**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, interviews, review of a facility policy titled Administration of Medication, and review of the facility job description for LPN/RN (Licensed Practical Nurse/Registered Nurse) CHARGE NURSE the facility failed to ensure Resident Identifier (RI) #7's Triamcinolone 0.1 percent (%) cream and Triamcinolone 0.025 % ointment was administered according to physician orders on 03/04/2023 and 03/05/2023 by Employee Identifier (EI) #8 LPN and EI #9 LPN. Further, the facility failed to ensure Employee Identifier (EI) #6 LPN did not give prepared medication to EI #5 a Certified Nursing Assistant (CNA) to administer to RI #7 on 03/07/2023. These deficient practices had the potential to affect RI #7, one of 12 residents sampled who received medications in the facility. Findings include: On 11/30/2022 the State Survey Agency received an anonymous complaint via the Alabama Department of Public Health Online Incident Reporting System. The anonymous complainant alleged RI #7 waited over three hours for anti-itch medication. A facility policy titled Administration of Medication, revised 08/01/2019, documented Policy Statement Residents shall receive their medications on a timely basis and in accordance with our established policies. Procedure 1. Drugs and biologicals may be administered only by licensed physicians, licensed registered or practical nursing personnel, or by other personnel who are duly authorized to perform such services under state law. An undated and unsigned facility Job Description titled LPN/RN CHARGE NURSE documented . JOB SUMMARY: . prepare and administer medications, assess and document findings of the residents in accordance with federal, state, local and facility standards and policy/procedures, . MEDICATION ADMINISTRATION . Prepare and administer medications to the proper resident as per MD orders, regulatory guidelines, and nursing standards. RI #7 was admitted to the facility on [DATE]. RI #7's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented RI #7 was assessed for a Brief Interview for Mental Status (BIMS) score of 15 which indicated RI #7 had intact cognition. RI #7's physician orders for March 2023 documented an order dated 02/09/2023 for Triamcinolone 0.1 percent (%) cream to be applied to a rash twice a day at 8:00 AM and 4:00 PM and an order dated 02/27/2023 for Triamcinolone 0.025 % ointment to be applied to the groin area twice a day at 8:00 AM and 4:00 PM for Eczema. RI #7's Electronic Treatment Administration Record (e-TAR) for March 2023 documented RI #7 was to receive Triamcinolone 0.1 % cream to be applied to a rash twice a day at 8:00 AM and 4:00 PM and Triamcinolone 0.025 % ointment to be applied to the groin area twice a day for Eczema at 8:00 AM and 4:00 PM. The 4:00 PM doses were not documented as having been administered and the areas provided for this documentation on the e-TAR were left blank. On 03/07/2023 at 9:38 AM RI #7 said, he/she had Eczema and Sunday night (03/05/2023), treatment for it was not provided. RI #7 was in bed and raised forward in the bed to show the surveyor his/her back with reddened areas all over his/her back and the back of his/her thigh. On 03/08/2023 at 4:21 PM EI #8 LPN was asked what shift she worked on 03/04/2023 and 03/05/2023. EI #8 said, 6:00 AM - 6:00 PM. When asked why the Triamcinolone 0.1 % at 4:00 PM was not documented on RI #7's treatment record, EI #8 said, it was given once on her shift and once on night shift. When asked if she applied the cream due at the 4:00 PM dose, EI #8 said, she just gave it one time in the morning. When asked why she did not document Triamcinolone 0.25 % at 4:00 PM on 03/04/2023 and 03/05/2023 for RI #7, EI #8 said, she did not give the cream. EI #8 said, EI #9 was the night shift nurse that gave the cream. EI #8 was asked, if a medication was scheduled to be given at 4:00 PM, when it should be given. EI #8 answered between 3:00 PM and 5:00 PM. EI #8 said, the risk of not giving the cream as prescribed would be the rash would not go away. On 03/08/2023 at 5:08 PM EI #9 LPN was asked what shift she worked on 03/04/2023 and 03/05/2023. EI #9 answered, 6:45 PM - 6:45 AM. When asked what cream she applied to RI #7, EI #9 answered, one was an ointment and one was a cream. When asked what time she applied the cream and ointment, EI #9 said, on Saturday, 03/04/2023, probably around 10:00 PM. EI #9 said, it was due at 4:00 PM. EI #9 said, she did not give the cream or ointment on 03/05/2023, Sunday night. EI #9 said, she did not document that she gave the cream or ointment on Saturday, but she gave it because RI #7 said it had not been administered. EI #9 said, if a medication was scheduled for 4:00 PM it should be given between 3:00 PM and 5:00 PM, not on her night shift. 03/09/2023 at 8:30 AM EI #2 DON was asked when a topical medication cream was to be administered at 4:00 PM who was supposed to administer the medication. EI #2 answered, the nurse that was on duty at 4:00 PM should have done the treatment. When asked what the risk was of a resident not getting Triamcinolone 0.1 % and 0.025 % at 4:00 PM, as ordered, EI #2 said, the nurses were not following the physician's orders. EI #2 said, the nurse at 4:00 PM should have administered the resident's cream. EI #2 said, the resident not receiving the cream resulted in the resident not receiving the medication like they were supposed to for Eczema. EI #2 said, the cream was for relief of itching and the itching would not be relieved if RI #7 did not get that medication. On 03/07/2023 at 7:15 PM an interview was conducted with RI #7. RI #7 was asked, when did he/she get his/her cream applied on that afternoon, 03/07/2023. RI #7 replied, after EI #5 checked and changed him/her. RI #7 said, EI #5 applied the cream and EI #5 told RI #7 the nurse told him what to do. RI #7 was asked if the nurse was in the room at the time EI #5 applied the cream. RI #7 replied, no. On 03/07/2023 