**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility policies titled Administering Medications and Self-Administration of Medications, the facility failed to ensure medications were not left at the bedside of two of 14 sampled residents (R) (R7 and R215) who were not assessed for medication self-administration. This deficient practice had the potential to place R7 and R215 at risk for the unsafe use of medications. Findings: Review of the facility policy titled Administering Medications, dated 2001, revealed the Policy Statement was Medications are administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation section included 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of the facility policy titled Self-Administration of Medications, dated 2001, revealed the Policy Statement was Resident have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. Review of the medical record for R7 revealed diagnoses that included, but not limited to, anxiety, constipation, and atrial fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed R7 had highly impaired vision and a Brief Interview of Mental Status score (BIMS) of 15 (indicating little to no cognitive impairment). Review of the Physician's Orders for R7 revealed no order for over-the-counter medication for stomach relief or diclofenac sodium gel (a topical medication used to treat pain). There also was no order for self-administration of medication for R7. During an observation and interview on 1/18/2025 at 4:57 pm in R7's room, stomach relief pills were found sitting in the window seal, and diclofenac sodium topical gel was found on the overbed table. The Administrator confirmed the medications in the room and informed R7 that the items would have to be removed. 2. Review of the medical record for R215 revealed diagnoses that included, but not limited to, a personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, unspecified dementia, mild without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Physician's Orders for R215 revealed no order for medication to treat fever blisters or Voltaren (a topical medication used to treat pain). There also was no order for R215 to self-administer medications. During an observation and interview on 1/18/2025 at 10:40 am with R215, a bottle of pills used to treat fever blisters was observed on the floor by R215's chair, and a tube of Voltaren was observed on the nightstand beside the bed. The Director of Nursing (DON) confirmed that the medications were in the room. The DON expressed that she was unaware the resident had the medications and stated there were no residents in the facility who had been assessed to self-administer medications at this time. The DON informed R215 that she would need to remove the medications because there was no order for them, and the resident reported that she had been taking the medications for years. During an interview on 1/19/2025 at 5:41 am, Licensed Practical Nurse (LPN) DD reported if residents had an order for medication self-administration, they were able to keep medications at their bedside and self-administer.

Based on observation, staff interviews, record review, and review of the facility policy titled Administering Medications, the facility failed to ensure a medication order was clarified with the physician prior to administering the medication to one of five residents (R) (R12) observed for medication pass. This deficient practice had the potential to place R12 at risk of avoidable medical complications due to a medication dosage order not being clarified prior to administration. Findings included: Review of the facility policy titled Administering Medications, dated 2001, revealed the Policy Statement was Medications are administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation section included 10. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of the medical record for R12 revealed diagnoses included, but not limited to, spinal stenosis in cervical region, polyarthritis, polyneuropathy, idiopathic gout, osteoporosis, and sacrococcygeal disorders. Review of R12s Physicians Orders revealed an order dated 9/21/2024 for celecoxib (a medication used to treat mild to moderate pain), one capsule by mouth one time a day. During observation of medication administration by Registered Nurse (RN) AA on 1/18/2025 at 8:45 am, R12 was administered celecoxib 200mg. In an interview on 1/18/2025 at 2:00 pm, RN AA confirmed celecoxib 200 mg was administered to R12 and confirmed the physician's order did not specify the dosage to be administered. In an interview on 1/19/2025 at 9:00 am, the Assistant Director of Nursing (ADON) stated all nurses can transcribe physician orders. She verified that R12's order for celecoxib was not transcribed accurately and should specify a dosage. In an interview on 1/19/2025 at 10:00 am, the Director of Nursing (DON) stated nursing staff was responsible for transcribing physician orders. The DON further stated the consulting pharmacist normally reviewed physician orders when ordered and monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy titled Laundry Services, dated 2014, revealed . 