**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, review of the State Agency's Online Incident Reporting System Report, and a facility policy Medication Administration, the facility failed to ensure licensed staff clarified medication orders for Paxlovid for Resident Identifier (RI) #182. The resident received an order for Paxlovid on [DATE], the Medication Administration Record (MAR) did not match the medication pharmacy label instructions as to give two tablets twice a day; three nurses administered the medication at the incorrect dose for two days before it was determined to be incorrect dose. This affected one of one resident reviewed for receiving Paxlovid. This deficient practice was cited as a result of investigation for complaint/number AL00042087. Findings Include: On [DATE] the facility submitted an incident through the Alabama Department of Public Health (ADPH) Online Incident Reporting System. The report of the incident documented . Name of staff member alleged to be involved: (Names of Employee Identifier's (EI) #10, EI #9 and EI #11) . Date and time of occurrence: [DATE] . Narrative summary of the incident: Resident tested positive for COVID-19 on [DATE]. On [DATE] an order for Paxlovid was written. When medication arrived from the pharmacy, the directions on the box were different from the Medication Administration Record (MAR). The above nurses failed to clarify order with pharmacy/MD. I was notified on [DATE] around 10am that resident had received incorrect doses of Paxlovid (under-dosed) from Friday-Monday. Resident on Paxlovid for COVID-19. Nurse Practitioner (NP) was made aware and saw resident at 11:33AM. Resident was sent to emergency room (ER) on [DATE] at 1pm due to decline in status. Facility received phone call on [DATE] around 2am stating that resident had expired around 12:52am. A review of the facility policy Medication Administration, dated [DATE], revealed . 11. Compare medication source (bubble pack, vial, .) with the MAR to verify resident name, medication name, form, dose, route, and time. 20. report any discrepancies to nurse manager immediately. A review of the medication order on [DATE] read Paxlovid 150/100 Milligram (mg) by mouth BID (Two times a day) x (times) 5 days (reduced dose due to CKD (chronic kidney disease)) GFR 44. This was verbal order by EI #13, the NP written by EI #8. RN. A review of the MAR revealed, Paxlovid (150/100) Tablet Therapy Pack 10 x 150 MG & 10 x 100MG (Nimatrelvir & Ritonavir 150/100) Give 1 tablet by mouth two times a day for COVID 19 . A review of the pharmacy label of the medication revealed, Paxlovid 150-100MG . GIVE 2 TABLETS BY MOUTH 2 TIMES A DAY X 5 DAYS. RI #182 admitted [DATE] DX congestive heart failure, Malignant neoplasm of kidney, acquired absence of Kidney, and Pacemaker. On [DATE] at 9:03 AM an interview was conducted with EI #8, Registered Nurse (RN) who said she wrote the order but could not recall much about the resident other than what unit the resident was on and that the resident had tested positive for COVID. EI #8 said EI #13, the NP, gave the order, she wrote it as he said which was a reduced dose due to CKD. EI #8 said she did not know anything about the medication nor what a usual dose was. On [DATE] at 9:58 AM and 11:31 AM the surveyor was unable to reach EI #10, Licensed Practical Nurse (LPN), she no longer worked at the facility. EI #10 was the nurse to administer the first dose of paxlovid. On [DATE] at 10:00 AM during an interview with EI #9, LPN said she recalled RI #182's medication label on the medication was different than the MAR but was not and still not familiar with that medication. EI #9 said she gave it as the MAR directed which was one tablet two times a day. EI #9 said it was started the evening before by EI #10. EI #9 said the medication label from the Pharmacy had Paxlovid 150/100 mg give 2 tablets two times a day for 5 days. When EI #9 was asked how did she verify the medication, she said by the MAR, and she did see it said different on the medication pack but she thought since EI #10 had started it the night before she may had forgotten to place a change in directions label on the medication. EI #9 said she should have called the doctor or the pharmacy to clarify the order when it did not match. EI #9 said she did not do that because she thought EI #10 had already done that and forgot to place a label change on the package. EI #9 said she had never given paxlovid before and was not familiar with how to give it, so she gave it how it read on the MAR. EI #9 was asked what the outcome could be if