Based on observation and interview, the facility failed to prepare food in accordance with professional standards of food service safety when the Facility [NAME] (COOK) used a cleaning cloth instead of a potholder to remove an item from the oven. This failure had the potential to result in cross-contamination, resulting in the potential for food-borne illness for 83 out of 90 residents who receive food from the kitchen. Findings: During an observation on 11/19/24 at 10:33 a.m. in the kitchen, the Facility [NAME] (COOK) removed a tray of chicken from the oven using a pot holder on her left hand and a red cloth to cover her right hand. The red cloth was observed to come into contact with liquid on the tray. During an interview on 11/19/24 at 10:40 a.m., COOK stated she used the red cloth and the pot holder to remove the chicken from the oven. COOK stated the chicken was heavy and required two hands. During an interview on 11/19/24 at 10:42 a.m., with the Dietary Services Manager (DSM), DSM stated the red cloth should be used for cleaning and pot holders should be used for food. Dietary Manager stated sanitizer chemical could have been on cloth and it could have come in contact with food. During an interview on 11/21/24 at 9:21 a.m. with the Infection Preventionist (IP), IP stated a cloth used for cleaning counters should not also be used to handle items that contain food because of the risk for cross-contamination (potentially dangerous bacteria could be spread around the kitchen, which could lead to food poisoning). During a review of the 2022 Food Code by the U.S. Food and Drug Administration, dated 1/18/23, the Food Code section 3-304.14 indicated that cloths used for wiping food spills should be used for no other purpose.

Based on observation, interview and record review, the facility failed to ensure to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of five sample selected residents (Resident 84, 48 and 43) when: 1. The facility's staff left the disconnected feeding tube uncapped and exposed to the air on the pole (pole was holding feeding liquid bags and water) and then staff touched the feeding bag and put the cap on the tip of tube with bare hand (no gloves). 2. The facility's staff did not change the gloves between clean and dirty supplies during the wound care for 48. 3. The facility's staff touched the equipment and belonging with bare hand (no gloves) for Resident 43. Residents 84, 48 and 43 were on EBP care (Enhanced Barrier Precautions is an approach to the use of personal protective equipment (PPE) to reduce transmission of Multi-Resistant Organisms (MDROs) between residents in skilled nursing facilities). Findings: A review of Resident 43's admission Record indicated, Resident 43 admitted to the facility with multiple diagnosis including Immunodeficiency (Inability to produce an adequate immune response because of an insufficiency or absence of antibodies, immune cells, or both). A review of Resident 43's Order summary report indicated . Resident on EBP, R/T (due to) upper abd (Abdomen) cholecystostomy (a surgical procedure that creates an opening in the gallbladder to drain bile and relieve symptoms) . A review of Resident 84's admission Record indicated, Resident 64 admitted to the facility with multiple disease including Gastrectomy (surgical removal of a part or the whole of the stomach) . A review of Resident 84's Order summary report indicated . Resident on EBP, R/T long term use of indwelling medical device GTF (Gastric Tube Feeding) . A review of Resident 48's admission Record indicated, Resident 48 admitted to the facility with multiple disease including pressure ulcers (damaged skin and tissue caused by constant pressure on the skin for a prolonged period). During a concurrent observation and interview on 11/18/24 at 11:25 a.m., with the Registered Nurse (RN)1 at Resident 84's room, observed the feeding tube connected to the formula bag was hang from the poll with no cap, RN1 confirmed and touched the formula bag and tube with bare hands while the resident was on EBP care. RN1 put the cap on the tip of the tube with bare hand and no gloves. RN1 stated she should have wear gloves before touching the supplies to prevent the infection, because Resident 84 is on EBP care due to having Gtube (Gastric Tube). During an observation and interview on 11/18/24 at 11:30 a.m., Infection Preventions (IP) entered to the room, IP had mask only, no gloves, IP touched the Resident 43's side table and moved it, then removed the communication board from the resident's bed which was touching the Resident 43's abdomen and then opened the board and started to talk to the resident with the board. IP confirmed that the Resident 43 is on EBP care and staff need to wear gloves, gown and mask when they are working with the residents on EBP care, and IP should have wear gloves when touched Resident 43's belonging specially when they were touched the Resident 43's body, due the infection prevention. During a