at 6:38 PM an interview was conducted with EI #5 CNA. EI #5 was asked, what care he provided for RI #7. EI #5 replied, changing, assisting with activities of daily living, and applying cream on RI #7. EI #5 was asked, where he got the cream from. EI #5 replied, the nurse gave the cream to him. EI #5 was asked, what kind of cream it was. EI #5 replied, Triamcinolone, for itching. EI #5 was asked, who applied the cream. EI #5 replied, he did. EI #5 was asked if the nurse was in the room. EI #5 replied, no. EI #5 was asked, why he applied the cream. EI #5 replied, the nurse told him to do it. EI #5 was asked, what time he put the cream on RI #7. EI #5 replied, after he changed RI #7. EI #5 was asked, about what time that was. EI #5 replied, 4:30 PM. On 03/07/2023 at 7:03 PM an interview was conducted with EI #6 LPN. EI #6 was asked about the cream RI #7 was to receive. EI #6 said the cream was Triamcinolone and was to be given for the rash RI #7 had. EI #6 was asked, when RI #7's Triamcinolone was applied on her shift. EI #6 replied, after RI #7 was changed by EI #5. EI #6 was asked, who applied the Triamcinolone. EI #6 replied, EI #5. EI #6 was asked, when should the CNA apply the Triamcinolone cream. EI #6 replied, CNAs can not apply Triamcinolone cream. EI #6 was asked, why EI #5 applied the cream. EI #6 replied, he should not have applied it. EI #6 was asked, why did he. EI #6 replied, she told him to apply it after he changed RI #7. EI #6 was asked, if the cream required an order. EI #6 replied, yes. EI #6 was asked, what was the concerns of a CNA applying the prescribed cream. EI #6 replied, he was not licensed. EI #6 was asked, what was the facility policy of the CNA applying a prescribed cream to a resident. EI #6 replied, the CNAs can not do a prescribed medication. EI #6 was asked, who should have applied prescribed cream to RI #7. EI #6 replied, she should have. On 03/09/2023 at 8:30 AM an interview was conducted with EI #2 Director of Nursing (DON). EI #2 was asked, who should administer prescribed creams and ointments. EI #2 replied, nurses or medication assistants. EI #2 was asked, when should a CNA administer prescribed creams and ointments to residents. EI #2 replied, CNAs should not. EI #2 was asked, what was the risk of a CNA administering Triamcinolone to residents. EI #2 replied, not following the physician's orders or not applying it the way that it was supposed to be applied. EI #2 was asked what staff members could provide treatments according to facility policy. EI #2 replied, nurses and medical assistants.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record review, and review of facility policies titled Resident Behaviors and Comprehensive Person-Centered Care Plans, the facility failed to ensure a behavioral care plan was developed with person-centered interventions for Resident Identifier (RI) #10, a resident with documented behavior health concerns who also received medications for Depression. This affected RI #10, one of three residents sampled for behavioral health concerns. Findings include: An undated facility policy titled Resident Behaviors documented the following: . It is the policy of this facility to provide appropriate behavioral interventions in order to effectively manage behavioral symptoms that are out of the ordinary for our residents. A facility policy titled, Comprehensive Person-Centered Care Plans, with two unspecified dates, 11/28/2017 and 10/24/2022, documented: .Policy The facility will complete comprehensive care plans for each resident based on an interdisciplinary team assessment. The Comprehensive care plans will be person centered, and include measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychosocial needs. RI #10 was admitted to the facility on [DATE]. RI #10's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/12/2022, documented RI #10 was assessed with a Brief Interview for Mental Status (BIMS) score of 13, which indicated RI #10 was cognitively intact; RI #10 was assessed as having a depressive mood and as exhibiting physical, verbal, and other behaviors. RI #10's quarterly MDS with an ARD of 11/7/2022 documented RI #10 was assessed with a BIMS score of 14, which indicated RI #10 was cognitively intact; RI #10 was assessed for mood as feeling down, depressed, or hopeless at least half of the time for the prior two weeks. RI #10's DAILY SKILLED NURSES NOTE records documented Mood/Behavior with an x marked in a box that indicated the following behaviors were present: On 08/07/2022 RI #10 was restless/fidgety/anxious. On 08/10/2022 RI #10 was restless/fidgety/anxious. On 08/13/2022 RI #10 had inappropriate verbal behaviors. On 08/16/2022 RI #10 was was restless/fidgety/anxious and had inappropriate verbal behaviors. On 08/18/2022 RI #10 was restless/fidgety/anxious. On 08/19/2022 RI #10 was restless/fidgety/anxious. On 08/23/2022 RI #10 was restless/fidgety/anxious and easily annoyed. On 08/25/2022 RI #10 was restless/fidgety/anxious, easily annoyed, and the note further documented RI #10 cried out for help even while staff was in the room providing care to RI #10. An undated note documented RI #10 was restless/fidgety/anxious, had inability to concentrate; and had inappropriate physical, social, and verbal behaviors. Documentation was reviewed, of RI #10's admission visit with the Certified Registered Nurse Practitioner (CRNP) dated 08/08/2022, that was signed as reviewed by the CRNP on 08/29/2022. The documentation of the visit listed problems to include: Adjustment Disorder with Depressed Mood; Insomnia; Noncompliance with medication regimen; and Suspected Victim of Elder Neglect that occurred prior to admission the facility. Documentation of RI #10's follow up visits with the CRNP was reviewed. RI #10 had behaviors reported to the CRNP during the visit dates as follows: On 08/18/2022 the facility nursing staff noted behaviors from the resident including aggression, agitation, and unwillingness