**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R31 was admitted to the facility on [DATE] with diagnoses that include but not limited to chronic obstructive pulmonary disease (COPD), muscle weakness, abnormalities of gait and mobility, and osteoarthritis. Review of R31's most recent quarterly MDS dated [DATE] documented that R31 had a BIMS score of 7, indicating R31 had severely impaired cognition. Section GG, Functional Status, documented that R31 requires substantial/maximal assistance with personal hygiene. Review of R31's care plan revised 10/17/2024 documented focus of self-care deficits related to advance age, impaired vision, muscle weakness, osteoarthritis, and COPD. Goals include needs will be met as evidenced by being clean, well groomed, and appropriately dressed. Interventions include but are not limited to extensive assist with toileting and incontinent care upon rising, after meals, at bedtime, and as needed. Observation on 11/12/2024 at 12:44 pm in the dining room revealed R31 eating independently. During this time, a black substance was observed underneath her fingernails. [NAME] hair was observed on her face. Observation on 11/12/2024 at 2:26 pm in the resident's room revealed fingernails to have a black substance underneath. [NAME] hair was observed on her face. Observation on 11/13/2024 at 12:17 pm in the dining room revealed R31 eating with her hands. A black substance was observed underneath her fingernails. [NAME] hair was observed on her face. Observation on 11/14/2024 at 10:26 am near the nurses' station revealed a black substance underneath R31's fingernails and chin hair on her face. Interview on 11/14/2024 at 2:24 pm with Certified Nursing Assistant (CNA) II confirmed R31's nails were dirty underneath and R31's face had noticeable chin hair. She stated that R31 received assistance with ADLs and did not refuse care. CNA II further stated that she cleaned the resident's nails in the morning when getting up, on shower day, during bed baths, when using the bathroom, and sanitized hands before and after meals. She stated that every day the care staff should be looking at facial hair and assisting residents. Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs) Policy, the facility failed to ensure activities of daily living relating to fingernail care and grooming were provided for five of 18 sampled residents (R) (R33, R42, R28, R55 and R31). The deficient practice had the potential to cause risk for unmet needs and a diminished quality of life. Findings include: Review of the policy titled Activities of Daily Living (ADLs) Policy revised October 2024 revealed under Policy Statement: Residents are provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Under Policy Interpretation and Implementation: 1. Care will be provided unless clinically inappropriate. 2. Services that will be provided which include grooming, mobility, elimination during dining, and communication. 5. Residents are clinically assessed to determine the amount of assistance needed for tasks and any decline in abilities are noted in Minimum Data Set (MDS). 1. Review of the electronic medical record (EMR) revealed R33 was admitted to the facility with diagnoses including but not limited to major depressive disorder recurrent, severe with psychotic symptom, anxiety unspecified, and muscle weakness generalized. Review of R33's annual MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates R33 was cognitively intact at time of assessment. Section GG, functional status, revealed R33 required substantial maximum assistance with activities of daily living (ADLs) with one/two or more-person assistance. R33 used a wheelchair for mobility. Review of R33's care plan dated 10/3/2024 indicated a problem of self-care deficits in part related to advanced age, arthritis, muscle weakness, and COPD. Goals included but not limited to needs will be met as evidenced by being clean, well-groomed and appropriately dressed. Interventions included but not limited to bathing/showering with moderate assist with bathing three times a week. Observation and interview on 11/12/2024 at 11:35 am with R33 revealed resident sitting up on the side of the bed, well-groomed with exception of long and dirty fingernails. R33 revealed the staff would cut her nails when they got around to it as weekend staffing was low as they don't come so quickly, not sure how long. Observation made on 11/13/2024 at 3:48 pm revealed R33 resting in bed on their left side. Fingernails remained long and less dirty. Observation on 11/14/2024 at 9:18 am of R33's fingernails revealed they had not been cleaned or trimmed. An interview on 11/4/2024 at 10:30 am with Certified Nursing Assistant (CNA) BB confirmed CNA's do fingernail care when providing baths or showers and in between as needed. CNA BB added she made sure they were clean as a lot of the residents eat with their hands. Interview on 11/14/2024 at 3:10 pm with the Assistant Director of Nursing (ADON), she stated resident nail care was either done by personal means otherwise CNAs should be monitored along with nurses, and toenails were taken care of by a podiatrist. The ADON stated if nails were unkept it was a lack of ADL care. Review of the EMR revealed R42 was admitted to the facility with primary diagnosis of fracture and other multiple trauma. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 13, which indicates R42 was cognitively intact at time of assessment. Section GG, functional status, confirmed R42 needs maximum assistance with ADLs. Observation and interview on 11/12/2024 at 12:10 pm of R42 revealed resident lying in bed with the head of the bed slightly elevated, awake, and watching television. She was dressed and her hair was combed. R42's fingernails on both hands were long and had dark material under them. R42 stated the staff here helped her when she needed it, and her fingernails were long and a bit dirty and they will cut them when they are ready. Observation on 11/13/2024 at 12:45 on revealed R42 sitting in wheelchair in the dining room finishing her lunch with no distress noted. Fingernails remained long and not cleaned. Review of the EMR revealed R28 was admitted to the facility with a primary diagnosis of non-traumatic brain injury. Review of R28's quarterly MDS dated [DATE] revealed a BIMS sccore of 11, indicating moderate cognitive impairment at time of assessment. Section GG, Functional Status, indicates R28 is dependent for lower body dressing and substantial maximum assistance with all other ADLs. Observation and interview on 11/12/2024 at 12:18 pm with R28 revealed an alert individual sitting in a wheelchair in the dining room, well-groomed except for the fingernails, which were long and dirty with dark, brownish-black material underneath them. R28 stated she was fine, but her fingernails needed to be taken care of. Observation on 11/14/2024 at 8:47 am revealed R28 at breakfast in the dining room, she shared no concerns, and her nails remained long. Review of the EMR revealed R55 was admitted to the facility with a primary diagnosis of metabolic encephalopathy. Review of R55's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8, indicating R55 had moderate cognitive impairment at the time of assessment. Section GG, Functional Status, revealed R55 required extensive assistance for activities of daily living (ADLs) with one/two or more-person assistance. Observation and interview on 11/12/2024 with R55 revealed the bed in low position pushed up against wall on the right side, fall mat in place, with R55 lying in bed with the head of the bed elevated with two smaller side rails up. R55's hair was uncombed, and fingernails were long and dirty. R55 was pleasantly confused, had difficulty finding her words. Observation on 11/13/2024 at 4:00 pm revealed R55 up in a reclining geriatric chair in their room with the door closed, yelling out continuously. R55 did quiet when spoken to and made attempts to converse, however speech was very unclear at this time. R55's fingernails remained long and dirty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled, Use of Psychotropic Medication, the facility failed to implement a stop date for a PRN (as needed) psychotropic medication for one of five Residents (R) (R53) reviewed for unnecessary medications. The deficient practice had the potential to affect the resident's highest practicable mental, physical, and psychosocial well-being. Findings include: Review of the facility's policy titled Use of Psychotropic Medication revised 7/2024 revealed under Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Under Policy Explanation and Compliance Guidance: . 