consecutive observation and interview on 11/19/24 at 01:51 p.m., observed Licensed Vocational Nurse (LVN) changed the dressing on Resident 48's coccyx, (The small bone at the bottom of the spine). LVN removed the old dressing and with the same gloves opened new gauze and saline solution, cleaned the wound and dry pat with the same gloves, LVN confirmed that did not change gloves between old dressing and cleaning the wound and stated LVN was supposed to change gloves between dirty and clean supplies for the infection prevention matter. During an interview on 11/21/24 at 09:11 a.m., with IP, IP stated the nurses after disconnecting the tube from the Gtube they need to put the cap on the tip of tube for the infection control. If nurses, see the tube with no cap they should replace the tube and not recap it. Stated the nurses should change the gloves after removing the old dressing because the gloves can transfer the bacteria from old dressing to the wound when they clean the wound with the same gloves. A review of the facility's policy and procedure (P&P) Clean Dressing Change revised 12/19/2022, indicated .9. Loosen the tape and remove the existing dressing . 10. Remove gloves .11. Wash hands and put on clean gloves. 12. Cleans the wound as ordered . A review of the facility's policy and procedure Personal Protective Equipment revised 12/19/2022, indicated . 1. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious material is likely . A review of the facility's policy and procedure Enhanced Barrier Precautions revised 12/19/2022, indicated . PPE for enhanced barrier precautions is only necessary when high contact care activities .High-contact resident care activities include . g. Device care or use: central lines, urinary catheters, feeding tubes, . It may be acceptable to use gloves, alone, for some uses of a medical device that involve only limited physical contact between the healthcare worker and the resident . During an interview on 11/21/24 at 09:11 a.m., with IP, IP stated that the facility does not have any specific P&P for Tube Feeding connected to the feeding bag's set up and keep the tube clean.

Based on observations, interviews, and record review, the facility failed to ensure a medication error rate below five percent for two of nine sampled residents (Resident 23 and 32) when: 1. Resident 32 was administered sennosides (medication to induce bowel movement) 8.6 milligram (mg, a unit of weight measurement) instead of docusate (medication to induce bowel movement) 200 mg as prescribed by physician's order; and 2. Resident 23 did not receive vitamin d3 (a vitamin needed for various body function) 25 mcg (microgram, a unit of measurement) as prescribed. This failure resulted in two medication errors out of 30 opportunities during observation of medication administration which resulted in the facility having a medication error rate of 6.67% and resulted in residents not receiving the correct medication or receiving the medication as prescribed. Findings: 1. During a concurrent medication pass observation and interview on 12/19/22, at 9:40 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 administered to Resident 32, two tablets of sennosides 8.6 mg. LVN 1 stated the two tablets of sennosides 8.6 mg was for Resident 32's order for docusate 200 mg. Docusate 200 mg was not given to Resident 32. A record review of Resident 32's physician's orders, dated 12/19/22, indicated Resident 32 did not have an order for sennosides 8.6 mg. The physician's order indicated Resident 32 had an order for docusate 200 mg, twice a day. During an interview and record review on 12/19/22, at 12:10 p.m., with LVN 1, Resident 32's Medication Administration Record (MAR) was reviewed. LVN 1 identified a bottle of sennosides 8.6 mg which two tablets were removed for Resident 32's order for docusate 200 mg. When asked to verify on the MAR if Resident 32 had an order for sennosides 8.6 mg, LVN 1 stated Resident 32 did not have an order for sennosides 8.6 mg. During an interview on 12/20/22, at 11:52 a.m., with the Director of Nursing (DON), the DON stated nursing staff should check medications against physician's order and MAR before administration. 2. A review of Resident 23's admission record dated 12/20/22 indicated Resident 23 had a diagnosis of vitamin d3 deficiency. During a medication pass observation and interview on 12/20/22, at 9:15 a.m., with LVN 2, LVN 2 administered three medications to Resident 23. LVN 2 stated the medications in the cup were two Tylenol (a pain reliever) 325 mg tablets, two sennosides 8.6 mg tablets, and two vitamin B12 (vitamin needed for blood production) tablets. LVN 2 stated a total of six pills were in the medication cup. A review of Resident 23's physician's orders, dated 12/21/22, indicated Resident 23 had another order for vitamin d3 25 mcg, once a day. During an interview and record review on 12/20/22, at 12:22 p.m., with LVN 2, Resident 23's MAR was reviewed. Resident 23's MAR indicated LVN 2 