the medication was not given correctly and she stated symptoms may not improve or could worsen. When EI #9 was asked what was the policy related to medication administration. EI #9 said pull up the MAR, get medication from the cart, match medication from cart to the MAR if they do not match, you should clarify any discrepancies and report it to the DON, which she did not do because she thought EI #10 forgot to change the label. On [DATE] at10:56 AM an interview was conducted with EI #15, Pharmacist. During the interview EI #15, said the order for RI #182 was paxlovid 150/100 mg twice a day for five days a reduced dose due to CKD. EI #15 said the usual dose was 300mg and 100 mg which was two tablets twice day. EI #15 said the reduced dose was 150/100 mg also two tablets twice a day for five days. On [DATE] at 11:30 AM during an interview with EI #11, LPN, she recalled RI #182 had paxlovid ordered, and the MAR had one tablet and the package had two tablets. EI #11 said in report EI #10 said it was the reduced dose to give one tablet. EI #11 said she later found out two tablets should have been given and that was the reduced dose. EI #11 said the incorrect dose was given for two days. EI #11 was asked what should she have done to make sure the correct dose was given. EI #11 said when the MAR said one tablet and package said two she should have either called the doctor or the pharmacy for clarification. EI #11 said they should follow the rules of giving medication, which were right resident, right dose, right medication. EI #11 said the concern with RI #182 not receiving the correct dose of medication was RI #182 may not have received the full dose. On [DATE] at 9:49 AM EI #12, LPN was interviewed. she said the order for paxlovid was 150/100 mg twice a day. EI #12 said she was not sure how many tablets were to be given; she recalled the package, and the MAR did not match so she notified the Director of Nursing (DON) and got clarification of the order. EI #12 said she discovered the medication had not been given as ordered when the package said give two tablets and the MAR said give one. EI #12 said this was an error because the wrong dose was given. EI #12 said the first nurse that gave the medication should have clarified the order, she was unsure who that nurse was. EI #12 was asked what was not done that may have prevented giving the incorrect dose. EI #12 said clarifying the order. On [DATE] at 2:08 PM during an interview EI #2, DON, who recalled the Paxlovid order for RI #182 was 150/100mg by mouth twice a day for five days. She did not know the usual dose and said the order was determined by the NP and doctor. EI #2 said EI #10 noticed it Saturday morning and did not do anything to clarify the order. EI #2 said the MAR said one tablet and the package said two, the medication was supposed to be two tablets twice a day for five days. EI #2 said the concern with the Paxlovid not given as medication package directed was that the correct dose was not given for two days. EI #2 said the outcome of the investigation was the medication was ordered, two tablets should have been given, only one was given and nurses did not realize two tablets were the correct dose. The nurse entered in quantity one tablet not realizing it was to be two tablets verses one. The pharmacy did not call facility to verify two tablets verse one. It was the fault of the nurse for not clarifying when she saw one tablet on MAR and two tablets on the Pharmacy package. EI #2 said the nurse EI #10 should have clarified the order, and nurses after her that noticed it should have verified it when they noticed it too. EI #2 was asked what was the policy for staff medication administration. EI #2 said compare MAR to resident with their name, medication name, drug strength to medication package or card. EI #2 said to validate nurses should be sure right resident, right medication, and right dose. EI #2 said three nurses gave the medication without clarifying and they noticed one tablet on MAR and two tablets on medication package label. EI #2 said the medication should be validated before giving medication to a resident, and anytime they noticed a discrepancy they should verify the order. EI #2 said if the MAR and the medication label did not match the nurse should verify or clarify the order which could be done by looking in the resident chart at the orders or call the NP or doctor to get clarification. EI #2 said a concern of the nurses giving medication with the MAR and the medication package not matching would be the accurate dose could not be given.