to cooperate with staff. On 08/22/2022 RI #10 was noncompliant with medications and was sent to the hospital Emergency Department after throwing a bottle at staff. On 08/26/2022 nursing staff continued to report behaviors such as yelling out to staff rather than pressing the call light. RI #10's Psychiatric Evaluation dated 08/18/2022 documented an Initial Evaluation for RI #10 as follows: RI #10 had a diagnosis of Adjustment Disorder; RI #10 was coping with many social and living stressors; staff had challenges with RI #10's behaviors starting from admission; RI #10 had mood symptoms to include depressed mood; RI #10's appearance and behaviors at the time of the assessment included tearfulness and crying; RI #10 was to start the medication Zoloft for irritability and Adjustment Disorder. Review of RI #10's PSYCHIATRIC PERIODIC EVALUATION for follow-up evaluations on the following dates revealed: On 09/13/2022 RI #10 had a diagnosis of Mood Disorder due to medical condition and also had Possible Personality Disorder; staff reported RI #10 had exhibited staff splitting/manipulative behaviors; Zoloft and Depakote medications were started for erratic moods and irritability; RI #10 would benefit from psychotherapy. On 01/04/2023 RI #10 said he/she had a negative view on things and reported his/her mood was fair. On 01/12/2023 RI #10 continued to make excuses for him/herself and was tearful at times. RI #10's March 2023 physician orders documented RI #10 was to receive medications everyday for Mood Disorder and Adjustment Disorder with Depression and Anxiety. A review of RI #10's care plans revealed RI #10 did not have a plan of care to address target behavior concerns or medications ordered for Mood Disorder and Adjustment Disorder with Depression and Anxiety. RI #10 had a care plan that was initiated on 03/08/2023, during the survey, to address a problem of Risk for unstable mood related to diagnosis of depression. On 03/08/2023 at 3:38 PM Employee Indentifer (EI) #10, MDS and Care Plan Coordinator, when asked was asked who was responsible for developing care plans for RI #10. EI #10 said RI #10 resided on the Behavioral Unit in the facility and she was responsible for developing care plans for RI #10. EI #10 said, RI #10 had a Diagnosis of Depression and was receiving medication for Depression, but there was not a care plan to address Depression for RI #10. When asked the reason there was not a care plan to address depression for RI #10, EI #10 said, it probably just got missed. EI #10 said, care plans were important to make sure the right care was provided to residents and that each care plan should be tailored to the individual needs of residents. On 03/09/2023 at 2:43 PM EI #11 Resident Service Director, Social Worker, was asked who was responsible for the behavior management program. EI #11 said, she and the DON were. EI #11 said, if a behavior was identified the resident was care planned for that behavior. EI #11 said, behaviors would be documented in the nurses notes by the charge nurse, who would report it to the unit manager and/or physician, and the unit manager would implement a care plan. On 03/09/2023 at 3:15 PM EI #2 DON was asked about RI #10's behaviors. EI #2 said, RI #10's behaviors started, according to the nurses notes, on 08/07/2022 and included anxious, fidgety and restless behaviors; and other behavior included RI #10's refusal to use the call light, RI #10 would holler and scream for help and when staff would assist RI #10 with needs, before they could leave the room, RI #10 would continue to ask for help. EI #2 said, she thought RI #10 was just lonely. EI #2 said, RI #10 did not have a care plan to address behaviors and Depression but there should have been one developed, and it was just missed. EI #2 said, the purpose of the care plan was to guide the care of the resident. EI #2 said, RI #10 had approaches for staff to use in managing behaviors listed on other care plans, there was just not a care plan specific to RI #10's target behaviors and Depression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, resident record review, and review of a facility policy titled POLICY AND PROCEDURE HAND HYGIENE, the facility failed to ensure Employee Identifier (EI) #4 Certified Nursing Assistant (CNA) washed or sanitized their hands between residents and EI #7 Licensed Practical Nurse (LPN) washed or sanitized their hands and utilized Personal Protective Equipment (PPE) such as gloves in a manner to prevent the spread of infection. On 03/07/2023, during observations, EI #4 failed to wash or sanitize their hands after picking up a breakfast tray from one resident and before obtaining and delivering milk to RI #12. On 03/08/2023, during observations, EI #7 failed to wash or sanitize her hands before providing a treatment to RI #7, failed perform hand hygiene between glove changes and failed to ensure gloves were intact, without holes or tears, during topical medication treatment for RI #7. This had the potential to affect RI #12 and RI #7, two of 12 residents sampled during the survey. Finding include: A facility policy titled HAND HYGIENE, revised 06/18/2020, documented: Policy Statement Hand Hygiene shall be regarded by this organization as the single most important means of preventing the spread of infection. Appropriate hand hygiene must be performed under the following conditions: . 3. Whenever hands are obviously soiled. 8. Before and after assisting a resident with meals. 11. Before preparing or handling medications. 14. After contact with blood, body fluids, visibly contaminated surfaces . 15. After removing personal protective equipment . gloves, . 