administered vitamin d3 25 mcg at 9:21 a.m. The MAR further indicated at 9:21 a.m., Resident 23 received two tablets of Tylenol 325 mg, two tablets of sennosides 8.6 mg and two tablets of vitamin B12. LVN 2 stated she gave Resident 23 all his morning medications at the same time and did not administer other medications before or after the 9:15 a.m. medication pass observation. LVN 2 recalled again six pills were in the medication cup. Reviewing Resident 23's MAR, LVN 2 stated Resident 23 should have received seven pills and could not recall giving vitamin d3. During an interview on 12/20/22, at 11:52 a.m., with the DON, the DON stated nursing staff should administer medications according to the MAR and document the administration after giving the medication. A review of facility policy and procedure (P&P) titled, Medication Administration, dated 9/2/22, indicated staff review MAR to identify medication to be administered and compare medication source with MAR to verify .medication name, form, dose, route and time.

Based on observations, interviews, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. two insulin (a medication to maintain blood sugar in diabetics) pens (an insulin dispensing device with replaceable needles) and a vial of insulin were found without an open or expiration date in a drawer in Medication Cart (Med Cart) 3; 2. six loose pills were found in two drawers in Med Cart 3; 3. two expired glucagon (a medication to raise blood sugar) auto-injectors (a device that automatically injects medication) were found in a drawer in Med Cart 3, 4. a bottle of fluticasone propionate solution 50 mcg/act (nasal spray used to relieve nasal symptoms, such as stuffy nose, itching and sneezing) was stored on Resident 30's nightstand. These failures had the potential for administration of expired medications to residents and administration of medications to the wrong resident. Findings: 1.During a concurrent inspection of Med Cart 3 and interview on 12/20/22, at 10:08 a.m., with Licensed Vocational Nurse (LVN) 2, two insulin pens and one vial of insulin were found in a drawer in Med Cart 3. LVN 2 stated the two insulin pens and vial of insulin did not have an open or expiration date written on the appropriate label. LVN 2 stated whoever opened the pens and vial should have labeled them appropriately. LVN 2 stated she did not know when the open dates for the two insulin pens or insulin vials were. During a review of manufacturer's storage recommendation for insulin pens and vial, dated 11/2019, the recommendations indicated opened insulin pens and vials be discarded after 28 days. 2.During an observation and interview on 12/20/22, at 10:08 a.m., with LVN 2, Med Cart 3 was inspected. Six loose pills were found in two of Med Cart 3's drawer. LVN removed the six pills and stated those pills should not be found loose in the drawers. 3.During an observation and interview on 12/20/22, at 10:10 a.m., with LVN 2, two expired glucagon auto-injectors were found in a drawer in Med Cart 3. LVN 2 stated the expiration date of the two glucagon auto-injectors was 8/22. During an interview on 12/20/22, at 10:20 a.m., with the Director of Nursing (DON), the DON stated expired medications needed to be removed from medication carts as they are found. During a review of facility policy and procedure (P&P) titled, Medication Storage, dated 9/2/22, the P&P indicated medication carts are routinely inspected by the consulting pharmacist for .medications with worn, illegible, or missing labels. The P&P further indicated medications be stored according to the manufacturer's recommendations .to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 4. During a concurrent observation of Resident 30's room and interview with LVN 3, on 12/19/22 at 9:40 a.m., there was a bottle of fluticasone propionate suspension 50 mcg/act (nasal spray used to relieve nasal symptoms, such as stuffy nose, itching and sneezing) placed on Resident 30's nightstand. LVN 3 acknowledged the bottle of fluticasone propionate suspension 50 mcg/act at Resident 30's nightstand. LVN 3 stated Resident 30 has no current orders for this medication. LVN 3 stated this medication should not be at Resident 30's nightstand for the resident's safety. During an interview on 12/21/21 at 1:40 p.m. with DON, DON stated Resident 30 has no orders to self-medicate. DON stated there is no assessment done for Resident 30's self medication. DON further stated medication should never be left at bedside for the safety of the residents. A review of the facility P&P titled, Medication Storage in the Facility, dated April 2008, indicated, Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deems appropriate in the judgment of the facility's interdisciplinary resident assessment team. The P&P Section A indicated, A written order for the bedside storage of medication is present in the resident's medical record and Section F further indicated, All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary.