9. PRN [as needed] orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). R53 was admitted to the facility with diagnoses that include but not limited to cognitive communication deficit, Alzheimer's disease, depression, and generalized anxiety disorder. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] documented that R53 had a Brief Interview for Mental Status (BIMS) score of 99, indicating R53 had severely impaired cognition. Section GG (Functional Status) documented that R53 is dependent on physical assistance with eating, transfers, and personal hygiene. Review of R53's care plan revised 11/7/2024 documented no focus related to antipsychotics. Review of the Physician Orders for R53 dated 6/24/2024 documented lorazepam 0.5 milligrams (mg) every 4 hours as needed for agitation, anxiety, and restlessness, and staff should monitor every shift for aggressive-impulse behavior, fidgeting, agitation, restlessness, and change in sleep patterns. The stop date was defined as indefinite. There was no documented clinical rationale for the duration of the PRN lorazepam. Review of the monthly medication review (MRR) dated 10/10/2023 revealed that the consultant pharmacist sent a note to the attending physician regarding a previous PRN order for lorazepam, reminding the physician that CMS regulations state that a PRN psychotropic medication order should be limited to 14 days unless the attending physician or prescribing practitioner documents their clinical rationale in the medical record and indicates the duration for the PRN order. Review of the Medication Administration Record (MAR) dated 11/2024 revealed R53's most recent dose of PRN lorazepam was administered on 11/7/2024. Observation on 11/13/2024 at 12:34 pm in the dining room, R53 was noted to be sleepily hunched over but eating with assistance. Observation on 11/14/2024 at 10:49 am revealed R53 crying coming out of the shower room near the first-floor nurses' station with the care aides. The care aides rolled her chair near the activity but not facing the activity. R53 was then sitting facing an empty table, hunched over in her chair sleeping. Further observation at 11:33 pm revealed R53 still sitting with no engagement and falling asleep. Interview on 11/14/2024 at 11:14 pm with Certified Nursing Assistant (CNA) PP revealed that R53 was usually seen crying and sleepy. Interview on 11/12/2024 at 2:04 pm with Registered Nurse (RN) AA revealed that R53 was sleeping most of the time and awake for a few hours.

Based on observations, staff interviews, and review of the facility policy titled, Storage of Medications, the facility failed to ensure medications were secured for one of two medication carts on one of two Halls (Hall B). The deficient practice had the potential for residents, visitors, and staff to access medications that may cause illness or injury. The facility census was 71. Findings include: Review of the policy titled Storage of Medications dated 3/1/2024 revealed under Policy Statement: All drugs and biologicals will be stored in a safe secure and orderly manner. Under Policy Interpretation and Implementation: 1. Drugs are stored in locked compartments stored in their packaging as received from pharmacy. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 9. Unlocked medication carts are not left unattended. Observation on 11/13/2402 at 8:19 am of medication administration on Hall B, Licensed Practical Nurse (LPN) EE was preparing for medication administration for R8 and walked down the hall leaving the medication cart unlocked with her back turned away from the medication cart. LPN EE obtained a blood pressure machine from the medication cart in the hallway and returned rolling the cart directly into R8's room with a cup of pills on top of the cart. While LPN EE was preparing medication, she left multiple medication cards on top of the cart, along with a medicine cup with three capsules in it. Medications left on cart: 1. senna plus 2 tablets 2. amiodarone 200 mg 1 pill 3. vitamin C 1 tablet 4. Caltrate 600 1 pill 5. Eliquis 5 mg 1 pill 6. gabapentin 100 mg 1 pill 7. Jardiance 10 mg 1 pill 8. Macrobid 1 pill 9. metoprolol 50 mg 1 pill 10. Areds2 1 capsule 11. vitamin D 2000 u 1 pill Interview on 11/13/2024 at 8:30 am with LPN EE revealed she was aware that a cup with capsules was left on the medication cart stating they were empty from giving medicine to another resident who had crushed medications and thought that was all right since they were empty capsules. LPN EE confirmed six medication cards and five bottles with over-the-counter medications were left on top of the medication cart stating she doesn't usually do that and thought the surveyor would need them again. LPN EE confirmed this was not appropriate practice and could be harmful to others. Interview on 11/14/2024 at 3:22 pm with the Assistant Director of Nursing (ADON) revealed their expectation was that no medications or empty capsules be left unattended. The ADON added this could lead to someone ingesting something that may cause them harm, even the capsules could have some medication remaining inside and the nurses know not to leave the medication cards unlocked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R19 was admitted to facility with diagnoses including but not limited to gastrostomy, dysphagia, oropharyngeal phase, unspecified dementia without behavioral disturbance. Diagnosis pressure ulcer stage four added 3/11/2024. Review of R19's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicates R19 identified to have severe cognitive impairment. Section GG, functional status, revealed R19 was dependent for all care. Section J, pain assessment, revealed R19 receives scheduled pain medication regimen as needed. Review of the care plan for R19 Focus of Care initiated on 11/17/2024 indicated a problem of R19 has a peg tube stoma and a healing stage four pressure ulcer to sacrum. She is at risk for additional alteration of skin integrity and pressure ulcers related to immobility, incontinence, and dementia. Goals included but not limited to sacral ulcer will show signs of healing. Interventions included but not limited to avoid positioning the provide pressure relief re-distribution to surface of bed. Follow up with wound care specialist. Hand splint and ROM with nursing restorative. Monitor and document sacral ulcer characteristics. Review of the Physician's Orders for R19 revealed the following order dated for 10/19/2024: wound care cleanse wound, pat dry, apply calcium alginate and Medihoney (wound and burn gel), to base of wound, house barrier cream to base of wound and cover with border island gauze. Observation on 11/14/2024 at 10:18 am revealed R19 lying down toward their left side with wedge pillow support. Registered Nurse (RN) AA was preparing for wound care. RN AA performed hand hygiene and was assisted by CNA BB. RN AA stated he medicated R19 for pain about an hour ago. No PPE or precaution signs were observed outside of the room. Staff put on exam gloves. RN AA gathered supplies as