Based on observations, interviews, review of the medical record and review of the facility policy titled, CATHETER CARE the facility failed to ensure that Resident Identifier (RI) #36's urinary catheter drainage bag was not hanging above the level of the bladder. This affected RI #36 one of two residents sampled for Catheter care. Findings include: A facility policy titled, CATHETER CARE with a revision date of 04/14/2020, revealed: . Policy: To prevent the spread of infection. To promote quality resident personal care. Policy Explanation and Compliance Guidelines: . 10. Catheter tubing should lay across the resident's leg and the bad (bag) should hang below the level of the bladder. On 06/13/2023 at 11:13 AM RI #36's urinary drainage bag was observed hooked and hanging on a cup-holder in the arm of their recliner. The drainage tubing was above the level of the bladder. On 06/13/2023 at 05:30 PM RI #36's urinary drainage bag was still hanging on the cup holder on the arm of the recliner. The tubing at the top of the drainage bag was approximately 4 inches above where the resident's bladder was as he/she was seated in the recliner seat. On 06/15/2023 at 10:56 AM an interview was conducted Employee Identifier (EI) #14, a Certified Nursing Assistant (CNA). EI #14 was asked who got RI #36 up Tuesday to the recliner. EI #14 said she did. EI #14 was asked where she hung the urinary drainage bag. She said she had threaded the tubing through his/her pants and had nowhere to hang it. EI #14 added it was supposed to be below the level of the bladder. EI #14 was asked where the urinary drainage bag should have been. She answered on the wheelchair. EI #14 was asked if the wheelchair was not there, where was the drainage bag hanging. She said on the recliner. EI #14 was asked where on the recliner. She said in the cup holder on the arm of the recliner. EI #14 was asked why she hung it in the cup holder if she knew it should be below the level of the bladder. She responded, I don't know. EI #14 was asked when the drainage bag was hanging in the cup holder, was the tubing above the level of the bladder. She said yes. EI #14 said she had hung it there before. EI #14 was asked what was the concern of the tubing to the urinary drainage bag hanging above the level of the bag. She said it may not drain or it might back up. EI #14 was asked what was the concern of the urine not draining or maybe backing up. She said an infection can happen. On 06/15/2023 at 12:08 PM an interview was conducted with EI #9, the Licensed Practical Nurse (LPN) for RI #36 on Tuesday 6/13/2023. EI #9 was asked on Tuesday when she observed RI #36 in his/her recliner, where was the urinary drainage bag hanging. EI #9 said the cupholder on the arm of his/her recliner. EI #9 was asked who identified the drainage bag was hanging in the cupholder on the arm of RI #36's recliner. EI #9 said she went in to help rehab (rehabilitation) staff that was helping the resident that day. She said that she took it off of the cup-holder on the arm of the recliner and lowered it to the side of the wheelchair. EI #9 was asked why she lowered it. She said she saw that it was high up above the bladder and knew it needed to go down. EI #9 was asked why it needed to be lowered. She said so it would drain and empty the bladder. EI #9 was asked what was the concern of the urinary drainage bag tubing being above the level of RI #36's bladder for over 6 hours. She said no drainage, the risk of holding the urine in that bladder and risk for a Urinary Tract Infection. On 06/15/23 at 2:01 PM an interview was conducted with EI #2, the Director of Nursing. EI #2 was asked what was the concern of the urinary drainage bag tubing being above the level of the bladder. She answered it could cause back-flow of urine back into the bladder and potentially cause a Urinary Tract Infection.

