Based on observations, staff interviews, and review of the facility's policies Handwashing/Hand Hygiene, and Medication Administration-General Guidelines, the facility failed to perform proper hand hygiene practices while observing two out of two Licensed Practical Nurses (LPN) (LPN AA and LPN BB) during medication administration. This deficient practices had the potential to increase the risk of infection transmission and compromise the health and safety of residents. The facility census was 55 residents. Findings include: Review of the facility's policy Handwashing/Hand Hygiene, dated February 2021 under the Policy Statement revealed, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to the personnel, residents, and visitors .7. Use an alcohol-based hand rub .for the following situations: .(b.) Before and after direct contact with residents;( c.) Before preparing or handling medications; (d.) Before performing any non-surgical invasive procedures .(i.) After contact with a resident's intact skin; .(l.) After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. (m.) After removing gloves .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections .Procedure. Applying and Removing Gloves. 1. Perform hand hygiene before applying non-sterile gloves .4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. Perform hand hygiene. Review of the facility's policy Medication Administration-General Guidelines, dated April 4, 2016, revealed, 2) Handwashing and Hand Sanitation: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident .(c.) Sanitization is not a substitute for proper handwashing, and washing should be done if there is any question. 1. Observation on 4/23/2025 at 8:40 am, during a medication pass revealed, LPN AA entered the Resident (R) 37 (R37), room without performing hand hygiene and waited several minutes while the R37 remained in the bathroom. During this time, she repositioned R37's roommate in bed but failed to perform hand hygiene afterward. LPN AA then proceeded to check R37's oximetry (measuring the oxygen saturation level using a device placed on the finger) and, after completing the check, placed the pulse oximeter in her pocket and administered R37's medications. After completing medication administration, LPN AA sanitized her hands, exited the room, and returned to her medication cart. Upon returning to the cart, she began preparing medications for the next resident without re-sanitizing her hands. In an interview that was conducted during this time with LPN AA revealed, when asked whether she should have sanitized her hands between residents or prior to preparing medications for the next resident, she acknowledged that she should have but did not. 2. Observation on 4/23/2025 at 9:04 am during a medication pass revealed, LPN BB prepared medications for R8 and entered the resident's room without performing hand hygiene. In an interview immediately following medication administration for R8, the surveyor asked LPN BB whether hand hygiene should have been performed prior to starting the task. LPN BB acknowledged that she should have performed hand hygiene but, stated that she was nervous and forgot. In an interview conducted on 4/23/2025 at 2:10 pm with the Infection Control (IC) Licensed Practical Nurse revealed that she expects staff to perform hand hygiene consistently before and after providing care to residents. When presented with a scenario in which a nurse, while assisting one resident, needs to provide care to the roommate, she confirmed that hand hygiene must be performed between interactions with each resident. 3. Observation on 4/23/2025 at 4:00 pm of LPN AA performing a blood glucose check on R19 revealed, LPN AA did not perform hand hygiene upon entering the resident's room or prior to performing the procedure or applying gloves. Upon completion, LPN AA removed the gloves and washed her hands. In an interview immediately after the procedure, the surveyor asked LPN AA whether hand hygiene should have been performed before starting the task and LPN AA responded that it was not necessary because she had worn gloves. In an interview with the Director of Nursing (DON) on 4/23/2025 at 4:05 pm, she revealed that staff are expected to perform hand hygiene before and after providing care to residents, including if a nurse pauses one task to complete another and then returns to the original task. DON confirmed that wearing gloves was not a substitute for handwashing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, and review of the facility's policy titled, Sanitation and Infection Control Oxygen Concentrator and Humidifier, the facility failed to ensure the filter on an oxygen concentrator for one of four residents (R) (R#20) receiving oxygen therapy was changed per physician's order. This failure had the potential to compromise R#20's access to the required level of oxygen. Findings include: Review of the facility's policy titled, Sanitation and Infection Control Oxygen Concentrator and Humidifier, revised September 2020, revealed oxygen filters were to be cleaned weekly and as needed and recorded on the Treatment Administration Record (TAR). Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the following: Section C-Cognition revealed that R#20 had a documented Brief Interview for Mental Status (BIMS) score of 14, indicating R#20 was cognitively intact. Section O-Special Treatments & Programs revealed that R#20 received oxygen therapy. Review of the care plan for R#20 revealed the nurse would clean the oxygen concentrator filter weekly if the filter was visibly dirty. Additionally, the filter would be changed on Fridays during the evening shift. Review of the Medical Doctor (MD) orders dated 12/30/2022 revealed the following: Clean the oxygen concentrator filter weekly if the filter is visibly dirty, every night shift, and every Friday when oxygen is in use. Review of the TAR for R#20 dated 4/1/2023 through 4/30/2023 revealed a facility nurse documented R#20's oxygen concentrator filter was changed on 4/7/2023 at 7:00 p.m. Observation on 4/14/2023 at 8:45 a.m. of R#20's oxygen concentrator revealed the filter had apparent signs of dust and debris noted on the entire filter. The oxygen tubing had a change date of 4/12/2023. Interview on 4/14/2023 at 8:47 a.m. with the Licensed Practical Nurse (LPN) AA revealed that R#20's oxygen concentrator filter was supposed to be changed every week. LPN AA acknowledged R#20's oxygen concentrator filter was dirty and appeared it had not been changed in a long time. However, LPN AA stated it was the night nurse's responsibility to change the filters weekly, and the date of change was indicated weekly on the TAR. Per LPN AA, the TAR showed the filter had been changed on 4/7/2023, but she went on to state it did not look like it had been changed. LPN AA added that the filters do not look that dirty after one week. LPN AA said she would generally back-check to ensure the filter was changed, even though the task fell to the night shift on Friday nights. Interview on 4/15/2023 at 1:12 p.m. with the Administrator revealed that they acknowledged R#20's oxygen concentrator filter was dirty. The Administrator stated it was their expectation for staff to follow MD orders and change the filter weekly and as needed. Interview on 4/15/2023 at 1:18 p.m. with the Assistant Director of Nursing (ADON) revealed they expected staff to change the oxygen concentrator filters per MD orders, which was weekly and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility's policies titled, Automatic Stop Orders, and Medication Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for four of four residents (R) (R#13, R#9, R#14, R#21) reviewed for unnecessary medications. This failure had the potential for medication interaction, adverse reactions, respiratory depression, falls, constipation, and increased anxiety. Findings include: Review of the facility's policy titled, Automatic Stop Orders, number IB3, effective date 4/1/2016, revealed the policy did not address a 14-day stop date for psychotropic medications. Review of the facility's policy titled, Medication Orders dated 4/1/2016 revealed the policy of new medication orders are subject to automatic stop orders unless the medication orders specify the number of doses or duration of medication. A time limit is included in recapped orders. The procedures sections D: revealed: all medication orders that do not specify duration or number of doses are automatically discontinued in accordance with the Stop Order policy; section G: when entering medications covered by the Stop Order policy on the Medication Administration Record (MAR), the automatic stop date is recorded in the appropriate area on the MAR. 1. Review of the Medical Doctor (MD) orders for R#13, dated 1/1/2023, revealed the MD ordered Ativan (for treatment of anxiety) 0.5 milligrams (mg), one tablet by mouth every six hours, as needed (PRN) for agitation. The order had no stop date. Review of the monthly MAR's for February 2023, March 2023, and April 2023 revealed R#13 received lorazepam (generic for Ativan) 0.5 mg by mouth on the following dates and times: February 3, 2023, at 8:30 p.m., February 6, 2023, at 8:56 p.m., February 8, 2023, at 3:53 a.m., February 9, 2023, at 8:34 p.m., February 10, 2023, at 9:52 p.m., and February 11, 2023, at 11:14 p.m. March 1, 2023, at 9:12 a.m., March 3, 2023, at 9:22 a.m., March 11, 2023, at 10:34 a.m., March 15, 2023, at 10:02 a.m., March 17, 2023, at 8:44 a.m., March 18, 2023, at 7:37 p.m., March 19, 2023, at 1:30 a.m., March 22, 2023, at 8:40 a.m., March 28, 2023, at 8:45 p.m., March 29, 2023, at 8:28 a.m., and March 30, 2023, at 8:46 a.m. and 9:30 p.m. April 1, 2023, at 9:30 p.m., April 2, 2023, at 9:49 p.m., April 11, 2023, at 9:15 p.m., and April 14, 2023, at 9:40 p.m. Interview on 4/15/2023 at 9:55 a.m. with the Assistant Director of Nursing (ADON) revealed that she was aware that antipsychotic medications required a stop date. She stated she believed antipsychotic and psychotropic medications had a 30-day mandatory stop date. She acknowledged R#13 had a PRN order for lorazepam 0.5 mg every 6 hours PRN, which the physician ordered on 1/1/2023. The ADON stated it was the pharmacist's responsibility to ensure medications had stop dates if a medication required one and to inform the physician. The ADON said the facility did not have a process to ensure the pharmacist monitored the medications for stop dates. 