follows: Medihoney, tongue blade, adhesive, non-sterile gauze pads, Allevyn Life Foam Dressing, dermal cleanser, and calcium alginate dressing, and placed on top of the treatment cart. RN AA rolled the treatment cart into the resident's room and placed it at bedside. RN AA remained in the room for the duration of the procedure. RN AA placed the tube feeding pump on pause and lowered the head of the bed. CNA BB assisted to turn resident over, wedge pillow was removed and was noted to have a tear with exposed foam. Hand hygiene was performed by RN AA and CNA BB. At 10:27 am, RN AA used the tongue blade to get the supply of Medihoney for the wound, then removed the dressing. RN AA stated to CNA BB to pull her diaper down and then he changed gloves, no hand hygiene was performed. R19 was moaning and her hands were shaking, resident was nonverbal. CNA BB stated R19 did this when hurting. RN AA placed spray dermal cleanser, barrier cream, wipes, gauze, Allevyn Life dressing, and another spray bottle label not visible on the resident's bed. RN AA cleaned area with dermal spray cleanser and gauze, placed Medihoney on wound, placed calcium alginate, barrier cream, and removed gloves, no hand hygiene was performed. R19 was still moaning, reassured by CNA BB. RN AA applied Allevyn Life over wound and dated it for today. R19 was positioned, moaning stopped, and she appeared comfortable. Observation on 11/12/2024 at 10:49 am of R19 revealed her lying in bed, turned on her right side and was not responsive to calling her name. A pressure-relieving machine mattress was on the bed. Interview on 11/14/2024 at 10:37 am with the IP, they stated proper procedure for wound care was to prepare what was needed after verifying the order. Then create a clean surface with a barrier in the room, usually the over bed table, and take what was needed in the room and place it on that barrier, no shared items should be taken in the room and the treatment cart remained outside of the room, locked. RN DD also stated hand hygiene must be performed before starting. She verified photo showing wound care items on bed both and stated that shared and single use items should never be placed there. Interview on 11/14/2024 at 10:42 am with RN AA revealed he felt the wound care went well even though the cart was not well stocked. RN AA revealed he normally took the cart in the resident room, and it was cumbersome. He further confirmed this was an isolation room and he should get items and take them in the room, and he would have to wipe the cart, then stated he already wiped the cart. RN AA confirmed any trash that was bloody went in the red bag, otherwise he collected the trash and took it out of the room. RN AA verified that items in the photo (shared and single use items) should not have been placed on the resident's bed. Interview on 11/14/2024 at 2:55 pm with the DON revealed you don't need to wear a gown unless the wound was infected. On 11/14/2024 at 3:19 pm, the ADON agreed that no carts should be taken into the resident's room. If the resident was shaking and moaning, the resident was uncomfortable and you should stop and see what may be wrong. Observation on 11/13/2024 at 8:19 am of medication administration on Hall B, LPN EE was preparing for medication administration for R8 and walked down the hall and obtained a blood pressure machine from the hallway and returned, rolling directly into R8's room. R8's blood pressure was taken over her sweatshirt and then brought back out placing it in the hallway. Interview on 11/13/2024 at 8:30 am with LPN EE revealed awareness that blood pressure cuffs should be cleaned after each use and with wipes, adding she did not do it and generally did this before returning the BP machine to the charging station. Interview on 11/14/2024 at 10:37 am with the IP, they stated no shared equipment should be left uncleaned. Interview on 11/14/2024 at 3:22 pm with the ADON shared expectations that all shared equipment should be wiped down when staff obtain it and then expected they wipe them all down immediately when finished. When taking blood pressure with residents up in a chair, there should be no clothing underneath the blood pressure cuff to ensure you get a correct reading. Without proper technique, you won't know if something was going wrong with the resident. Based on observations, record review , staff interviews, and review of the facility policies/documents titled, Infection Prevention and Control Program, Infection Prevention and Control Committee, Surveillance Plan, Help Keep Our Residents Safe-Enhanced Barrier Precautions In Nursing Homes, Enhanced Barrier Precautions (EBP) Implementation-Observations Tool, and Wound Care, the facility failed to provide proper surveillance and monitoring for infections and communicable diseases for 71 of 71 residents (R) residing in the facility. In addition, the facility failed to ensure Enhanced Barrier Precautions signs were on residents' doors for 15 of 15 (R) on enhanced barrier precautions. Furthermore, the facility failed to provide wound care following appropriate technique to prevent spread of infection for one of eight sampled (R) (R19), and to ensure staff practiced infection prevention techniques relating to shared equipment use cleaning. These deficient practices had the potential to cause the spread of infection. The sample size was 26. Findings include: Review of the undated facility policy titled Infection Prevention and Control Program documented under the section titled Procedure: 1. It is the policy of this facility's Infection Prevention and Control Program to follow recommendations from the state, CDC recommendation through surveillance, auditing, and monitoring. The Infection Prevention and Control Program includes a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to regulatory requirements and following accepted nation standards. The following guidelines, standards, with policies and procedure will be followed. A. Written standards, policies, and procedures for the Infection Prevention and Control program include, but not limited to: 1. Surveillance: A system of surveillance designed to identify possible communicable diseases or infections before that can spread to another person in the facility. 2. Reporting: When and to whom possible incidents of communicable disease or infections should be reported. Review of the undated facility policy titled, Infection Prevention and Control Committee documented under the section titled Responsibility and Scope of Activities: 1. Surveillance of Infections - Review surveillance data looking for unusual epidemics, clusters of infections, infections due to unusual pathogens or any occurrence of healthcare associated infections; initiate isolation procedures as indicated. 3. Standard and transmission -based precautions to be followed to prevent spread of infections. 4. When and how isolation should be used for a resident; including but not limited to: a. The type and duration of isolation, b. Depending upon the infecting agent or organism involved. Review of the undated facility policy titled Surveillance Plan documented under the section titled Surveillance Process: The facility conducts surveillance daily by reviewing laboratory orders and results, antibiotic orders, admission/discharge/transfer records, and medical records. In addition, infection control designee attends morning update meetings to identify residents with a change in signs and symptoms to identify infections needing isolation as quickly as possible. Cases or persons meeting surveillance criteria for infection are identified using McGeer 2012 surveillance criteria for long-term care and/or National Healthcare Safety Network (NHSN) criteria for long-term care. Data is documented in files and stratified according to short-stay and long-stay residents and by unit as needed. Data is aggregated weekly, monthly, quarterly, and annually and compared on monthly, quarterly, and annual basis. Focus areas for surveillance include but are not limited to multi-drug-resistant organisms; influenza; pneumonia, C. difficile and other gastroenteritis infections; skin, wound, and soft tissue infections; urinary tract infections (with or without catheters). Surveillance goals and objectives are based on the results of the annual infection control risk assessment. Review of the undated facility document titled Enhanced Barrier Precautions (EBP) Implementation Observations Tool documented under 9. *Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE to be worn when caring for the resident. The EBP sign should also include a list of the high-contact resident care activities for which PPE (gown and gloves) should be worn. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure EBP are followed. Signs should not include information about a resident's diagnosis or the reason for the use of EBP (e.g., presence of a resistant germ, wound). Review of the facility policy titled Wound Care revised October 2010 revealed under Preparation: 3. Assemble the equipment (e.g., gowns, gloves, mask, etc., as needed). Revealed under Steps in the Procedure: 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam gloves. Loosen tape and remove dressing. 5. Pull glove off and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on PPE. 13. Any items belonging to resident for multiple use should be wiped down with alcohol and placed in drawer with direction in next step stating only take disposable supplies that are needed into the room. 1. An observation on 11/12/2024 of the facility's Infection Control Book revealed the facility did not have evidence of infection control surveillance/ monitoring/ tracking for the last six months. An interview conducted on 11/13/2024 at 3:11 pm with the Infection Preventionist (IP) revealed that there had been no infection control tracking for the past six months. The IP explained that she had requested access to the records from the Director of Nursing (DON), but was informed that the DON did not have access to the records from the previous IP. The IP mentioned that she had only been able to track infection control data for the month of October, specifically focusing on residents who had been prescribed antibiotics or had experienced any type of infections. The IP acknowledged her responsibility to maintain infection control records but noted that due to insufficient time and incomplete training, she had been unable to fully carry out the required tracking and reporting duties. The IP further expressed several concerns about how infection control issues were currently being handled. The IP noted a lack of clarity around the reasons for certain tests and highlighted a breakdown in the chain of communication regarding testing, such as urinary tract infections (UTIs). The IP mentioned that when she first joined the facility, there were no existing policies or procedures in place for infection control, and she had to build the system from the ground up. Additionally, she reported that infection control issues, like UTIs, were not addressed in a timely manner. The IP also expressed frustrations with insufficient training for her role, a lack of assistance, and uncertainty about what was required in her position. An interview on 11/14/2024 at 2:41 pm with the Assistant Director of Nursing (ADON) revealed that infection surveillance had not been continuously monitored at the facility. The ADON further explained that the IP had not received full training in infection prevention when she was hired. It was included in her agreement that she would seek training; however, she had been utilized in other roles within the facility. The ADON stated the IP worked on infection control prevention duties on Mondays, Tuesdays, and Wednesdays, while on Thursdays and Fridays she was assigned to pass medications. An interview on 11/14/2024 at 02:46 pm with the DON revealed that the expectation was for the facility to implement proper infection control procedures to prevent the spread or transmission of disease. The DON stated she was aware that infection surveillance was not being conducted and mentioned that if needed, she would contact the sister company for additional support or guidance. When asked about the potential negative outcomes of inadequate infection control, the DON highlighted the risk of infections spreading. An interview conducted on 11/14/2024 with the Administrator revealed his expectations for infection control, which include identifying infection locations, tracking and trending infections throughout the building, notifying the clinical team, and leveraging their expertise to help mitigate infection-related issues. The Administrator emphasized the importance of educating staff on infection control practices, stating that this was an essential responsibility that must be carried out. He mentioned that infection control issues were discussed during their Quality Assurance and Performance Improvement (QAPI) meetings. When asked about the potential negative outcomes of inadequate infection control, the Administrator noted the risk of mass spread of infections, exposing other residents unnecessarily, and infections going untreated. An observation on 11/13/2024 at 3:40 pm revealed no EBP signs on residents' doors were observed on Halls A, B, C, D, E, or F, which were located on the first and second floors. Review on 11/14/2024 of a list provided by Clinical IT OO revealed 17 residents on EBP. An interview conducted on 11/14/2024 at 10:29 am with the IP revealed that EBP was required for residents with multi-drug-resistant organisms (MDROs) and those who had infections that were resistant to antibiotics. The IP stated in these cases, staff must use personal protective equipment (PPE) and that supply carts for infection control should be placed outside residents' rooms but did not elaborate on their current implementation. The IP noted that when she arrived at the facility, there were no EBP signs. The IP confirmed she was aware of the need for signage and had it available in her office, but because of her lack of time, she has not implemented EBP. The IP believed the training she received was insufficient and noted that infection control procedures had not been fully implemented at the facility. Additionally, the IP expressed concern that without proper signage and staff awareness of the need for PPE, there was a risk of infections spreading to both staff and other residents. An interview was conducted on 11/14/2024 at 10:20 am with Licensed Practical Nurse (LPN) JJ revealed having one patient with an indwelling catheter who occasionally experienced UTIs and was treated with antibiotics. LPN JJ stated that there was no signage for EBP on the patient's room (E5B) door. LPN JJ further explained that staff were not given PPE supply carts outside of rooms for patients requiring EBP unless there were concerns about contagions. LPN JJ mentioned that she informed other people about the patient's EBP status, when asked about how other staff or visitors know about the resident being on EBP. LPN JJ acknowledged having received an in-service on infection control about a week ago. An interview conducted on 11/14/2024 at 10:43 am with LPN EE indicated that the type of PPE required depended on whether the patient had a wound, was using a foley catheter, or had an airborne infection. When asked how visitors would know which PPE to use, LPN EE responded that signage was essential, and she confirmed that she hadn't seen any signs when she was hired. LPN EE recognized the importance of signage to prevent exposure to others. An interview conducted on 11/14/2024 at 11:20 am with Certified Nursing Assistant (CNA) KK