Based on interviews, medical record reviews, review of facility policies titled, ABUSE, NEGLECT AND EXPLOITATION and REPORTING ALLEGATIONS OF ABUSE, NEGLECT AND EXPLOITATION and review of a document titled, Alabama Department of Public Health Online Incident Reporting System, the facility failed to timely report 13 allegations of abuse to the State Agency after the incidents occurred. This affected 14 of 71 facility reported incidents that were reviewed and affected Resident Identifier's (RI) #434, #74, #79, #47, #8, #69, #115, #22, #21, #104, #46, #38, #109, #70 and two unsampled, discharged residents. Findings Include: A review of the facility policy titled ABUSE, NEGLECT AND EXPLOITATION, with no date, revealed the following: .The facility must: .13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, . A review of the facility's policy titled, REPORTING ALLEGATIONS OF ABUSE, NEGLECT AND EXPLOITATION, with no date, documented: Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation to appropriate agencies in accordance with current state and federal regulations. Review of the Alabama Department of Public Health Online Incident Reporting System, revealed the following: 1) An incident of mistreatment was reported by a Certified Nursing Assistant (CNA), regarding another CNA being abnormally rough with Resident Identifier (RI) #434 on 04/25/2019 at 10:30 AM. This incident was not reported to the State Agency until 04/25/2019 at 3:29 PM. 2) An incident of verbal abuse was reported occurring on 01/12/2019 at 6:57 PM where RI #79 was fussing at other residents and staff and RI #74 threatened to kill RI #79. This incident was not reported to the State Agency until 01/14/2019 at 8:04 AM. 3) An incident of physical abuse was reported occurring on 01/08/2019 at 10:00 AM where RI #47 reported that a CNA, was rough and jerked RI #47 in the bathroom. This incident was not reported to the State Agency until 01/09/19 at 1:37 PM. 4) An incident of physical abuse was reported occurring when RI #8 reported that a CNA, was rough when giving a shower on 11/22/2018 at 5:00 p.m. This incident was not reported to the State Agency until 11/23/2018 at 10:02 AM. 5) An incident of physical abuse was reported occurring on 10/31/18 at 5:54 PM where RI #115 hit RI #69 on the shoulder and RI #69 pushed RI #115 onto the bed. This incident was not reported to the State Agency until 11/01/18 at 7:22 AM. 6) An incident of neglect was reported occurring on 10/31/18 at 6:00 PM where a CNA, refused to change RI #22 and talked hateful to RI #22. This incident was not reported to the State Agency until 11/01/18 at 9:02 AM. 7) An incident of physical abuse was reported occurring on 10/30/18 at 8:30 PM where RI #104 stated that RI #21 grabbed and bent his/her hand back. This incident was not reported to the State Agency until 10/31/18 at 7:36 AM. 8) An incident of physical abuse was reported occurring on 10/30/18 at 8:30 PM where RI #115 went up to RI #79 and started slapping RI #79's hands. This incident was not reported to the State Agency until 10/31/18 at 7:47 AM. 9) An incident of physical abuse was reported occurring on 10/27/18 at 5:00 PM where RI #115 walked into RI #46's room and hit RI #46 on the left shoulder. This incident was not reported to the State Agency until 10/29/18 at 7:08 AM. 10) An incident of physical abuse was reported occurring on 10/23/18 at 12:00 AM where RI #38 went into RI #46's room and RI #46 twisted RI #38's arm. This incident was not reported to the State Agency until 10/25/18 at 4:27 PM. 11) An incident of physical abuse was reported occurring on 09/16/18 at 8:45 AM where RI #79 came around the corner of the nurse's station where RI #109 was sitting in a wheelchair and RI #109 kicked RI #79's wheelchair and RI #79 grabbed RI #109's lower leg and squeezed it. This incident was not reported to the State Agency until 09/16/18 at 2:31 PM. 12) an incident of physical abuse on 09/10/18 at 1:15 PM where a unsampled, discharged resident came in to the activity room and tapped RI #70 on the arm and told RI #70 to move because it was his/her spot. This incident was not reported until 09/12/18 at 1:43 PM, 13) An incident of injuries of unknown source was identified on 08/28/18 at 9:30 PM when RI #88 was noted to be guarding his/her right arm per EI #12, Licensed Practical Nurse (LPN), and xrays revealed a fracture of the right distal humerus and elbow joint. The incident was not reported to the State Agency until 08/29/18 at 12:26 PM. 