**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to remove expired medications from current medication supply for 2 (R17, R45) of 2 residents reviewed for pharmacy services in the sample of 35. Findings include: 1. R17's Face Sheet documents an admission date of 5/1/23 with diagnoses including in part fibromyalgia, lower abdominal pain, other chronic pain, pain in right hand, pain in left wrist, and pain in throat. R17's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 12 indicating moderately impaired cognition. R17's Continuity of Care Document dated May 22, 2025, documents an order for Tramadol (schedule IV narcotic) tablet 25 milligrams (mg) 1 tablet oral twice a day for pain ordered on 3/7/24 and discontinued on 5/20/25. On 5/20/25 at 11:24 AM, there was an expired card of tramadol HCL 50 mg half tablets for R17 in the medication cart with an expiration date of 2/14/25. R17's Medication Administration Record (MAR) dated 2/1/2025-2/28/2025 documents that R17 received tramadol 25 mg on 2/15/25 at 7:12 PM and 2/16/25 at 6:50 PM. R17's MAR dated 5/1/2025-5/20/2025 documents that R17 received tramadol 25 mg on 5/3/25 at 7:45 PM. On 5/20/25 at 12:20 PM, V4 (Registered Nurse/RN) confirmed the tramadol for R17 was expired. V4 removed the card from the medication cart and stated it should have been removed from the cart when it expired. V4 stated the director of nursing checks the medication carts for expired medication and a pharmacy representative was just in the facility and should have found it. 2. R45's Face Sheet documents an admission date of 2/8/24 with diagnoses including in part arthritis and pain. R45's MDS dated [DATE] documents a BIMS of 9 indicating moderately impaired cognition. R45's most recent Care Plan documents a problem of R45 is at risk for pain related to diagnosis of arthritis with a start date of 9/19/24, goal of R45 will have pain under control with medication or resolved as seen by verbalization or free of signs or symptoms of pain, and approach of observe effectiveness of medication and provide analgesics as ordered and as needed. R45's Continuity of Care Document dated May 22, 2025, documents a current order for albuterol sulfate solution for nebulization 0.63 mg/2 milliliters (ml) inhalation every 6 hours as needed ordered on 2/26/24. On 5/20/25 at 11:50 AM, there was expired albuterol nebulizer solution 0.63 mg/3 ml for R45 in the medication room cabinet with other resident's medications with an expiration date of April 2025. On 5/20/25 at 12:27 PM, V6 (RN) confirmed R45's albuterol nebulizer solution was expired as of April 2025. V6 removed the medication from the medication room and stated it should have been taken out of the room when it expired. An undated facility policy titled Storage of Medication documents under Procedures, it documents H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed form inventory, disposed of according to procedures for medication dispose and reordered from the pharmacy, if a current order exists. On the same document under Expiration Dating, it documents F. The nurse will check the expiration date of each medication before administering, G. No expired medication will be administered to a resident, H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to double lock controlled medications 1 of 1 (R27) residents reviewed for medication storage in the sample of 35. Findings include: R27's admission Record documents an admission date of 10/18/2022 with diagnoses including in part spondylosis, polyosteoarthritis, age-related osteoporosis, and chronic pain. R27's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 13 indicating that R27 is cognitively intact. R27's most recent Care Plan documents a problem area of R27 has pain at times due to degenerative joint disease, goal of resident will have no episodes of uncontrolled pain, and approach of medications as ordered. R27's Continuity of Care Document dated May 22, 2025, documents an order for hydrocodone-acetaminophen-(schedule II narcotic) tablet 3-325 milligram (mg), 1 tablet oral every 6 hours as needed, ordered 9/7/23. On 5/20/25 at 11:08 AM, a medication card belonging to R27 with hydrocodone/acetaminophen 5-325 Milligram (mg) was in an unlocked cabinet, in the locked medication room. At this time, V3 (Registered Nurse/RN) stated the medication was in that cabinet because it needed to be destroyed. On 5/20/25 at 12:24 PM, V3 and V4 (RN) stated they don't know if the door on the cabinet locked where the narcotic was located. V4 tried her keys on the cabinet lock and the key turns but the lock does not lock the door and it still opens. On 5/22/25 at 8:32 AM, V4 stated hydrocodone/acetaminophen should be double locked. An undated facility policy titled Controlled Substance Storage documents under Procedures B. Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications or per state regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow the Pneumococcal Immunization Policy to ensure accurate documentation and administration of the Pneumococcal Immunization for 1 of 5 (R3) reviewed for Pneumococcal Immunizations in the sample of 35. Findings Include: R3's Resident Face Sheet documents an admission date of 12/09/2024, with a date of birth indicating that R3 is [AGE] years of age. The same Face Sheet documents the following diagnoses in part; type 2 diabetes mellitus without complications and cough. R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating R3 is moderately cognitively impaired. R3's Continuity of Care Document dated 5/22/25 documents under Immunizations documents the date 12/21/20 next to Pneumococcal Vaccine with a status of completed. There is no documentation in R3's medical record documenting the type of Pneumococcal Vaccine that R3 received. On 05/21/2025 at 11:37am, V1 (Administrator) stated vaccinations should be in the electronic medical record. V1 stated when a resident admits they ask the resident or the family about