6. Laundry Handling: The community must implement procedures that prescribe how clean laundry and soiled laundry is to be handled. Proper linen handling according to a written procedure will help avoid cross-contamination of clean and soiled laundry. This is an important infection control consideration. Use of universal precautions will reduce the risk of exposure to laundry staff to pathogenic microorganisms. During the initial laundry tour on 1/18/2025 at 10:12 am with the Executive Director, observation revealed no laundry staff present at that time. Observation in the dirty laundry area revealed two clear trash bags with housekeeping cleaning towels and tablecloths in them, sitting on top of full containers of laundry detergent and on the floor next to the laundry detergent. During observation and interview on 1/18/2025 at 10:15 am, Housekeeper/Laundry Staff EE reported that she placed the towels in the plastic bags and put them in the soiled room because she had to work in housekeeping as well and had to put them somewhere until she was able to come back to the laundry room to finish processing them. During an interview on 1/18/2025 at 11:42 am, the Director of Nursing (DON) stated that best practice would be for cleaned items to not be stored in the soiled laundry area, even if they were in bags. She stated the clean items would have to be relaundered. Based on observation, staff interview, record review, and review of the facility policies titled Standard Precautions, Dressings, Dry/Clean, and Laundry Services, the facility failed to ensure infection control practices were adhered to during wound care for one of three residents (R) (R12) reviewed for wound care. The facility also failed to ensure laundry practices were conducted so as not to cause cross-contamination of clean linen with soiled linen. The deficient practices had the potential to increase R12's risk of infections due to cross-contamination during wound care and had the potential to place all residents residing in the facility at risk of infections due to cross-contamination due to inappropriate handling of linen. Findings include: Review of the facility's undated policy titled Standard Precautions revealed the Policy Interpretation and Implementation section included 1. Standard precautions apply to the care of all residents regardless of suspected or confirmed presence of infectious disease. The Hand Hygiene section included b. Hand hygiene is performed with alcohol-based hand rub (ABHR), or soap and water (1) before and after contact with the resident; (2) before performing an aseptic task; (3)before moving from work on a soiled body site to a clean body site on the same resident ; (4)after contact with items in the resident's room; and after removing gloves. Review of the facility's undated policy titled Dressing, Dry/Clean revealed the Steps in the Procedure section included 1. Clean bedside stand, establish a clean field. 2. Place the clean equipment on the clean field, arrange supplies so they can be easily reached. 5. Wash and dry your hands thoroughly. 6. Put on clean gloves, loosen tape and remove soiled dressing. 8. Wash and dry your hands thoroughly. Record review revealed R12 had diagnoses of, but not limited to, pressure ulcer of sacral region and pressure-induced deep tissue damage of sacral region. Review of R12's admission Minimum Data Set (MDS) dated [DATE] revealed Section M (Skin) documented the resident had an unhealed stage four pressure ulcer/injury over the bony prominence. Review of R12's Physician Orders revealed an order dated 12/31/2024 to cleanse the sacral wound with wound cleaner, apply Medihoney (a product used to treat wounds and burns) to wound bed only and cover with foam dressings one time daily. Review of R12's care plan revealed the resident had altered skin integrity related to a pressure wound to the sacral area. The goal indicated skin areas will not worsen through the next review date. Interventions, dated 9/21/2024, included observing for signs and symptoms of infection and notifying the physician if present. Roho cushion in place. Resident states a pillow on top of the cushion is most comfortable. Treatments per physician orders. Air Mattress in place. During wound care observation on 1/18/2025 at 10:15 am conducted by Registered Nurse (RN) AA revealed RN AA came to the conference room to get the surveyor for wound care observation for R12 with the wound care supplies in her ungloved hands that included a tube of Medihoney, dry gauze, Opti foam dressing, and wound cleanser. Observation revealed RN AA took the supplies into the resident's room and placed them on the overbed table that was located against the wall on the left side of the room. Once RN AA donned gloves and a gown, she then placed the supplies on the bedside table by the resident's bed without cleaning or disinfecting the area or placing a barrier on the table to place the supplies on. Continued observation revealed no wound dressing on the area of R12's wound, and the resident was sitting on the side of the bed. RN AA cleaned the wound with the wound cleanser and wiped the area with the dry gauze on the resident's table. After cleaning the wound, the nurse did not remove her gloves to wash or sanitize her hands before applying the Medihoney to the wound bed. Further observation revealed RN AA squeezed an undisclosed amount of Medihoney onto her right index finger, applied it directly to the resident's wound bed with her finger, and applied the Opti foam dressing. In an interview on 1/18/2025 at 10:30 am, RN AA confirmed that she did not provide a clean surface to place the wound care supplies on during R12's wound care. Further interview revealed RN AA confirmed that she did not wash or sanitize her hands at any time during the wound care treatment. RN AA revealed that she was unaware that she should wash her hands and change her gloves during the wound care procedure. In an interview on 1/18/2025 at 11:00 am, the Director of Nursing (DON) revealed that when completing wound care, the nurse should first check the order to ensure that the proper treatment was being completed. Once the order has been verified, the nurse should gather supplies and ensure the area where the supplies will be resting is cleaned and sanitized and a barrier placed on the table. Further interview revealed the expectation was that during wound care, the nurse should change gloves between dirty and clean process during wound care and wash and sanitize hands during those glove changes. In an interview on 1/18/2025 at 2:00 pm, the Administrator revealed that the staff should follow infection control practices when completing wound care and other tasks with residents.

Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed quarterly for two residents (R) (#1 and #2) of 13 sampled residents. Findings include: 1. Review of a listing of R#1's completed and transmitted MDS revealed that a Quarterly MDS with an Assessment Reference Date (ARD) of 2/26/22 was the last MDS completed. 2. Review of R#2's MDS listings revealed that a Quarterly MDS with an ARD date of 3/2/22 was the last MDS completed. Review of an alphabetical resident census revealed that R#1 and R#2 were currently residents in the facility. Interview with Social Services Director on 7/7/22 at 12:10 p.m. revealed the MDS coordinator gives out the schedule of when the assessments are due to be completed. The care plans are scheduled in accordance with the assessment due date that is provided by the MDS coordinator and once the schedule is received the care plan meetings are set up by the social services department with the families and the residents. Interview with MDS Coordinator on 7/7/22 at 1:24 p.m. revealed staff started in the middle of March 2022 at this facility doing MDS. There was a calendar that was created every month that showed the ARD and Care Plan date that is given to Social Services Director (SSD) and Activities Director. During the interview it was also disclosed that staff member was not sure exactly how the assessments were missed. When the calendar is created every resident is reviewed at that time. Further interview also revealed that calendar of assessments for July had been created for residents upcoming assessments.

Based on record review and staff interview, the facility failed to ensure there was a Physician' Order for a wound treatment for one resident (R) (#64) and failed to document when the treatment order was completed. The sample size was 13 residents. Findings include: Review of Physician's Orders from 7/1/22 revealed that there was no order for pressure ulcer wound care. Review of the care plan revealed R#64 has alteration in skin integrity R/T (related to) stage II to his coccyx. - Observe for s/s (signs/symptoms) of infection and notify physician if present. Turn and reposition at least every two hours. Interview with Licensed Practical Nurse (LPN) AA on 7/6/22 at 1:00 p.m. revealed R#64's pressure areas have healed. She confirmed that there was not a treatment order for wound care. LPN AA stated she was told by the off going nurse that R#64 had a pressure ulcer to his sacrum, and what treatment to put on it. LPN AA further stated she provided wound care to R#64 when she worked. Interview with the Director of Nursing (DON) on 7/7/22 at 2:24 p.m. revealed R#64 had a stage II area to the inner side of his right buttock. She stated there was apparently no treatment order however they were putting Mepilex on the area every three days. DON stated she gave the order to use Mepilex as a treatment. DON stated that she knew what to use on the wounds because she was a WOCN (Wound, Ostomy, and Continence Nurse), but she did not keep her certification up. DON stated she ran it by the Physician and that he stated that it was okay to use Mepilex. DON further stated she did not write the order and apparently it got missed. Further interview with the DON confirmed there is not a treatment administration record or anywhere for the nurses to document when they did R#64's wound care.

Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed annually and upon admission for three residents (R) (#3, #4 and #65) of 13 sampled residents. Findings include: 1. Review of R#3's MDS listings revealed that a Quarterly MDS with an Assessment Reference Date (ARD) date of 3/4/22 was the last MDS completed. 2. Review of R#4's MDS listings revealed that a Quarterly MDS with an ARD date of 2/24/22 was the last MDS completed. 3. Review of R#65's MDS listings revealed that an Entry MDS with an ARD date of 4/30/22 was the last MDS completed. Review of an alphabetical resident census revealed that R#3, R#4 and R#65 were currently residents in the facility. Interview with Social Services Director on 7/7/22 at 12:10 p.m. revealed the sections competed by their department are C, D, E, V which are completed by social services when there is a new admission or significant change. The MDS coordinator gives out the schedule of when the assessments are due to be completed. The care plans are scheduled in accordance with the assessment due date that is provided by the MDS coordinator once the schedule is received the care plan meetings are set up by the social services department with the families and the residents. Interview with MDS Coordinator on 7/7/22 at 1:24 p.m. revealed staff started in the middle of March at this facility doing MDS. There was a calendar that was created every month that showed the ARD and Care Plan date that is given to Social Services Director (SSD) and Activities Director that indicated when assessments were due for completion. If an admission comes in after the calendar goes out, an email is sent out to let the staff member know of the ARD date for that resident. Continued interview also revealed that the calendar is kept on coordinators' laptop for review. During the interview it was also disclosed that staff member was not sure exactly how the assessments were missed. When the calendar is created every resident is reviewed at that time. Further interview also revealed that calendar of assessments for July had been created for residents upcoming assessments. The process for annual assessments is to print off the previous MDS and talk to the residents to find out how their pain is, see if there have been any changes that have not been brought up in morning meetings, bowel, and bladder habits. Interview with Director of Nursing (DON) on 7/7/22 at 2:36 p.m. revealed the MDS's were placed in a Performance Improvement Plan (PIP) in April and were being monitored weekly by pulling the CMS report. There was no indication that any assessments were late or had not been submitted. Further interview also revealed that DON acknowledged that the system that was used to ensure that the MDS assessments were completed was ineffective. During interview it was also disclosed that going forward the mechanism for ensuring assessments are completed is to manually check every resident's chart for completion.