revealed that she was aware of which residents were on EBP through her knowledge from working at the facility for an extended period. However, CNA KK confirmed that she had not seen any EBP signage recently, though she recalled seeing it during the COVID-19 pandemic. CNA KK stressed that the lack of signage could lead to exposure risks. An interview was conducted on 11/14/2024 at 11:25 am with Dining Server (DS) LL who reported that he delivered food trays to residents but was not so familiar with EBP. DS LL recalled seeing EBP signs during the COVID-19 pandemic but noted that he had not seen them in recent months. DS LL expressed concern about his safety now that he was aware of the importance of EBP signage, adding that he had never received in-service training on infection control. An interview was conducted on 11/14/2024 at 11:32 am with the Restorative Wellness Instructor (RWI) MM who stated that she was familiar with EBP. RWI MM confirmed seeing signage for EBP during COVID-19 but noted that she had not seen any signs recently. RWI MM added that shewas aware of which residents are on EBP through a list she received when conducting restorative therapy but had not seen any signage on residents' doors. An interview was conducted on 11/14/2024 at 11:39 am with the Maintenance Engineer NN, stated he was not familiar with EBP but speculated that it involved isolation procedures and the use of PPE. Maintenance Engineer NN stated that he had seen signs for EBP in the past but had not observed any in recent months. Although he did not personally feel concerned about non-contact infections, he understood the importance of having signs for everyone's safety. An interview was conducted on 11/14/2024 at 11:43 am with the Clinic Information Technology (CIT) OO revealed she was familiar with EBP. CIT OO mentioned that she would typically check the signs on residents' doors to determine the required PPE or would ask a nurse. While CIT OO didn't recall seeing any signs recently, she confirmed that residents with wounds, UTIs, and catheters were supposed to be on EBP, which required signage on their room doors. An interview conducted on 11/14/2024 at 2:41 pm with the ADON revealed that EBP should include signage indicating the proper PPE to use for residents with wounds, lines, drains, or those on antibiotics, as well as for any residents with conditions that were out of the ordinary. However, the ADON mentioned that EBP had not yet been fully implemented at the facility. The ADON recalled that when he arrived in July 2024, he did not see any signs related to EBP and noted that it was not a focal point for him at the time. The ADON further revealed that the IP voiced her concerns regarding their being no EBP signs since day one when she walked through the door. When asked about his concerns regarding infection control, the ADON mentioned that as a nurse, his primary concern included the risk of infections spreading. He noted that with fewer barriers in place and without proper precautions, there were more open pathways for infections to be transmitted and transported. An interview conducted on 11/14/2024 at 2:46 pm with the DON revealed that the negative outcome of not properly following EBP precautions could result in the spread of infection, potentially leading to widespread contamination. An interview conducted on 11/14/2024 at 3:21 pm with the Executive Director revealed that the expectation was that all residents on EBP must have signage displayed on their doors. The Executive Director noted that failing to follow this protocol could result in negative outcomes, including the potential risk of cross-contamination and the infection of other individuals within the facility.

Based on observations, record review, staff interviews, and review of the facility policy titled, Antibiotic Stewardship Policy, the facility failed to establish and maintain an antibiotic stewardship facility-wide monitoring system (line listing) for residents on antibiotics. The deficient practice had the potential to affect all 71 residents residing in the facility. Findings include: Review of the facility policy titled Antibiotic Stewardship Policy not dated, documented under section titled, Governance of Antimicrobial Stewardship, as part of the Infection Prevention and Control Program (IPCP), the facility has established a committee to oversee antimicrobial stewardship functions. The Infection Preventionist (IP), who is responsible for the overall IPCP, is an integral part of the committee. The Antibiotic Stewardship Committee will meet at least quarterly and review this policy annually and as needed. Under Composition: 1. An Antibiotic Stewardship Committee has been established and is composed of the following personnel: a. Infection Preventionist (IP), b. Director or Assistant Director of Nursing, c. Medical Director, d. Consulting and/or Dispensing Pharmacist, e. Administrator, f. Attending Physician or Nurse Practitioner, g. Nurse, h. CNA (Certified Nursing Assistant). 2. The IP will incorporate antibiotic stewardship into their current activities and will allocate dedicated time (10 hours/week) specifically for antimicrobial stewardship activities. The IP is required to complete the Nursing Home Infection Preventionist Training Course provided by The Centers for Disease and Control (CDC). 3. The Director of Nursing, Medical Director and Administrator for Presbyterian Village are responsible for ensuring that adequate staffing and resources are allocated to support the functions and efforts of the IP and the Antibiotic Stewardship committee. The determinations for adequate staffing and resources will be informed by the facility assessment used to establish and update the IPCP. Under Procedures, A. The Antibiotic Stewardship Committee will: 1. Support and promote antibiotic use protocols which will include: a. Assessment of residents for infection using standardized tools and criteria. The criteria used by this facility are adapted from the revised McGeer Criteria. b. Therapeutic decisions regarding antibiotic prescriptions based on evidence (e.g., guidelines and consensus statements from clinical and academic societies) that is appropriate for the care of long-term care facility residents. c. Specifying a dose, duration, and indication on all antibiotic prescriptions. d. Reassessment of empiric antibodies after 2-3 days for appropriateness and necessary, factoring in results of diagnostic tests, laboratory reports and/or changes in the clinical status of the resident. e. Whenever possible, choose narrow-spectrum antibiotics that are appropriate for the condition being treated. 2. Develop and maintain a system to monitor antibiotic use, which includes: a. Review antibiotics prescribed to residents upon their admission or transfers to the facility and those during the course of evaluation by a prescribing practitioner who is not part of the Facility's staff (e.g., emergency department provider, specialty provider). b. Periodically (quarterly) review a subset of antibiotics. prescriptions for inclusion of dose, duration and indication (or length of therapy, documentation of an antibiotic time-out, appropriateness based on antibiotic use protocols and written documentation of clinical justification for antibiotic use that does not comply with the facility antibiotic use protocols). Periodically review rates of prescriptions for any antibiotics or conditions identified by the committee as being of special interest. c. Annually review antibiotic use data by the facility and/or by individual providers to determine if there is excessive use of specific antimicrobial agents. The assessment will measure antibiotic starts (antibiotic days of therapy, defined daily doses of antibiotics) per 1000 resident days of care (and/or length of therapy). If excessive use or other conditions are identified, the facility will take action to address these problems. d. Provide feedback on the facility's antibiotic use data to the Quality Assessment and Assurance (QAA) Committee. 