Based on observation, interview, and record review, the facility failed to store and serve food in a sanitary manner when food items stored in the snack refrigerator were unlabeled and food items served during lunch did not have their temperatures checked before being served. These deficient practices had the potential to cause food borne illness that can affect all residents. The facility census was 99 and 95 residents were served food from the kitchen. Findings: During a concurrent observation and interview on 12/19/22 at 9:10 a.m. of the kitchen with Dietary Manager (DM) 1, three food items stored in the snack refrigerator were not labeled. DM 1 confirmed the three food items stored in the snack refrigerator were not labeled. DM 1 stated food items stored in the snack refrigerator should all have a label to identify what food items are stored in the container. During an observation and interview on 12/20/22 at 12:30 a.m. with [NAME] 1 during lunch service, two servings of rice, one serving of carrots and one serving of hot dog were served. [NAME] 1 stated the two servings of rice, one serving of carrots and one serving of hot dog were all prepared earlier in the kitchen. During a concurrent record review and interview on 12/20/22 at 12:45 p.m. of the 12/20/22 lunch temperature log, the temperatures of the rice, carrots and hot dog were not recorded. DM 1 acknowledged the temperatures of the rice, carrots and hot dog's temperatures were not recorded. DM 1 further stated the rice, carrots and hot dog were served to residents for lunch. A review of the facility document titled, Labeling and Dating of Foods, undated, indicated Policy: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated . All prepared foods need to be covered, labeled and dated . Leftovers will be covered, labeled and dated. A review of the facility document titled, Record of Food Temperatures, undated, indicated Policy: It is the policy of this facility to record food temperatures daily to ensure food that is at the proper serving temperature(s) before trays are assembled . 1. Food temperatures will be checked on all items prepared in the dietary department . 6. Measure and record the temperatures for each food product and mil at all meals. Record temperatures on temperature log.

Based on observation, interview, and record review, the facility failed to provide personal hygiene assistance (combing hair, brushing, teeth, shaving, washing, and drying the face and hands) to one of 18 sampled residents (Resident 36) when Resident 36's facial hair was not shaved. This failure resulted in Resident 36, a female, having overgrown facial hair resembling a mustache and beard. Findings: During a review of Resident 36's Minimum Data Set (MDS, an assessment tool used to guide care) dated 10/2/19, indicated Resident 36 had a Brief Interview for Mental Status (BIMS, a tool used to assess mental function) score of 03, indicating Resident 36 was severely cognitive impaired. The MDS also indicated Resident 36 needed extensive assistance of one person with her Activities of Daily Living (ADLs). During a concurrent observation and interview on 12/2/19 at 12:20 p.m., with Resident 36 and the Director of Staff Development (DSD), in the main dining room, Resident 36 was observed to have overgrown facial hair (beard and mustache). Resident 36 stated, I don't like it but no one does it for me. The DSD stated, She used to refuse to be shaved, but they will do it today. When the DSD asked Resident 36 if she wanted to be shaved, Resident 36 indicated she did want to be shaved. During an interview on 12/4/19 at 1:31 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 indicated Resident 36 sometimes refused to be shaved, but not all the time. CNA 1 also indicated she was aware Resident 36 was not shaved on 12/2/19. During a review of the facility's policy and procedure (P&P) titled, Routine Resident Care, dated September 2011, the P&P indicated, Residents receive the necessary assistance to maintain good grooming and personal hygiene .