 8:59 AM, R32 was observed leaning in bed and stated that she wished she could have a straw to drink her juice with so it wouldn't spill. Further observation revealed R32 activated her call light for assistance and at 9:08 AM, there was still no response to the call light. During an interview with Licensed Practical Nurse (LPN) 4 on 02/02/22 at 9:08 AM revealed LPN4 stated he would assist R32 after surveyor intervention. Further interview at 9:15 AM with LPN4 stated that the call light system was a pager system and when activated, the pager gives an alert to the Certified Nursing Assistant (CNA) and also showed on the facility's computer system at the nurse's station. During the Resident group meeting on 02/02/22 at 11:03 AM, R10, R22, R29, R32, R39 stated that they had to wait extended times when they activated their call light system. During an interview on 2/03/22 with the Director of Nursing (DON), it was stated that they are working on call light response times and making sure the call light pagers are actually working. Audits were completed in January for this process.

Based on observation and interview, the facility failed to respond to Resident (R)41 during a hallucination episode. Findings Include: An observation on 2/2/22 at 11:09 AM revealed R41 in the dining area having a hallucination episode for 20 minutes with little to no staff intervention or redirection attempts. Certified Nursing Assistant (CNA)1 was observed during this time period on their phone in close proximity to the resident. Further observation revealed Physical Therapist (PT) 2 redirect the resident and assist them to the therapy gym. An interview on 2/2/22 at 11:37 AM with CNA1 revealed that he heard the resident yelling, but didn't think to help with an intervention because he thought the therapy staff had it covered. Further interview confirmed that CNA1 was on the phone looking through messages during the time of R41's hallucination episode. A phone interview with the Resident Representative for R41 revealed ongoing concerns related to staffing and the quality of care R41 is currently receiving at the facility. An interview with the Director of Nursing (DON) on 2/3/22 at 3:20 PM revealed CNA1 was terminated from the facility due to lack of providing care to multiple residents.

Based on observations, interviews and review of the facility policy titled, Administering Medications, the facility failed to ensure medications were not touched for Resident (R)145 with bare hands during administration of medications on the 200 Hall for 4 medications out of 25 opportunities for error. The medication error rate was 16 percent. Findings Include: An observation on 2/1/22 at approximately 8:00 AM of medication administration for R145 revealed Licensed Practical Nurse (LPN)1 administering medications to R145. The LPN had 4 pills in a medicine cup and went to R145's room. She sat the cup of medications on a 3 drawer compartment outside R145's room door used for personal protective equipment. The LPN accidentally knocked over the cup of medications and picked them up one by one using her bare hands. The Director of Nursing was observing and asked the LPN if she had made sure that the cup now contained the total of 4 and the LPN stated it did. LPN1 then carried the pills into the resident's room and administered them to R145. During an interview on 2/1/22 at approximately 8:15 AM with LPN1 and the Director of Nursing, they both confirmed that LPN1 had touched the medications with her bare hands. Review on 2/1/22 at approximately 9:00 AM of the facility policy titled, Administering Medications, states under the Policy Statement, Medications are administered in a safe and timely manner and as prescribed. The Policy Interpretation ad Implementation states under #2, The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Number 25 states, Staff follows, established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc) for the administration of medications, as applicable.

Based on observations, interviews and review of the facility policy titled, Storage of Medications, the facility failed to ensure expired medications were removed from the 200 North Hall medication cart and not stored with medications for resident use on 1 of 4 medication carts observed . The facility further failed to ensure medication carts were locked on on the 100 North Hall and on the 200 South Hall for 2 of 4 medication carts observed. The facility additionally failed to ensure expired mediations were removed from the refrigerator in the 200 South Hall medication room for 1 of 4 medication rooms reviewed. Findings Include: An observation on 2/1/22 at 3:00 PM of the 200 North Hall medication cart revealed the medication, [MEDICATION(S)] 1 tablet of 5 milligrams expired on 1/20/22. The medication [MEDICATION(S)] 1 tablet of 10 milligrams expired on 1/20/22 and [MEDICATION(S)] Hydrocel 1 tablet of Lot A KvK-Tech expired on 1/20/22. During an interview on 2/1/22 at 3:00 PM the Director of Nursing confirmed the expired medications and removed them from medications for resident use. An observation on 2/2/22 at 8:00 AM revealed the medication cart on 100 North Hall unlocked and unattended. An observation on 2/2/22 at 11:55 AM revealed mediation cart on the 200 South Hall unlocked and unattended. An interview on 2/2/22 at 8:00 AM with Registered Nurse (RN)2 confirmed the findings and locked the cart and using the key pad on the cart. Review on 2/2/22 at 9:50 AM of the facility policy titled, Storage of Medications, states, under policy statement, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Under, Policy Interpretation an Implementation, number 4 states,Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Number 6 states, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. An observation on 2/3/22 at 3:05 PM of the 200 South medication room refrigerator revealed 8 droppers of Serum 50% Ophthalmic Drops Lot# 021@9 with a use by date of 5/3/21. The findings were confirmed and removed by the consulting Pharmacist.

Based on observations, interviews and review of the facility policy titled, Administering Medications, the facility failed to ensure medications were not touched for Resident (R)145 with bare hands during administration of medications on the 200 Hall for 4 medications out of 25 opportunities for error. Findings Include: An observation on 2/1/22 at approximately 8:00 AM of medication administration for R145 revealed Licensed Practical Nurse (LPN)1 administering medications to R145. The LPN had 4 pills in a medicine cup and went to R145's room. She sat the cup of medications on a 3 drawer compartment outside R145's room door used for personal protective equipment. The LPN accidentally knocked over the cup of medications and picked them up one by one using her bare hands. The Director of Nursing was observing and asked the LPN if she had made sure that the cup now contained the total of 4 and the LPN stated it did. LPN1 then carried the pills into the resident's room and administered them to R145. During an interview on 2/1/22 at approximately 8:15 AM with LPN1 and the Director of Nursing, they both confirmed that LPN1 had touched the medications with her bare hands. Review on 2/1/22 at approximately 9:00 AM of the facility policy titled, Administering Medications, states under the Policy Statement, Medications are administered in a safe and timely manner and as prescribed. The Policy Interpretation ad Implementation states under #2, The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Number 25 states, Staff follows, established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc) for the administration of medications, as applicable.