3. Develop and maintain a system to monitor resistance data, which will: a. At least annually, review surveillance data pertaining to microorganisms related to antibiotic use (e.g., methicillin resistant Staphylococcus aureus, Carbapenemase-Resistant Enterobacteriaceae spp. (CRE) or Clostridium difficile). An observation on 11/12/2024 of the facility's Infection Control Book revealed the facility did not have data of Antibiotic Stewardship line listing. An interview conducted on 11/14/2024 at 2:46 pm with the Infection Preventionist (IP) revealed she does not currently have a list of residents on antibiotics or a line listing. The IP explained that she started her infection prevention training on October 7, 2024, but due to staffing shortages, she had been primarily focused on passing medications. As a result, she was now working part-time as the IP and part-time as a Registered Nurse (RN). The IP noted that she had not yet completed her full training for the IP role, and while the Assistant Director of Nursing (ADON) was supposed to be training her, he had not had the opportunity to do so. As of now, she did not have a list of infections, and she felt that she had not been able to fully perform the duties she was hired for, despite having several meetings to discuss these concerns. An interview conducted on 11/14/2024 at 2:41 pm with the ADON revealed that the IP's role in antibiotic stewardship should involve running reports in the morning and ensuring that McGeer's criteria was being followed. However, he noted that the IP was not trained when she was hired and it was included in her agreement that she would seek training, but she had been assigned to other roles within the facility. The ADON mentioned being aware of clusters related to Urinary Tract Infection's (UTIs), which were discussed during Quality Assurance Performance Improvement (QAPI) meetings, but he observed that no actions were taken as a result. The ADON also mentioned that while he tracked antibiotic use in August and October 2024, the data for October 2024 was not yet complete. An interview conducted on 11/14/2024 at 2:46 pm with the Director of Nursing (DON) revealed she was aware that an antibiotic stewardship line listing was required, and that the antibiotic stewardship had not been adequately monitored. The DON stated her expectations were to ensure that antibiotics were properly tracked, and that the facility was consistently following antibiotic stewardship protocols. The DON emphasized that failing to meet these expectations could lead to the spread of infections, which could significantly impact the health and safety of residents. An interview conducted on 11/14/2024 at 3:21 pm with the Executive Director revealed that his expectations were for the facility to maintain an antibiotic stewardship line listing and to fully implement the antibiotic stewardship program. Furthermore, the Executive Director noted that failure to adhere to these expectations could lead to the overuse of antibiotics, potentially resulting in the development of antibiotic resistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and review of the facility policy titled, Antibiotic Stewardship Policy, the facility failed to employ a certified Infection Preventionist (IP) and experienced a lapse in infection prevention leadership. The deficient practice had the potential to affect all 71 residents residing in the facility. Findings include: Review of the undated facility policy titled Antibiotic Stewardship Policydocumented under section titled, Governance of Antimicrobial Stewardship, as part of the Infection Prevention and Control Program (IPCP), the facility has established a committee to oversee antimicrobial stewardship functions. The Infection Preventionist (IP), who is responsible for the overall IPCP, is an integral part of the committee. Under Composition revealed in 2. The IP will incorporate antibiotic stewardship into their current activities and will allocate dedicated time (10 hours/week) specifically for antimicrobial stewardship activities. The IP is required to complete the Nursing Home Infection Preventionist Training Course provided by The Centers for Disease and Control (CDC). Review of employee files on [DATE] revealed The Centers for Disease Control and Prevention (CDC) completion for Nursing Home Infection Preventionist Training Course Certificate for the IP revealed a completion date of [DATE], with 19.75 hours awarded. Interview on [DATE] revealed that the IP was hired on [DATE], but did not complete the required Infection Prevention training until [DATE], resulting in 19 days of employment without the proper training. Furthermore, according to the ADON, the former IP's last day was on [DATE]. The facility did not have a fully trained IP until the current IP was hired on [DATE]. However, the current IP did not complete the required Infection Prevention training until [DATE], resulting in a gap of approximately two months without a IP in place, and 19 days of employment without the proper training. An interview conducted on [DATE] at 3:11 pm with the IP revealed she started her IP training on [DATE], when she was hired. The IP acknowledged her responsibility to maintain infection control records, but noted that due to insufficient time and incomplete training, she had been unable to fully carry out the required tracking and reporting duties. The IP further expressed several concerns about how infection control issues were currently being handled. The IP noted a lack of clarity around the reasons for certain tests and highlighted a breakdown in the chain of communication regarding testing, such as Urinary Tract Infections (UTIs). The IP mentioned that when she first joined the facility, there were no existing policies or procedures in place for infection control, and she had to build the system from the ground up. Additionally, she reported that infection control issues, like UTIs, were not addressed in a timely manner. The IP also expressed frustrations with insufficient training for her role, a lack of assistance, and uncertainty about what was required in her position. An interview conducted on [DATE] at 2:41 pm with the Assistant Director of Nursing (ADON) revealed that he was training the IP when she first got hired. When asked if he had an Infection Prevention Certificate from the CDC, he stated he did the training about 5 years ago and didn't know it expired. The ADON further explained that the IP had not received full training in infection prevention when she was hired. It was included in her agreement that she would seek training; however, she had been utilized in other roles within the facility. The ADON stated the IP worked on Infection Control Prevention duties on Mondays, Tuesdays, and Wednesdays, while on Thursdays and Fridays she was assigned to pass medications. An interview conducted on [DATE] at 2:46 pm with the Director of Nursing (DON) revealed she did not have an Infection Control Training Certificate, and she was not aware that the IP needed to complete the training before she was hired. An interview conducted on [DATE] at 3:21 pm with the Executive Director revealed that his expectations were for at least one person in the building to have an active IP certification. The Executive Director noted that the negative outcome of not meeting this expectation would be missing out on crucial expertise to educate and counsel staff, thereby exposing individuals to unnecessary risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of facility policies titled Activities and Social Services and Activities Attendance, the facility failed to provide