21. After removing gloves. The use of gloves does not replace handwashing. RI #12 was admitted to the facility on [DATE]. On 03/07/2023 at 9:11 AM EI #4 CNA was observed coming out of a resident's room, into the hallway, carrying a dirty breakfast tray from the room. EI #4 placed the dirty meal tray on a food cart. EI #4, without washing or sanitizing their hands, continued on to enter RI #12's room, came back out of RI #12's room, went to the milk cooler, and got a carton of milk to carry back to RI #12. On 03/07/2023 at 9:18 AM an interview was conducted with EI #4 CNA. EI #4 was asked, what they were doing with the tray. EI #4 replied, they took a finished breakfast tray from a room and put it on the food cart. EI #4 was asked, where they placed the dirty trays. EI #4 replied, on the food cart. When asked if that tray was clean or dirty, EI #4 said, it was dirty and the resident was finished with the breakfast tray. EI #4 was asked, when they sanitized their hands after placing the dirty meal tray on the food cart. EI #4 replied, after coming out of RI #12's room from delivering the milk. EI #4 said they did not sanitize their hands because they were told to sanitize their hands after every two trays. EI #4 was asked, why they did not wash or sanitize their hands before entering RI #12's room. EI #4 replied, they should have. EI #4 was asked, why did they not wash or sanitize their hands before picking up the milk in the cooler. EI #4 replied, they were not thinking about it. EI #4 was asked, what was the risk of not washing or sanitizing their hands before going into the cooler for milk. EI #4 replied, infection control. EI #4 was asked, what should have been done. EI #4 replied, they should have sanitized their hands before going into a resident's room and after picking up trays and putting them down on the food cart. RI #7 was admitted to the facility on [DATE]. RI #7's physician orders for March 2023 documented an order dated 02/09/2023 for Triamcinolone 0.1 percent (%) cream to be applied to a rash twice a day and an order dated 02/27/2023 for Triamcinolone 0.025 % ointment to be applied to the groin area twice a day for Eczema. On 03/07/2023 9:38 AM RI #7 showed the surveyor the reddened area all over his/her back and the back of his/her thigh. On 03/08/2023 at 9:07 AM EI #7 LPN was observed providing the Triamcinolone treatment for RI #7. EI #7 went into RI #7's room with a medicine cup filled with Triamcinolone 0.1 % cream. EI #7 put on gloves, closed the curtains while wearing the gloves, and then assisted RI #7 with positioning in the bed. EI #7 while wearing the same gloves, picked up the medicine cup and applied the cream with the spoon to her left hand. EI #7 then applied the cream to the resident's right arm, under arm, and right side. EI #7 then dipped her gloved hand into the cream in the medicine cup multiple times to apply the cream to different areas on the resident to include: the residents back and bottom; right chest and stomach and right leg; back of the left thigh; and after applying cream to all the areas, she removed her gloves and washed her hands. EI #7 stated she needed to get more cream and the other cream (0.025 %), and she would be back. At 9:23 AM, EI #7 came back in RI #7's room, put the medicine cups down on the bedside table, put on gloves, and with a spoon dipped some cream from the medicine cup onto her left gloved hand. EI #7 then applied the cream to RI #7's right lower abdomen. EI #7 then picked up the cream with her left hand, dipped her right hand in the medicine cup, and applied the cream to RI #7's left lower abdomen. EI #7 held the cream in her left hand with the same glove she had applied the cream on the right side of the resident. EI #7 dipped her right hand with a glove that was torn at the bottom and applied the cream with her right hand with the torn glove, to RI #7's abdomen, got more cream with the same torn glove, and applied the cream with her flat hand on RI #7's back, getting the cream on the whole palm of her hand. EI #7 removed her gloves and washed her hands with soap and water and put on new gloves. EI #7 removed the Triamcinolone ointment 0.025 % from the medicine cup and applied the ointment to RI #7's groin area. EI #7 removed the gloves and placed them and the medicine cups in the garbage can, then put on new gloves without sanitizing her hands. EI #7 then assisted in putting the gown back on the RI #7 and assisted in positioning RI #7, pulling back the curtains, and moving the bedside table to the resident's preference. EI #7 then removed the gloves and threw the gloves in the garbage. EI #7 then handed the call button to the resident without sanitizing her hands. EI #7 scratched her head with her bare hands, turned on the air conditioner, shook RI #7's hand, all before she washed her hands with soap and water. An interview was conducted on 03/08/2023 at 9:40 AM with EI #7 LPN. EI #7 was asked, what creams she applied to RI #7. EI #7 replied, Triamcinolone 0.1 % and Triamcinolone ointment 0.025 %. EI #7 was asked, when did she change her gloves after pulling the curtains and before applying the cream. EI #7 replied, she did not. EI #7 was asked, when should she change her gloves when applying cream to the residents. EI #7 replied, when a different cream and/or medication was used. EI #7 was asked, where was the tear in the glove on her right hand when she came back in the room from getting more cream. EI #7 replied, down by the palm. EI #7 was asked, how big was the tear. EI #7 replied, about an inch. EI #7 was asked, why did she use the gloves that had a tear in them to apply the cream. EI #7 replied, she did not know there was a tear in the glove. EI #7 was asked, if there was cream on her hands from applying the cream to the resident. EI #7 replied, yes, a little bit was on her hands. EI #7 was asked, how long the tear had been there before she noticed it. EI #7 replied, she did not know. EI #7 was asked, why she did not notice the tear. EI #7 replied, she did not know because she had cream all over her hands. EI #7 was asked, what was the risk of wearing gloves with a tear in them. EI #7 replied, risk of infection. EI #7 was asked, what was the risk of not changing gloves before applying the cream