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the physician's order for oxygen administration for one of 18 sampled residents (Resident 29), when Resident 29's oxygen flow rate was not at the specific ordered rate. This failure had the potential to result in life threatening adverse effects for Resident 29, who had a medical history of Chronic Obstructive Pulmonary Disease (COPD, a term used to describe progressive lung diseases including emphysema, chronic bronchitis, and non-reversible asthma) due to oxygen toxicity. Findings: During a review of Resident 29's face sheet dated 12/4/19, the face sheet showed Resident 29 was admitted with multiple diagnoses, including COPD and lung cancer. During a review of the Brief Interview for Mental Status (BIMS, a tool used to assess mental function) in Resident 29's Annual Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/25/19, Resident 29's BIMS score was 15, meaning Resident 29 was cognitively intact. The MDS also indicated Resident 29 required oxygen therapy. During a concurrent observation and interview on 12/2/19, at 10:19 a.m., with Resident 29, in room [ROOM NUMBER]-2, Resident 29 was receiving oxygen via a nasal cannula (NC, a tube used to deliver supplemental oxygen) and set at a flow rate of 3.5 Liters (L, a unit of measurement). Resident 29 stated the flow rate is supposed to be 2 L NC. Resident 29 indicated that due to his medical conditions, he needs oxygen all the time. During a concurrent observation and interview on 12/2/19, at 11:58 a.m., with Licensed Vocational Nurse 2 (LVN 2), in room [ROOM NUMBER]-2, LVN 2 confirmed the oxygen administration rate was set at 3.5 L NC. LVN 2 stated Resident 29's flow rate was supposed to be at 2 L NC. LVN 2 indicated if Resident 29 felt short of breath and notified the licensed nurse, LVN 2 would assess the resident and provide the 'as needed' (PRN) inhaler or nebulizer as ordered. LVN 2 would then notify the physician. LVN 2 stated there is no order for the oxygen flow rate to be titrated (adjusting the concentration). During a review of Resident 29's Medication Administration Record (MAR) for December, the MAR indicated a physician's order was placed on 2/28/18 at 6:01 p.m. for oxygen to be administered at 2 L/NC, continously. During a subsequent interview with LVN 2, on 12/4/19, at 1:53 p.m., LVN 2 stated that with Resident 29's medical history of COPD and lung cancer, the oxygen flow rate for Resident 29 needed to be monitored and not increased without an order. LVN 2 indicated Resident 29 should not be given more oxygen than what was ordered because it could cause a build up of carbon dioxide (CO2) in the blood, and Resident 29 would not be able to expel CO2 properly from his lungs when feeling short of breath.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe storage of medications when a bottle of Timolol Maleate eye drops (a medication used to lower pressure in the eyes) was stored in the medication refrigerator instead of at room temperature, as per the manufacturer's specifications. This failure had the potential for the effectiveness of the medication to be reduced and residents receiving the medication to not receive the full therapeutic benefit of the drug. Findings: During a concurrent observation and interview on 12/3/19, at 8 a.m., with Registered Nurse 1 (RN 1), in Medication Storage room [ROOM NUMBER], a bottle of Timolol Maleate eye drops was seen in the medication refrigerator and the refrigerator's temperature was 40 degrees Fahrenheit. The medication instructions printed on the Timolol Maleate box indicated Store at 25 degrees Celsius (77 degrees Fahrenheit). RN 1 stated, I don't know why this is here but it should not be stored in the refrigerator. We missed it. RN 1 indicated inappropriate storage of medications causes the medication to lose its efficacy. During a review of the facility's policy and procedure (P&P) titled, Storage of Medication, dated 05/12, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .Medications and biologicals are stored at their appropriate temperatures and humidity according to the United States Pharmacopeia guidelines for temperature ranges. Medications requiring storage at 'room temperature' are kept at temperatures ranging from 15 degrees Celsius (59 degrees Fahrenheit) to 25 degrees Celsius (77 degrees Fahrenheit).