an ongoing program of activities based on resident representative input and/or activity preference assessments for four of 24 sampled residents (R) (R#42, R#40, R#53, R#38) reviewed for the activities. Findings include: 1. During an observation and interview with R#42 on 7/12/22 at 10:15 a.m., she stated that she would like to participate in activities but there are no group activities being offered. She stated that she is extremely frustrated because she has obeyed all the rules, took all four of her COVID shots and boosters. She stated, I am sick and tired of the staff blaming COVID for everything Resident was observed coloring with markers in adult coloring books and had puzzles at her bedside. She stated, All I do is either color or do puzzles and I want to do something else. A review of Electronic Medical Records (EMR) for R#42 revealed the resident was admitted on [DATE]. A review of the most recent comprehensive Minimum Data Set (MDS) Assessment for R#42 dated 6/1/22, the resident presented with a Brief Interview for Mental Status (BIMS) score of 15, meaning the resident is cognitively intact. The assessment further indicated that the resident enjoys contact with others prefers to choose own activities, prefers small group settings and activities in the activity room. Comments included R#42 cannot attend group activities at this time due to COVID restrictions. She does express an interest in attending the morning group activities and goes outside on nice days. 2. During an interview and observation of R#40 on 7/12/22 at 10:00 a.m. R#42 was in her room seated in a wheelchair sorting and organizing her closet. She confirmed what her roommate R#40 had stated and added there is nothing to do, and we can't go out of our room to participate in activities because of COVID. Further revealed back in April they got to do a few activities but then it all stopped again. Continued interview revealed there is nothing to do except puzzles, books, and television. The resident expressed a desire to play bingo and do group exercises. A review of the most recent comprehensive MDS Assessment for R#40 dated 3/17/22, the resident presented with a BIMS score of 15, meaning the resident is cognitively intact. The assessment further indicated that the resident enjoys contact with others, prefers to choose own activities, and prefers small group settings and activities in the activity room. 3. An interview with R#53 on 7/12/22 at 11:48 a.m. regarding the level of activities that are being offered within the facility revealed that there is not much to do. However, he states he does color, work on jigsaw puzzles and sometimes exercises with programs on television when he remembers to tune in. Further stated he would like to have more activities to choose from including group activities with other residents. A review of the Annual MDS assessment, completed on 7/14/22, R#53 had a BIMS score of 15 out of 15 which indicated he is cognitively intact. A review of an assessment noted the resident enjoys contact with others, prefers to choose own activities, and prefers to be with people prefers both small and large group settings. 4. An interview with R#38 on 7/14/22 at 9:10 a.m. regarding the level of activities that are being offered within the facility revealed that, BINGO was finally offered on yesterday and that she really enjoyed it because there have not been many activities offered in a long time. She continues to state that BINGO was a great start because without activities it gets boring around here. Further interview revealed she is bored and wants to be with the other residents and participate in activities other than what she had been doing for months in her room. A review of the most recent comprehensive Minimum Data Set (MDS) Assessment for R#38 dated 5/24/22, the resident presented with a Brief Interview for Mental Status (BIMS) score of 15, meaning the resident is cognitively intact. The assessment further indicated the resident enjoys contact with others prefers to choose own activities, does not refuse to attend activities, prefers small group settings, activities in the activity room, and accepts invitations to most group activities. A review of R #38 care plan dated 3/2/22 revealed Problem: Resident leads a self-directed daily lifestyle of choice, inclusive of choice, inclusive of attending those structure activities of her interest, and engaging in her own chosen pursuits of interest in context with her health status at the time. Goal: Resident will engage in her own self-directed leisure pursuits for 1/3 to 2/3 of the time. Interventions: Invite, remind and escort to activities of this resident's interest. Provide with encouragement for leisure pursuits. Provide with leisure materials of this resident's interest. Provide with monthly activity calendars An interview 7/12/22 at 10:15 a. m. with the Activities Director revealed she is doing one to one activity with residents at this time. Continued interview revealed while in outbreak status she is not allowed to do group activities and she tries to spend quality time with each resident and provide word search, jigsaw puzzles, coloring sheets, books, magazines, snacks, and mail. Further revealed briefly during April some group activities had taken place but were stopped due to the most recent Covid outbreak. Further revealed she encourages the residents to tune in to the Presbyterian Village TV station on Channel 78 for yoga and exercise and provides an enlarged calendar each month for the resident's closet door. Stated the TV calendar was the only planned activities, and they are to watch the TV in their own rooms. Further revealed she tries to do social visits and tries to individualize to each resident's needs. Continued interview revealed she goes by the Administrators direction since he is her supervisor, and she confirmed the facility had no group activities since May. A review of the resident's medical records revealed no documentation of one-on-one visits with the Activities Director or staff. There were no activities recorded of any nature on four of four sampled residents. The Activity Director confirmed she has no documentation of any of the activities she provides the residents. An interview 7/12/22 at 10:35 a. m. with the Administrator revealed the facility follows The Centers for Disease Control and Prevention (CDC)recommendations and while in outbreak status the facility per his direction has not been allowing group activities. Further revealed the residents have been in their rooms except for some dining at individual tables six feet apart and it is his understanding no group activities should be occurring. Continued interview revealed to prevent the spread of COVID-19 residents should not be allowed to gather for activities. During an interview on 7/13/22 at 10:57 a. m., the Director of Nurses (DON) revealed that the facility is using the CDC Guidance that was released February 2022 regarding activities and social gatherings. She stated that she had a discussion last week on Thursday with the Activity Director regarding resuming group activities and told her residents could do activities as long as they were non-symptomatic, up to date with immunizations, wore mask and six feet apart to social distance. Further interview revealed residents are not restricted to their rooms and are allowed to come out while wearing masks and social distancing and some have been dining together in the communal dining areas. During an interview on 7/13/22 at 11:05 a.m., the DON, Activities Director and Administrator confirmed there has been no group activities since April except for a 4th of July parade outside. The Activity Director said she talked to the DON last week about group activities and was told the Activity Director could resume. She stated that she went to ask the Administrator