after pulling the curtain and assisting RI #7 to position in the bed. EI #7 replied, infection. A follow up interview with EI #7 was conducted on 03/08/2023 at 9:54 AM. EI #7 was asked, when did she wash or sanitize her hands after removing the dirty gloves and putting on new gloves before pulling RI #7's curtain. EI #7 replied, she did not realize that was what she did. EI #7 was asked, when did she sanitize her hands between glove changes before pulling the curtains and before moving the residents tray. EI #7 stated, she did not know she had to. EI #7 was asked, what was the risk of not sanitizing her hands before applying new gloves, after applying cream to RI #7. EI #7 replied, infection. EI #7 was asked, when should she have sanitized her hands. EI #7 replied, every time she changed her gloves. An interview was conducted on 03/08/2023 at 11:58 AM with EI #3 Infection Preventionist/Registered Nurse. EI #3 was asked, what was the policy for hand hygiene. EI #3 replied, when coming on shift, in between residents, between passing trays and picking up trays, before the employee eats, when visibly soiled, with any kind of patient care, and anytime. EI #3 was asked, how often was staff educated on hand hygiene. EI #3 replied, on hire, during the skills fair that was done yearly. EI #3 was asked what the risk was for a staff member to hold a dirty tray, put it on the food cart, and then go into another resident's room, come out, and then get a milk carton out of the cooler and take it to a resident without washing or sanitizing their hands. EI #3 replied, infection. EI #3 was asked, what was the risk of staff not changing gloves or washing or sanitizing their hands before applying a medication cream to a resident. EI #3 replied, infection. EI #3 was asked, what should have happened when a staff member put on gloves, pulled the curtain around the resident, then assisted with positioning the resident, and then, with the same gloves, applied cream to the resident. EI #3 replied, remove the gloves, wash hands, and put new gloves on before applying the cream. EI #3 was asked, when should staff use gloves that had a hole in them to apply cream to a resident. EI #3 replied, never. EI #3 was asked, what was the risk of a staff member applying cream to a resident with a hole in the glove and getting cream on themselves. EI #3 said, infection. EI #3 was asked, what should she have done. EI #3 replied, EI #7 should have looked at the gloves closely for tears/holes. EI #3 was asked, what was the risk of staff not washing or sanitizing their hands after applying cream to a resident and then putting on gloves and assisting the resident in the bed, then removing the gloves and moving the resident's bedside table without sanitizing their hands. EI #3 replied, infection. On 03/09/2023 at 8:30 AM an interview was conducted with EI #2. EI #2 was asked, when should staff wash or sanitize their hands. EI #2 replied, when staff entered the building, before and after care on a resident, before and after passing out trays, after care, after feeding, after they eat or to go to the bathroom, when in doubt, and when visibly soiled. EI #2 was asked, how often was staff educated on hand hygiene. EI #2 replied, on hire, skills fair, and if there was an issue. EI #2 was asked, what should have been done when staff brought out a dirty tray from a resident's room, went into another room, exited the room and reached in the cooler to get out a milk carton and took it into a resident's room without washing or sanitizing their hands. EI #2 replied, after putting the tray on the cart before entering the other resident's room they should have washed or sanitized their hands. EI #2 said, there was risk of infection of that resident when the staff did not wash or sanitize their hands after handling the soiled tray before getting milk for the resident. EI#2 was asked, what was the policy for hand hygiene. EI #2 replied, extensive detail on how and when to wash your hands. EI #2 was asked, what was the risk of staff not changing gloves or washing or sanitizing their hands before applying a medication cream to a resident. EI #2 replied, the organisms on their hands could get on the resident and that was a risk for infection. EI #2 was asked, when should staff have used the gloves that has a hole in them to apply cream to a resident. EI #2 replied, staff should not use gloves that have holes in them. EI #2 was asked, what was the risk of a staff member applying cream to a resident with a hole in the glove and getting cream on self. EI #2 replied, contamination to the staff member. EI #2 was asked, what should have been done. EI #2 replied, they should have stopped and removed the gloves and washed their hands and then put on new gloves to apply the cream. EI #2 was asked, what was the risk of staff member not washing or sanitizing their hands after applying cream to a resident and then putting on gloves and assisting the resident in the bed and then removing the gloves and moving the resident's bedside table without sanitizing their hands. EI #2 replied, contaminating the resident's belongings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of facility policies titled SMALL VOLUME NEBULIZER and SELF ADMINISTRATION OF MEDICATION, the facility failed to ensure the licensed nurse remained with Resident Identifier (RI) #111, a resident not assessed to self- administer his/her nebulizer breathing treatment, when RI #111 received a nebulizer treatment on 06/15/22. This deficient practice affected RI #111, one of one sampled resident observed receiving a nebulizer breathing treatment. Findings Include: Review of an undated facility policy titled SMALL VOLUME NEBULIZER, revealed the following: Procedure: . * Administer therapy until the medication is depleted (usually 10-15 minutes). Nurses must remain with resident during administration unless a self-administration order and complete assessment is in place. Review of a second facility policy titled SELF ADMINISTRATION OF MEDICATION, with a revised date of 12/01/13, revealed the following: POLICY: This facility will comply with Applicable Law and the State Operations Manual with respect to resident self administration of medications. Procedure 1. The facilities interdisciplinary team will assess and determine whether self administration of medication is safe and appropriate. 