14) An incident of physical abuse was reported occurring on 07/14/18 at 10:00 PM where another unsampled, discharged resident complained that RI #69 (spouse) was hitting him/her in the chest. This incident was not reported to the State Agency until 07/15/18 at 6:16 AM. On 05/09/19 at 2:45 p.m., an interview was conducted with EI #2, Registered Nurse (RN)/Assistant Director of Nursing (ADON)Abuse Coordinator. EI #2 was asked, when should an allegation of abuse be reported to the State Agency. EI #2 said within two hours. EI #2 was then asked to individually review the 14 incidents listed and asked whether they were reported to the State Agency within the designated two hour time frame. EI #2 answered no, to all 14 incidents and explained that some of the incidents had been slid underneath her office door and she found them on her return to work. She further stated that she had found one of the incidents written on a 24 hour report form. On 05/09/19 at 4:08 p.m., an interview was conducted with EI #1, Administrator. EI #1 was asked if he had been made aware of the facility not reporting incidents timely to the State Agency. EI #1 said yes. EI #1 was asked what was the reason identified for the reports being submitted late. EI #1 stated they had been doing education with the employees identified for not reporting timely and that all employees receive abuse training twice a year. This citation resulted from the investigation of complaint/report # AL00036246.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of a facility policies titled, STORAGE OF MEDICATIONS AND BIOLOGICALS and CONTROLLED MEDICATION STORAGE, observations and interviews, the facility failed to ensure: 1. the A Wing medication storage room / cabinet did not contain expired medications, including five unopened bags of normal saline intravenous fluids, along with eight other medication including creams, ointments, gel, liquid and tablets and 2. the Medication Cart for the 600 hall did not include a medication (narcotic) labeled with an unreadable expiration (discard) date. This affected one of two medication rooms observed and one of four medication carts observed. Findings include 1. A review of the facility's policy titled, 3.1: STORAGE OF MEDICATIONS AND BIOLOGICALS, with a date of 3/11, revealed: . Procedure . 11. Outdated, contaminated, or deteriorated medications and . are removed from stock, disposed of according to procedures for medication disposal, . The Surveyor reviewed another facility policy titled, 4.3: Disposal of Medication Non-Controlled Medication Destruction, with a date of 3/11, . Policy . expired medications, .are destroyed or disposed of per federal/state regulations. On 05/08/19 at 04:29 pm, the Surveyor observed, with Employee Identifier (EI) # 5, the A Wing Medication Storage Room. Observations were made of the following items: One of the lower cabinets contained a paper bag with expired intravenous fluids (see the expiration dates below). The Surveyor observed with EI# 5, a total of five unopened bags of normal saline 0.9 Sodium Chloride injection, labeled for a resident,t one bag with an expiration of [DATE], one bag with an expiration date of September 2018 and three bags with an expiration date of April 2018. The Surveyor also observed, with EI# 5, an upper cabinet containing the following: 1. one opened bottle of Icy Hot Arthritis pain relief lotion 5.5 ounces with a handwritten first name on it, expired 6/14; 2. one opened tube of Preparation H ointment 2 ounces with Resident Identifier # 32 hand written name on it, expired 6/2017; 3. one opened tube of Capzasin HP Arthritis Pain relief topical analgesic cream 1.5 ounces, expired 7/17; 4. one opened tube of Risamine Ointment with a label for a resident, expired 3/18; 5. one opened Hydrocortisone 1 percent Iodoquinol 1 percent cream with label for a resident, expired 7/17; 6. one opened bottle of Allergy Tablets Chlorpheniramine Maleate 4 mg tablets 1000 tablets with a resident's name hand written on it expires 3/18; 7. one opened bottle of Pepto Bismol Max Bismuth Subsalicylate 4 ounce bottle, expired 2/16 and 8. one tube of Orajel maximum tooth ache get unopened instant pain relief .42 ounces, expired 2018, with a resident's name handwritten on the box. On 05/08/19 at 05:37 pm, the Surveyor interviewed EI #5. EI #5 was asked if she observed expired intravenous fluids with the surveyor in the Medication Storage Room cabinet. EI # 5 replied, yes ma'am. She was asked, how many bags