2. Review of the Medical Doctor (MD) orders for R#9, dated 9/14/2022, revealed the MD ordered Ativan 0.5 mg, one tablet by mouth every four hours, PRN for agitation. The order had no stop date. Review of the MAR's for October 2022 through April 2023 revealed a nurse administered R#9 lorazepam (generic for Ativan), 0.5 mg by mouth, on the following dates and times: October 4, 2022, at 11:40 p.m., October 17, 2022, at 1:55 p.m., and October 24, 2022, at 8:12 p.m. November 3, 2022, at 7:44 p.m., November 2022 at 7:55 p.m., and November 13, 2022, at 8:15 p.m. January 17, 2023, at 8:53 a.m. and 9:05 p.m. February 2, 2023, at 12:09 a.m., February 6, 2023, at 10:50 a.m. and 9:01 p.m., February 11, 2023, at 11:13 p.m., February 15, 2023, at 10:58 p.m., February 16, 2023, at 11:42 p.m., February 17, 2023, at 9:03 p.m., February 20, 2023, at 8:09 p.m., February 21, 2023, at 8:51 a.m., February 22, 2023, at 9:20 p.m., and February 25, 2023, at 9:41 a.m. March 11, 2023, at 10:35 a.m., March 16, 2023, at 9:11 p.m., March 18, 2023, at 7:37 p.m., March 28, 2023, at 4:22 p.m. and 9:00 p.m., March 29, 2023, at 8:30 p.m., and March 31, 2023, at 8:42 a.m. and 9:20 p.m. April 1, 2023, at 9:30 p.m., April 2, 2023, at 8:52 p.m., April 11, 2023, at 9:17 p.m., and April 14, 2023, at 9:33 p.m. 3. Review of the medical record for R#14 revealed diagnoses including but not limited to Alzheimer's disease, dementia, delusional disorders, anxiety disorder, depression, muscle weakness, dysphagia, hallucinations, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for R#14 indicated Section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) was coded as 2, which indicated severe cognitive impairment. Section G-Activities of Daily Living (ADL's) revealed R#14 required extensive assistance of two or more persons for bed mobility, transfers, dressing, toileting, and personal hygiene. Section N-Drug Regimen Review revealed R#14 received an antipsychotic medication seven days a week, an antianxiety medication seven days a week, and an antidepressant medication seven days a week during the look back period. Review of the physician orders for R#14 revealed an order dated 12/15/2022 for lorazepam 0.5 mg one tablet daily two times day and PRN, every six hours PRN for agitation. The physician order did not have a stop or end date. There is no evidence of a rationale from the physician for the extension past 14 days. Interview on 4/16/2023 at 10:10 a.m. with the ADON confirmed that R#14 had an order for PRN lorazepam with no stop/end date. The ADON revealed that the consult pharmacist should have alerted them to the issue of PRN lorazepam needing a 14 day stop date. 4. Review of the medical record for R#21 revealed diagnoses including vascular dementia, unspecific psychosis, generalized anxiety disorder, and major depressive disorder. Review of the significant change MDS dated [DATE] revealed sections C revealed BIMS was not documented, section D-Mood Disorders was not documented, section E-Behavior revealed physical behaviors directed toward others one to three days, rejection of care or evaluation one to three days; section N revealed antianxiety medication was received seven days a week. Review of the physician's orders for R#21 revealed an order dated 12/15/2022 for lorazepam 0.5 mg one tablet by mouth every six hours PRN for agitation. Review of the physician's orders did not indicate that the use of PRN medications had been evaluated by the physician for continued use beyond 14 days. There was no stop date for the order. Review of the care plan for R#21 revealed a focus area of using anti-anxiety medications related to anxiety disorder with a goal that resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions included medications as per physician's orders including Ativan (lorazepam) tablet PRN. Review of the MARS dated January 2023, February 2023, March 2023, and April 2023 revealed R#21 received lorazepam 0.5 mg thirteen times. Review of the Gradual Dose Reduction (GDR) document dated 3/8/2023 for R#21 revealed the medication lorazepam 0.5 mg was documented as being reviewed with no recommended changes. Review of the last six months of the Monthly Medication Review (MMR) for R#21 revealed there were no changes recommended for the medication lorazepam 0.5mg. Interview on 4/15/2023 at 1:37 p.m. with Licensed Practical Nurse (LPN) EE revealed she had worked at the facility for two years. She revealed nurses transcribe physician orders into the Electronic Medical Records (EMR) system. She revealed nurses follow a template within the EMR system when transcribing and the order is transmitted to the pharmacy. She revealed the pharmacist reviewed all medications every month and recommended changes go to the ADON and Director of Nursing (DON). She revealed she would notify the physician if she questioned a medication order and was unsure if a psychotropic medication should have a stop date. Interview on 4/15/2023 at 2:00 pm with LPN AA revealed nurses transcribe physician orders into the EMR as written by the physician. She revealed she would consult with the physician if she questioned an order. She went on to revealed she was not aware if lorazepam should be ordered as a prn medication for more than fourteen days. Interview on 4/15/2023 at 2:20 pm with the Director of Nursing (DON) revealed PRN psychotropic medication orders should be discontinued after 14 days and a new physician's order obtained. She revealed when nurses transcribe medications into the EMR, an end date of 14 days should be placed in the system. She verified that R#21 had an order dated 12/15/2022 for lorazepam tablet 0.5 mg give one tablet by mouth every six hours PRN for agitation. She verified the facility did not have a process to ensure the pharmacist monitored the medications for stop dates.