3. The facility should ensure that orders for self administration list the specific medication (s) the resident may self administer. RI #111 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease with Acute Exacerbation. RI #111's Significant change in status assessment, with an Assessment Reference Date of 05/04/22, assessed RI #111 as scoring a 3 on the Brief Interview for Mental Status, indicating RI #111 had severe impaired cognition. RI #111's 2022 June order Summary Report (Physician's Orders) revealed RI #111 was receiving the nebulizer treatment, Ipratropium Bromide/Albuterol Sulfate four times a day. On 06/15/22 at 6:16 AM, Surveyor observed RI #111 lying in bed receiving a nebulizer breathing treatment with no staff present in room. At 6:38 AM, Employee Identifier (EI) #1 entered room, cut nebulizer off and threw tubing and mask in the trash. On 6/15/22 at 6:38 AM, an interview was conducted with (EI) # 1, Licensed Practical Nurse (LPN). EI #1 was asked if RI #111 was getting a nebulizer treatment. She stated that was what it looked like. EI #1 informed the surveyor she was the oncoming nurse and she works from 6:15 AM-2:30 PM. She stated this was her fist time seeing RI #111 this morning. EI #1 stated, RI #111 gets a nebulizer treatment every 4-6 hours. When asked who was the off-going nurse EI #1 stated, EI #2, Registered Nurse (RN). EI #1 admitted it was not normal practice to leave the room while administering a nebulizer treatment to a resident. EI #1 stated, RI #111 does not have an order to self-administer his/her nebulizer treatment and went on to say RI #111 was noncompliant most of the time. He/she will take it off and needs redirection to put back on. On 06/15/22 at 9:27 PM, a telephone interview was conducted with EI #2, EI #2 stated she administered RI #111's nebulizer treatment this morning. She admitted she left the room while administering the treatment. When asked should you leave the room when administering a nebulizer treatment, EI #2 stated, no. She admitted policy was not followed and possible concern of leaving the room while administering a nebulizer treatment could be the resident choking, aspirating, and not getting the recommended medication dosage. On 6/16/22 at 2:52 PM, an interview was conducted with EI #3, RN, Unit Manager. EI #3 was asked what was the process when a resident requested to self-administer medication. EI #3 stated, the nurse manager goes over the administration of medication with resident to see if they were able to administer medication and the order had to be signed off by the Nurse Practitioner or Physician. EI #3 stated RI #111 does not have an order to self-administer nebulizer treatments. She stated, the nurse should have stayed in the room while RI #111 was receiving the nebulizer treatment. EI #3 stated, the concern of the nurse not staying in the room while RI #111 was receiving a nebulizer treatment was him/her not accurately receiving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and a review of the facility's policy titled SHOWER/TUB BATH, the facility failed to ensure Resident Identifier (RI) #375 received showers according to his/her shower schedule on 04/21/22, 04/26/22 and 04/28/22. This deficient practice affected RI #375, one of three residents sampled for activities of daily living. Findings include: Review of an undated facility's policy titled Shower/ Tub Bath revealed Policy The purpose of this policy and procedure are to promote cleanliness and comfort, to relax the resident, to stimulate circulation, and to observe the condition of the resident's skin. RI #375 was admitted to the facility on [DATE] with diagnosis to include Muscle Wasting and Atrophy. RI #375's Minimum Data Set (MDS) assessment, with an ARD (Assessment Reference Date) of 04/19/22, revealed RI #375 was coded for substantial/maximal assistance for shower/bath and extensive assistance with one person assist for personal hygiene tasks. A review of the facility's South Unit Shower Scheduled with an updated date of 04/18/22, revealed RI #375 was to receive showers on Tuesdays, Thursdays and Saturdays on 3-11 shift. The shower sheet revealed RI #375 did not receive showers on 04/21/22, 04/26/22 and 04/28/22. On 06/16/22 at 10:18 AM, an interview was conducted with Employee Identifier (EI) #3, Registered Nurse (RN), Unit Manager. EI #3 was asked according to shower sheets, would she say RI #375 received showers as scheduled. EI #3 stated, she did not see where all the days showed RI #375 received showers. EI #3 admitted the facilities shower schedule was not followed regarding RI #375. EI #3 stated the concern of a resident not getting showers as scheduled was the resident not being clean. EI # 3 further stated it was unsanitary and could cause skin breakdown. This deficient practice was cited as a result of Complaint/Report # AL00041828

Based on observations, interviews and review of facility policies, titled Sanitation: Food Handling, the facility failed to ensure food in the kitchen's walk-in cooler/freezer was labeled with an open and use by date and that out of date food was discarded. This had the potential to affect 124 of 124 residents who received meals from the kitchen. Findings include: A review of the facility's undated policy titled Sanitation: Food Handling revealed Policy Statement Foods are prepared and served in a sanitary manner, in order to prevent bacterial, biological and physical contamination and the possible spread of infection. Policy Interpretation and Implementation .11. Leftover foods are labeled and dated. These are used within 72 hours. 