before resuming and he had not gotten back to her. The Activities Director said she has only been doing one-on-one activities because she felt like she should not be doing groups while in outbreak that it would be wrong. The DON revealed she had gone over the CDC guidance with the Activities Director on Thursday of last week (7/14/22) discussing, social distancing of six feet, wearing masks, and non-symptomatic and there was no reason residents could not participate in group activities if those recommendations were followed. The Administrator revealed he was unaware activities were allowed during an outbreak and felt it was safer to avoid group activities. The DON and Administrator both confirmed the facility uses the CDC guidelines to make decisions for the facility. A review of the Centers for Disease Control and Prevention (CDC) document updated 2/2/22 was presented by the DON and she stated this is the guidance the facility uses for Covid recommendations. The DON referred to the section titled Manage Residents with Close Contact which stated in general residents who are up to date with all recommended COVID-19 vaccine doses do not need to be quarantined, restricted to their room unless they develop symptoms of COVID-19, are diagnosed with SARS-Cov-2 infection, or the facility is directed to do so by public health. During an interview on 7/14/22 at 9:24 a.m., the Social Worker revealed she is aware the residents are bored and requesting to do activities. Continued interview revealed when she was hired three months ago residents were doing small group activities, but activities had shifted to one-on-one in the residents' rooms to minimize spread of COVID. Further interview revealed it has been discussed in the morning meetings and the Activity Director had asked occasionally about resuming gatherings, but the Administrator kept saying to keep activities on hold. Continued interview revealed the facility held a 4th of July parade outside which the residents loved. She revealed when she visits with the resident's, several of them has asked her when the outside room activities will resume because they miss interactions with other residents. During an interview on 7/14/22 at 10:30 a.m., Certified Nursing Assistant (CNA) BB revealed the residents are complaining about not having activities because of COVID and would like to start gathering again because they miss their friends. During an interview on 7/14/22 at 10:05 a.m., Licensed Practical Nurse (LPN) AA revealed the facility has not been allowing group activities and that the residents have been requesting gatherings. Review of the facility policy titled Activities and Social Services, (no date) revealed the Policy Statement: Residents shall have the right to choose the types of activities and social events in which they wish to participate as long as such activities do not interfere with the rights of other residents in the facility. Interpretation and Implementation Choosing Activities/Events Residents are encouraged to choose the types of recreational, cultural, and religious activities and social events in which they prefer to participate. Activity and Social Care Plan stated, when the Care Planning Team develops the resident's activity and social care plans the resident will be given an opportunity to choose when, where, and how he or she will participate in activities and social events. As much as possible the facility will provide activities, social events, and schedules that are compatible with the resident's interests, physical and mental assessment, and overall plan of care. A Review of the facility policy titled Activities Attendance (no date) revealed Policy Statement: The Activity Department records activities attendance and participation of all residents. Attendance Record Expectations: Attendance and participation is recorded for every resident in group and individual activities on a daily basis. Attendance records are filed for minimum of three years. Attendance records are used when completing residents' progress notes to determine their participation as it relates to their activity plan.

Based on observation, interviews and policy review, the facility failed to discard expired medications in the storage room and one of four medication carts. The sample size was 32. Findings include: During medication storage observation on 2/25/18 at 11:20 a. m., with Registered Nurse (RN) BB, the facility has two medication storage rooms on each floor, four medication carts and one central supply room. Second floor medication room was observed with RN BB, she revealed that one bottle of unopened natural force slow release iron 50 milligrams (mg) tablet with code number 112234, expired on 04/17, and one box of Loperamide Hydrochloride 2 milligrams (mg), anti-diarrheal tablet lot: number 2737023 expired on 10/2018. It was found stored with house stock medications not discarded according to their medication storage policy. Observed two medication carts; first floor medication cart on east hall revealed one unopened bottle Vitamin B Complex with Vitamin B-12 tablet with code number 46680, expired on 10/18. It was found in the medication cart together with administering medications not discarded according to facility's medication storage policy. Review of the facility policy titled, Medication Storage Policy, revised 2019, indicate that the facility should ensure that medications and biologicals have an expiration date on the label and have not been retained longer than recommended by the manufacturer or supplier. The policy revealed on number D Nurses will check for expiration dates of medications and medical supplies in the medication room weekly (11-7 Shift) and document checks on a log. All expired medications and supplies will be properly disposed of. Medications should be reordered as needed. E revealed that nurses will be responsible for checking expiration dates of all medications and supplies before removing them from the medication room and storing them on the medication cart. F revealed that nurses are responsible for checking their assigned medication cart daily for expired prescription medications and over the counter (OTC) medications. Expired medications should be properly disposed of. G revealed All Over the Counter (OTC) medications and supplies delivered to each medication room by the Central Supply Director should be checked for expiration dates, before storage in the medication rooms. H reveals The Central Supply Director will check expiration of all Over the Counter (OTC) Medications and supplies stored in the medication rooms twice a month. An interview was conducted on 2/26/19 at 11:48 a.m., with Registered Nurse (RN) BB, stated the policy for opened or unopened medications storage and medication cart was that all nurses should check for expired medications daily and dispose it per facility policy; there is no reason for leaving expired medications since 4/17 and 10/2018 in the medication storage room or medication cart. RN BB, stated that it was a human error. Interviewed Licensed Practical Nurse (LPN) AA, on 2/26/19 at 12:00 p.m., he stated that the facility policy for opened and unopened medications in the medication cart was for the assigned nurse to check daily for expiration dates of medications before the administering them to residents. He verified that he was not aware that the unopened bottle Vitamin B Complex with Vitamin B-12 tablet with code number 46680, expired on 10/18. LPN AA stated he did not check his medication cart that day and he did not know how the medication got in his medication cart. An interview was conducted with RN CC, on 2/26/19 at 12:10 p.m.; stated she could not explain how the expired medications in the medication room and medication cart had remained stored for so long; the only reason she could offer was human error.