Based on observations, staff interviews, and review of facility policies titled, Pot and Pan Washing and Sanitation, Dishwashing, Food storage and Inventory, Food temperatures, and Personal Hygiene, the facility failed to ensure pans were stored dry to prevent bacterial growth; failed to store food items off the floor in the dry storage area and walk-in refrigerator; failed to ensure resident nourishment refrigerator food items were properly labeled and dated; failed to ensure all food items served on the steam table were held above 135 degrees Fahrenheit; and failed to ensure male dietary staff completely covered facial hair. These deficient practices affected all 39 residents consuming an oral diet. Findings include: 1. Review of the facility's policy titled, Pot and Pan Washing and Sanitation revealed after pots and pans are dry, they must be inspected and stored inverted in a clean dry protected area. Review of the facility's policy titled, Dishwashing revealed allow all items to thoroughly dry before unloading racks or storing items. Observation on 4/14/2023 at 8:27 a.m. of stored steam table pans reveal a stack of five square pans. When the top pan was pulled from the stack, the inside had moisture that covered the bottom and sides. Interview on 4/14/2023 at 8:30 a.m. with Dietary [NAME] CC confirmed that the square steam table pan was wet and stated that dietary staff know not to stack pans when wet. Additional kitchen observation on 4/16/2023 at 9:05 a.m. of a stack of five square steam table pans, the pan second from the top was pulled to reveal the inside the bottom of the pan had moisture. Interview on 4/16/2023 at 9:05 a.m. with the Certified Dietary Manager (CDM) confirmed that the square pan had moisture inside and staff should have let it dry completely before stacking. 2. Review of the facility's policy titled, Food Storage and Inventory revealed food to be stored a minimum of 6 inches above the floor and 18 inches from the ceiling and sprinkler heads. Observation on 4/14/2023 at 8:34 a.m. of the walk-in refrigerator revealed a black colored milk crate on the floor near the door. The crate contained cans of carbonated beverage. Observation on 4/15/2023 at 8:18 a.m. of one of two emergency supply storage closets revealed a stack of beverages directly on the floor. The stacked beverages were two cases of electrolyte beverage bottles and four cases canned ginger ale. Interview on 4/15/2023 at 8:18 a.m. the CDM confirmed that the stack of beverages in the emergency storage closet were sitting on the floor and not stored off the floor. The CDM stated that all food items should be stored off the floor. Observation on 4/16/2023 at 9:03 a.m. of the walk-in refrigerator revealed the black colored milk crate containing canned beverages remained on the floor. Interview on 4/16/2023 at 9:03 a.m. the CDM confirmed that the crate with canned beverages was on the floor of the walk-in refrigerator. The CDM stated that the crate should not be directly on the floor. 3. Review of the facility's policy titled, Food Storage and Inventory revealed leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Observation on 4/15/2023 at 8:25 a.m. of the resident nourishment room refrigerator revealed on the middle shelf four sandwiches in individual plastic bags with no label or date. Continued observation revealed a small square plastic container on the bottom shelf that contained an orange colored food item which had no label or date. Further observation revealed the top freezer contained two frozen meals with no label or date and one frozen Salisbury steak meal with no label or date. The freezer also contained a half gallon container of rocky road ice cream with no label or date. Interview on 4/15/2023 at 8:25 a.m. the CDM stated that dietary staff is only responsible for stocking the refrigerator and freezer with food items for the residents. The CDM stated that housekeeping is responsible for cleanliness, temperature taking, and ensuring all food items are properly labeled and dated. The CDM confirmed that the four sandwiches in the refrigerator had no label and dated and stated that the sandwiches likely came from the dietary department. The CDM stated that dietary staff should have labeled/dated the sandwiches before they left the kitchen and before being stored in the resident refrigerator. Interview on 4/15/2023 at 8:33 a.m. with Housekeeper DD confirmed that housekeeping staff is responsible for ensuring food items in the refrigerator are labeled and dated. Housekeeper DD stated that if food items are not labeled and dated, they are to be discarded. 