23. All expired food and food products should be discarded. On 06/13/22 at 4:35 PM, an initial kitchen tour was conducted with Employee Identifier (EI) #4, Dietary Manager. The walk-in cooler was observed to have a plastic container without a label. EI #4 stated it was apple sauce. Another Plastic container was observed without a label. EI #4 stated it was egg salad, a plastic bag with a bundle of kale and peppers without label or dates was observed. An observation was made of an aluminum pan covered with aluminum foil dated 06/8/22- 06/10/22. EI #4 stated the pan contained ground beef. A plastic container of liquid eggs dated 06/06/22- 06/09/22 and plastic container of liquid cheese dated 06/05/22- 06/12/22 were also observed. The walk-in Freezer was observed to have an opened bag of Okra without a label, opened bag of tater tots without a label, Ziploc bag of meat without a label. EI #4 stated it was an opened bag of hamburger patties without a label and an opened bag of diced chicken without a label. EI #4 was interviewed during the Initial Kitchen Tour on 06/13/222 at 4:35 PM. EI #4 stated the cook or baker that put the food up was responsible for labeling leftovers and open containers. EI #4 stated leftovers and open containers should be labeled with name of food, date opened and use by date. EI #4 admitted all items in walk-in cooler and walk-in freezer should have been labeled with an open date and use by date. EI #4 admitted the facility's policy was not followed which could lead to expired food being served. EI #4 admitted the ground beef dated 06/08/22- 06/10/22, liquid eggs dated 06/06/22-06/09/22 and liquid cheese dated 06/05/22-06/12/22 should have been discarded. EI # 4 stated the cook and baker are responsible for discarding out dated food. EI #4 stated saving old food could make residents sick. EI #4 admitted the facility's policy was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and a review of resident's medical records, the facility failed to ensure Resident Identifier (RI) #83 care plans were reviewed and/or updated quarterly. This deficient practice affected RI #83, one of 28 residents selected in the final sampled whose care plans were reviewed. Findings Include: An undated facility policy and procedure titled, Careplans-Quarterly Reviews, revealed each resident's care plan shall be reviewed at least quarterly. RI #83 was admitted to the facility on [DATE], with diagnosis including Chronic Systolic (congestive) Heart Failure, Type 2 Diabetes Mellitus with Diabetic Neuropathy, unspecified and Hypokalemia. RI #83 care plans were last reviewed on 04/19/19. On 12/12/19 at 9:21 a.m., the surveyor conducted an interview with Employee Identifier (EI) #4, Registered Nurse (RN) Minimum Data Set (MDS) Coordinator. EI #4 was asked how often should RI #83 care plans be updated and or reviewed. EI #4 said with every assessment. EI #4 was asked when reviewing RI #83 care plans when was the care plans lasted reviewed or updated. EI #4 said April 19,2019. EI #4 was asked when reviewing and or updating should RI #83 care plans have a date and initials making staff aware of the update. EI #4 said yes. EI #4 was asked why was RI #83 care plan not updated or reviewed during the quarterly assessments. EI #4 said she was not sure. EI #4 was asked who reviewed RI #83 care plans. EI #4 said the person doing the MDS along with the entire Interdisciplinary Team. EI #4 was asked what was the purpose of the care plans. EI #4 said to help every one know how to take care of the resident. EI #4 was asked what was the potential harm with not reviewing and or updating RI #83 care plans. EI #4 said not caring for the resident in the correct way.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and review of, FUNDAMENTALS of NURSING, the facility failed to ensure Resident Identifier (RI) #19 was not left unattended while receiving nebulizer treatment. This deficient practice affected one of one resident observed receiving a nebulizer treatment during the initial tour of the facility. Findings include: A review of the manual titled [NAME] & [NAME] Ninth Edition Fundamentals of Nursing BOX 32-2 Evidence-Based Practicepage 618 revealed, . Application to Nursing Practice . nurses need to remain vigilant and consistently follow medication administration policies and protocols to ensure safe medication administration. RI #19 was admitted to the facility on [DATE]. RI #19 was code on the Quarterly Minimum Data Set (MDS) date 11/26/19 for Asthma, Chronic Obstructive Pulmonary Disease (COPD) or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung diseases such as asbestosis). On 12/10/19 at 9:12 a.m., during the initial tour of the facility the surveyor observed RI #19 receiving a breathing treatment. At this time, the mask was on the resident's face and the machine was on. There was no nurse present in the resident's room during the treatment. On 12/10/19 at 9:23 a.m., Employee Identifier (EI) #9, Registered Nurse (RN) entered RI #19 room. The surveyor conducted an interview with EI #9. The surveyor asked EI #9 was she the nurse for the resident. EI #9 said yes. The surveyor asked EI #9 what type treatment was the resident receiving. EI #9 said Albuterol Nebulizer treatment. The surveyor asked EI #9 was there a nurse with the resident during the full time of the treatment. EI #9 said no ma'am. The surveyor asked EI #9 what were the concerns with leaving the resident during treatment. EI #9 said they are supposed to stay with the resident to make sure they get the full treatment, make sure they are not taking the mask off and to make sure the treatment goes for the right amount of time. On 12/10/19 at 4:39 p.m., the surveyor conducted an interview with RI #19. The surveyor asked RI #19 did the nurse stay with them while they are receiving the breathing treatment. RI #19 said no. On 12/12/19 at 8:42 a.m., during a second interview with