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure their infection control and prevention program was followed for two of 18 sampled residents when: 1. Licensed Vocational Nurse 1 (LVN 1) did not wash his hands between glove changes and after providing wound care to Resident 10. 2. The urinary drainage bag for Resident 58 was on the floor. These failures had the potential to spread infection to Resident 10 and Resident 58. Findings: 1. During a wound dressing change observation on 12/2/19 at 9:45 a.m. with LVN 1, LVN 1 donned gloves, removed the soiled dressing, removed the gloves, put a new pair of gloves on without washing his hands, cleansed the wound, applied an ordered medical treatment to the wound, and covered the wound wearing the same pair of gloves. LVN 1 gathered the soiled dressing materials, discarded them, then removed his gloves. LVN 1 used hand sanitizer, and then exited Resident 10's room without washing his hands During an interview on 12/2/19 at 9:55 a.m. with LVN 1, LVN 1 admitted he did not wash or sanitize his hands between glove changes, and after cleansing the wound but prior to applying treatment to the wound. LVN 1 indicated he was supposed to wash his hands after every glove change and stated, I am supposed to wash with soap and water after doing [the wound care] treatment. During an interview on 12/2/19 at 11:20 a.m. with the Director of Staff Development (DSD), DSD stated, Staff must wash their hands before and after a procedure and after use of gloves before donning a new pair. During a review of the facility's policy and procedure (P&P) titled, Clean Dressing Change, dated 12/09, the P&P indicated, Put on gloves Remove soiled dressing, place in bag for disposal. Remove/dispose of gloves, wash hands, don clean gloves. Clean wound as ordered Remove/dispose of gloves, wash hands, don clean gloves. Apply dressing and secure as ordered Remove gloves; place in bag for disposal. Wash hands. 2. During a review of Resident 58's admission Record, dated 10/19/19, the admission Record indicated Resident 58 was admitted with multiple diagnoses, including obstructive and reflux uropathy (occurring when urine cannot drain through the urinary tract; urine then backs up into the kidneys and causes the kidneys to swell) and urinary retention. During an observation on 12/2/19 at 9:10 a.m. of room [ROOM NUMBER], Bed 2, Resident 58 was in bed with his urinary drainage bag hanging on the right side of his bed and touching the floor. During an interview on 12/2/19 at 9:15 a.m. with LVN 1, after LVN 1 checked the urinary drainage bag, LVN 1 stated, Yes, the catheter bag is touching the floor. How many inches should the catheter bag be off the floor? A review of the facility's policy and procedure titled, Infection Prevention Program Overview, dated 2/18, did not reveal any specific information regarding catheter maintenance for the prevention of catheter-associated urinary tract infections. During a review of the professional guidelines the facility indicated they followed, Lippincott procedures on indwelling urinary catheter (Foley) care and management, dated 11/15/19, the Lippincott procedures indicated, .don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI [catheter associated urinary tract infections]. During a review of the Centers for Disease Control's (CDC), Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009, the CDC guidelines indicated at Proper Techniques for Urinary Catheter Maintenance, that the urine collection bag should not rest on the floor.