of expired fluids were in the cabinet. EI# 5 replied, to be honest it was four or five. EI #5 was asked, did she observe eight medications including, tubes of ointments,creams, lotion, liquid medication and tablets that had expired, with the surveyor in the medication storage room cabinet. EI#5 replied, yes ma'am. She was asked, what was the facility policy regarding expired medication in the medication storage room/cabinet. EI# 5 replied, expired medications are supposed to be turned in to the Director Of Nursing (DON) to be destroyed. EI #5 was asked, according to the policy what was the correct time frame expired medication should be turned in to the DON. EI# 5 replied, she could not tell the exact time frame, but in a timely manner. EI #5 was asked, what was the potential harm for having expired medications including, intravenous fluids, creams, liquids and tablets in the medication storage room cabinets. EI# 5 replied, the potential harm was it could be used on another resident. 2. A review for the facility policy titled, 3.2 CONTROLLED MEDICATION STORAGE revealed: . 10. Controlled medication expiration dates and storage dates are periodically monitored by the consultant staff. On 05/08/19 at 08:38 am, the Surveyor observed with EI# 6, the Medication Cart for the 600 hall and found: 1. Label -Resident # 92 Lorazepam 0.5 mg total 27 verified, 3/8/19 date on top right corner of the label. Part of the label was cut off bottom of card, was unreadable. The Surveyor and EI #6 were unable to read the Discard after date. The Surveyor asked EI #6 how did she know what the expiration date was for that medication. EI# 6 replied, you don't positively know. On 05/09/19 at 08:10 am, the Surveyor interviewed EI# 6. EI #6 was asked, on May 8th 2019 did she observe an Ativan card of medication that had an unreadable discard date, on the medication cart in the locked narcotic box. EI# 6 replied, yes she did and she did correct that. EI #6 was asked was medication signed out off on the card that had an unreadable expiration date. EI# 6 replied, yes there were three or four of them. EI #6 was asked what was the potential harm with a medication on the cart with an unreadable expiration date. EI# 6 replied, it could have been expired, the medication strength may not have been as potent. And EI# 6 continued, they should not be giving out dated medications.

Based on observation, interviews and a review of a facility policy titled, Infection Prevention and Control Program, the facility failed to ensure EI (Employee Identifier) #4 folding laundry, did not allow the laundry to touch the floor or her clothing. This affected 1 of 1 laundry staff observed folding clean laundry. Findings include: A facility policy titled, Infection Prevention and Control Program, date implemented, 11/28/17, revealed, Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: .10. Linens: a. Laundry and direct care staff shall handle, store, process and transport linens so as to prevent spread of infection. d. Never place linen on floor . An observation was made on 05/09/19 at 10:11 a.m. of the laundry area. EI #4 was observed folding sheets, gowns, and under pads. Two sheets were observed touching the floor while being folded. Multiple sheets, gowns and under pads were observed touching EI #4 's clothing as he/she folded. On 05/09/19 at 10:38 AM, an interview was conducted with EI #4 , laundry staff. EI #4 was asked, should laundry touch your clothing while folding. EI #4 replied, she did not think so. EI #4 was asked, should the laundry touch the floor while folding. EI #4 replied, no. EI #4 was asked, did the laundry touch her clothing, or the floor, when she was folding clothes. EI #4 replied, if so, it was by accident, the fans were blowing everywhere. EI #4 was asked, where was that load of laundry going, that she was folding. EI #4 replied, each wing, it was divided up. EI #4 was asked, what was the potential concern of the laundry touching she clothing or touching the floor. EI #4 replied, it would be considered dirty. On 05/09/19 at 10:48 AM, an interview was conducted with EI #3 Assistant Director Of Nursing (ADON)/ Infection Control. EI #3 was asked, should laundry touch the floor while being folded. EI #3 replied, no. EI #3 was asked, should laundry touch an employee's clothing while being folded. EI #3 replied, no. EI #3 was asked, what was the potential concern of the laundry touching the floor or the employee's clothing. EI #3 replied, infection control.