RI #19 the surveyor asked did they know the names of the medications they were taking. The resident answered, Oh' no, were they supposed too. The surveyor asked RI #19 how long had they been taking the breathing treatments. RI #19 said they had no ideal, maybe months. RI #19 said they thought it was started because they used to smoke. The surveyor asked RI #19 had they always administered the breathing treatment their self. RI #19 said yes, she (the nurse) gets it ready and the resident would know when it was ready because it would be standing up with a plastic bag over it On 12/12/19 at 11:52 a.m., the surveyor conducted an interview with EI #2, Director of Nursing (DON). The surveyor asked EI #2 had RI #19 been educated on self administering the nebulizer treatment. EI #2 said no. The surveyor asked EI #2 what are the issues with a resident administering a medication without a nurse supervision. EI #2 said they may not get the dosage they are suppose to get.

Based on observations, interviews and record reviews, the facility failed to ensure a License staff washed his hands after administering eye drops and prior to going into the medication cart. This deficient practice had the potential to affected one of two residents observed receiving eye drops during medication pass. Findings include: On 12/11/19 at 3:49 p.m., the surveyor observed Employee Identifier (EI) #8, Licensed Practical Nurse (LPN) enter a resident's room, wash his hands, apply gloves, and administer the resident eye drops. EI #8 then returned to the medication cart, removed a disinfectant wipe and wrapped a glucometer with the wipe, all before removing soiled gloves and washing his hands. On 12/11/19 at 4:12 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 when did he put the gloves on. EI #8 said before he gave the eye drops. The surveyor asked EI #8 how did he gather the supplies from the cart. EI #8 said he was sorry, he should have taken the gloves off before removing the supplies from the medication cart. The surveyor asked EI #8 what were the issues with keeping the same gloves on to gather supplies he was wearing when he gave the eye drops. EI #8 said he should have taken the gloves off, washed his hands then put on clean gloves. EI #8 said contamination. On 12/12/19 at 11:15 a.m., the surveyor conducted an interview with EI #2, the Director of Nursing. The surveyor asked EI #2 when should a nurse wash their hands after giving eye drops. EI #2 said when the gloves are removed and before leaving the patient's area. The surveyor asked EI #2 what are the issues with administering eye drops and not removing gloves or washing hands before leaving a resident's room. EI #2 said contamination and infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, and a review of the facility's policies titled,SAFE MEDICATION ADMINISTRATION/INJECTION SAFETY and . INTRAMUSCULAR MEDICATION, the facility failed to ensure a licensed staff member aspirated (pulled back on) the syringe prior to injecting Rocephin (an antibiotic) mixed with Lidocaine into Resident Identifier (RI)#160's muscle. Further, the facility failed to ensure a licensed staff member discarded a multiple use vial of Lidocaine that was contaminated with Rocephin. This affected one of one resident receiving an intramuscular injection and one of three nurses observed during medication administration. Findings Include: A review of the facility's policy titled, SAFE MEDICATION ADMINISTRATION/INJECTION SAFETY, dated November 28th, 2017, revealed: POLICY Injectable medication will be administered in accordance with safe injection practices and standards. PROCEDURE . 9. Medication vials should always be discarded whenever sterility is compromised or questionable. A review of the undated facility policy titled, .INTRAMUSCULAR MEDICATION revealed: Policy: The nurse will administer an aqueous suspended medication into the intramuscular tissue safely and accurately. Procedure: . Insert needle .Pull back on plunger to see if needle is in a blood vessel. RI #160 was admitted to the facility on [DATE] with diagnoses to include Type 2 Diabetes Mellitus with Hyperglycemia and Atherosclerotic Native Arteries of Extremities with Intermittent Claudication of Right Leg. On 10/23/18 at 3:16 p.m., during medication administration, the surveyor observed Employee Identifier (EI) #1, (LPN) Licensed Practical Nurse, access the Lidocaine vial and inject the Lidocaine into the Rocephin vial in order to mix the medication. EI #1 again accessed the Lidocaine vial with the same needle used to enter and mix the Rocephin. EI #1 then placed the vial of Lidocaine contaminated with Rocephin into the medication cart. On 10/23/18 at this time, the surveyor observed EI #1 inject Rocephin into RI #160's muscle without aspirating the syringe. After this observation on 10/23/18, an interview was conducted with EI #1. EI #1 was asked, what did she do with the vial of Lidocaine after accessing the vial with the same needle used to inject Lidocaine into the Rocephin. EI #1 stated,It is sitting on the cart. EI #1 was asked, what should have been done with it EI #1 stated, I will throw it away. The surveyor then followed EI #1 back to the medication cart. The Lidocaine vial was found to be in the top drawer of the medication cart. EI #1 disposed of the Lidocaine vial in the medication destruction container. EI #1 was asked, did she aspirate before giving the Lidocaine injection. EI #1 stated, I usually do, I don't know . An interview was conducted on 10/24/18 at 2:51 p.m. with EI #2, a Registered Nurse/Director of Nursing. EI #2 was asked, what should be done with the Lidocaine vial after mixing Lidocaine with Rocephin and again accessing a multiple dose vial of Lidocaine. EI #2 stated,It should be destroyed, it should go into sharps container. EI #2 was asked, how should an intramuscular injection be given. EI #2 stated in her description, . aspirate to make sure I am not in a blood vessel .