Based on interview and record review, the facility failed to ensure competency skills checks for three of five licensed nursing staff were completed. This failure had the potential for care to be provided by licensed nurses in an unsafe and incompetent manner. Findings: During an interview on 12/4/19, at 12:04 p.m., with the Director of Nursing (DON), DON acknowledged her role as the nursing supervisor included conducting competency skills checks for all licensed nurses. During an interview on 12/4/19, at 12:33 p.m., with Registered Nurse 1 (RN 1), RN 1 stated DON had never done a competency skills checklist with her. During a review of employee personnel files, the files indicated RN 1 was hired on 10/24/11, LVN 1 was hired on 8/21/17, and LVN 4 was re-hired on 10/3/18. No competency skills checklists for RN 1, LVN 1, and LVN 4 could be found in their employee personnel files. During a concurrent interview and record review on 12/4/19, at 12:49 p.m., with DON, DON could not show current and previous years' competency skills checklists for three licensed nurses.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (5%) when, during a medication pass observation, three medication errors out of 32 opportunities resulted in a 9.3% error rate because: 1. Licensed Vocational Nurse 2 (LVN 2) did not follow the manufacturer's specifications when administering a potassium chloride tablet without food to Resident 32. 2. Licensed Vocational Nurse 3 (LVN 3) incorrectly crushed and administered an enteric-coated aspirin to Resident 83 and also administered a potassium chloride tablet without food to Resident 83. These failures had the potential to result in undesired health outcomes for Residents 32 and 83, such as stomach irritation, gastric ulcer, and gastric bleeding. Findings: 1. During a medication pass observation on 12/4/19 at 9 a.m., LVN 2 prepared and administered 13 medications to Resident 32, including potassium chloride (Klor-con). During a review of the Order Summary Report for Resident 32, the physician's order, dated 9/2/14, stated, Klor-con M20 ER [ER, extended release] 20 MeQ [MeQ, a unit of measurement] tab--give one tablet a day for supplement. Administer with meals. During a review of the Klor-con M20 medication label, the label stated, Give with food/meals. Take with plenty of water. During an interview on 12/4/19 at 1:16 p.m., with LVN 2, LVN 2 indicated she should have given the Klor-con with food, according to the physician's orders. LVN 2 stated, This medication interacts in the stomach. It has something to do with binding . LVN 2 also indicated the pharmacist told the licensed nurses to give the medications as instructed on the label. 2. During a medication pass observation on 12/4/19 at 9:50 a.m., LVN 3 prepared and administered seven tablets to Resident 83, including enteric-coated (EC) aspirin and Klor-con to Resident 83. (Enteric coating is a delayed-release safety coating designed to allow the aspirin tablet to pass through the stomach to the small intestine before dissolving, thereby providing added stomach protection.) LVN 3 crushed all the tablets, including the enteric-coated aspirin, and mixed them in applesauce in a medicine cup. LVN 3 placed the Klor-con tablet in a separate medicine cup and administered it separately with apple sauce. During a review of the Order Summary Report for Resident 83, a physician's order, dated 12/3/19, indicated, Potassium Chloride (KCL) ER tab 10 MeQ, give one tablet by mouth one time a day for supplement. Give with food. During a review of the KCL ER medication label, the label stated, Take this medication with a meal. Take with plenty of water. During a review of the Order Summary Report for Resident 83, a physician's order, dated 11/3/19, indicated, Aspirin EC Tablet Delayed Release, 81 mg [milligrams, a unit of measurement] (Aspirin)--give 1 tablet by mouth, one time a day for A. Fib [atrial fibrilation, a heart condition]. During an interview on 12/4/19 at 1 p.m. with LVN 3, LVN 3 admitted crushing the enteric-coated aspirin, and stated, Coated medications should not be crushed. LVN 3 also indicated Resident 83 had eaten breakfast at 7:30 a.m., and the KCL tab should have been given with food. LVN 3 stated, It is for better absorption, with food. During a telephone interview on 12/4/19 at 1:26 p.m. with the facility's Registered Pharmacist (RPh), RPh stated, Enteric-coated medications should not be crushed. It may be harmful to the patients. The crushed enteric-coated medications also loses the protective coating which could be harsh on the stomach. During a review of the manufacturer's instructions for the administration of potassium chloride, the instructions indicated Klor-Con M tablets should be taken with meals and with a glass of water or other liquid. This product should not be taken on an empty stomach because of its potential for gastric irritation. During a review of the Institute for Safe Medication Practices (ISMP) guidelines titled, Oral Dosage Forms That Should Not Be Crushed, commonly referred to as the Do No Crush list, enteric-coated aspirin is listed as a medication that should not be crushed because it is coated and designed to be released slowly. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 06/08, the P&P indicated, Medications are administered in accordance with the written orders of the attending physician .The nurse is responsible to read and follow precautionary or instructions on prescription labels .Check the Do Not Crush list before crushing medications.