4. Review of the facility's policy titled, Food Temperatures revealed to keep the temperature of hot foods no less than 140 degrees during tray assembly. Review of the Resident Count by Diet Order report revealed that the facility has 10 residents receiving a puree consistency diet. Steam table temperatures were completed on 4/15/2023 at 12:30 p.m. The CDM assisted with taking the temperatures of food items using the facility's calibrated thermometer. Continued observation revealed that not all hot food items could fit into the steam table and several small steam table pans were kept on top of lids which were on top of hot food items in the steam table. The pureed Creole sauce had a temperature of 122 degrees. Interview on 4/15/2023 at 12:30 p.m. with the CDM confirmed that the puree Creole sauce only had a temperature of 122 degrees and stated that it needed to be re-heated. The CDM revealed that hot food should be held on the steam table at least 135 degrees. Interview on 4/15/2023 at 12:30 p.m. with Dietary [NAME] BB revealed that seven residents receiving puree consistency diets remained to be served a lunch meal. Dietary [NAME] BB stated there are 10 residents total receiving a puree diet. Dietary cook BB revealed there was not enough room directly in the steam table for the pureed Creole sauce. 5. Review of the facility's policy titled, Personal Hygiene revealed head covering to be worn, hair must be completely covered with a hair net at all times. Observation on 4/16/2023 at 9:07 a.m. of Dietary [NAME] BB revealed he was in the kitchen preparing resident's lunch meals. Dietary [NAME] BB had facial hair and only wore a paper surgical mask which allowed the sides of his beard to be exposed. Interview on 4/16/2023 at 9:07 a.m. with Dietary [NAME] BB revealed that he typically wears a hair net over his facial hair and thought wearing the mask was enough. Interview on 4/16/2023 at 9:07 a.m. the CDM confirmed that Dietary [NAME] BB's facial hair was not completely covered with sides exposed. The CDM stated that she expected all facial hair to be covered. The CDM confirmed that the policy regarding dietary staff personal hygiene did not include anything regarding facial hair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews and review of the policy titled Sanitation and Infection Control Oxygen Concentrator and Humidifier, the facility failed to ensure humidification was provided for one resident (R#10) receiving two liters of Oxygen therapy. The sample size was 27 residents. Findings include: Review of the facility policy titled Sanitation and Infection Control Oxygen Concentrator and Humidifier revealed the purpose is to ensure that oxygen concentrators, humidifier bottles, and nebulizer setups remain clean, revised 9/2020. General information is to follow the schedule and intervals specified in this procedure unless State specific requirements specify more frequent time frames. Procedure number two (2) revealed Changing Schedule- oxygen mask, oxygen tubing, and nebulizer tubing are to be changed weekly. Humidifier bottles are to be changed when empty and as needed. Review of the clinical record for R#10 revealed the resident was admitted to the facility with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), shortness of breath, major depressive disorder, hypoxemia, history of recurrent pneumonia, personal history of Covid-19, and hypertension. The resident's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was assessed as three, which indicated severe cognitive impairment, and was assessed for oxygen use. Observation on 1/4/22 at 12:34 p.m. revealed the resident was receiving oxygen with the concentrator set on two liters being delivered via nasal cannula (N/C). The water humidification bottle on the concentrator was empty. Observation on 1/5/22 at 8:30 a.m. revealed the oxygen was in use at two (2) liters via concentrator, and the water humiliation bottle is dry although the R#10 was not using oxygen at this time. Observation on 1/5/22 at 8:45 a.m. revealed R#10 was using oxygen set at two liters via N/C and the water humidification bottle remains dry. An interview on 1/5/22 at 8:50 a.m., with Licensed Practical Nurse (LPN) AA revealed that oxygen supplies are changed on Fridays and as needed, along with the humidification bottles. She stated that the nurse is supposed to date the tubing and the water bottles each time they are changed. She further stated that the humidification bottles can be changed more often if they become empty. She stated that she assesses each resident, verifies the flow rate, looks at the dated tubing and the humidification bottles. She stated she did not check the oxygen tubing and humidification for R#10 this day and confirmed that the humidification bottle was dry. An interview on 1/5/22 at 8:56 a.m. with the Director of Nursing (DON) revealed that oxygen supplies are changed weekly on Friday and as needed if the humidification bottle is empty or other supplies are damaged or dirty and that the nursing staff is responsible for this task.