vaccination history. V1 stated if they don't know they may call the doctor to see what he recommends. A document titled Vaccine Consent and Release in R3's medical record dated 12/26/2024 and signed by R3's Power of Attorney (POA) indicates that R3's POA agrees to the Pneumococcal vaccination schedule. It also indicated they did not recall R3's vaccination history or if she had received the pneumococcal vaccine before. On 05/21/2025 at 11:38am, V2 (Business Office Manager/BOM) stated she would try to see if she could print off vaccinations from R3's local hospital records. V2 stated she was pretty sure there were vaccinations on there. On 5/21/25, V2 provided R3's local hospital's electronic medical records with a print date of 05/21/2025, documenting that R3 received the following Pneumococcal vaccinations, PCV13 (pneumococcal 13-valent conjugate vaccine) on 11/18/2019 and 12/16/2020. The facility was unable to provide reproduceable evidence that R3 received vaccinations at this facility. According to the Center for Disease Control (CDC) located at (https://www.cdc.gov/vaccfines/vpd/pneumo/hcp/pneumoapp.html) a patient who is over the age of 50, who has only received the PCV13, and none of the others; is recommended to be given one dose of PCV20 (20-valent pneumococcal conjugate vaccine) or PCV21 (21-valent conjugate pneumococcal vaccine) at least one year after PCV13. Regardless of which vaccine is used, (PCV20 or PCV21) their pneumococcal vaccinations are complete. The facility policy titled Pneumococcal Vaccine with a revision date of February 11, 2022, under Policy, documents It is the policy of (name of facility) that all residents are protected from incident of pneumonia by obtaining pneumococcal vaccines, if desired, per the CDC guidelines. In the section titled Schedule for Administering Pneumococcal Vaccines it states Follow CDC guidelines with use of Pneumo Recs VaxAdvisor mobile app. On 05/22/2025 at 1:00pm, V5 (Licensed Practical Nurse/Infection Prevention) stated if a resident is admitted and their Power of Attorney signed a consent for a pneumonia vaccination, they might contact the doctor to see if he had any recommendations if previous vaccinations are unknown. V5 stated if the doctor was contacted it would be in the Progress Notes. V5 stated she was not aware of the specifics of the Center for Disease Control (CDC) guidelines of completing the series for pneumococcal vaccinations or the app associated with it. V5 could not confirm whether R3 had any pneumococcal vaccinations. There is no documentation of communication with R3's doctor about the pneumococcal vaccination documented in R3's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow proper infection control techniques during wound care for 1 of 5 residents (R30) reviewed for infection control in the sample of 30. The findings include: R30's face sheet documents an admission date of 12/15/23 with diagnoses including: Sepsis, unspecified, Unspecified open wound, left foot, Laceration without foreign body of left lesser toe(s) without damage to nail, Other iron deficiency anemias, Type 2 diabetes mellitus with unspecified complications, Venous insufficiency (chronic) (peripheral), Muscle wasting and atrophy, not elsewhere classified, multiple sites, Unspecified open wound of unspecified toe(s) without damage to nail, sequela, Pain, unspecified, Other hypoglycemia, Unspecified atrial fibrillation, Muscle weakness (generalized), Other abnormalities of gait and mobility, and Other lack of coordination. R30's Minimum Data Set (MDS) dated [DATE] documents under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates that R30 is cognitively intact. Section GG documents R30 is dependent with toileting, showering, and dressing. R30's Current Care Plan documents under problems: R30 has a diabetic ulcer to left heel with intervention of: enhanced barrier precautions per facility protocol and treat ulcer as ordered. R30's Care Plan documents that R30 is at risk for skin breakdown or pressure ulcers related to decreased mobility with interventions of: keep skin clean and dry as possible and observe skin condition with daily care. R30's Care Plan documents that R30 is at risk for complications due to diabetes diagnosis with intervention of: notify V13 (Medical Doctor) as needed. R30's Physician orders documents an order dated 03/06/24 for Betadine 10% solution to open wound, to left foot, cleanse wound with normal saline (NS) apply betadine and calcium alginate and gauze wrap every day. On 04/24/24 at 1:38 PM, V4 (Registered Nurse) was observed donning a gown and gloves and entering R30's room, which had a sign on the door that stated enhanced barrier precautions. V4 placed a clean towel on a bedside table and placed treatment supplies with several pairs of gloves on the towel. V4 removed a pair of scissors from her pocket. V4 cut the soiled dressing off R30's foot with the scissors, the contaminated scissors were placed on the clean towel next to the clean dressing supplies without cleansing the scissors. V4 doffed her soiled gloves and donned clean gloves without performing hand hygiene between. V4 used the soiled scissors and cut a clean piece of gauze from a roll. V4 took the piece of gauze and some normal saline and cleansed R30's foot. V4 doffed her gloves and donned a new pair of gloves without performing hand hygiene. V4 applied betadine to R30's left heel along with calcium alginate. V4 then wrapped R30's left foot with the gauze she had cut with the soiled scissors. V4 doffed her gloves, placed the dirty scissors in her pants pocket and then performed hand hygiene. On 04/24/24 at 2:00 PM, V4 stated she did not clean the scissors after she removed the old dressing from R30's left foot. V4 stated, she did have an alcohol wipe she was going to use to wipe off the scissors after she removed the old dressing, however she lost or misplaced the alcohol wipe when she entered R30's room. V4 stated, she did cleanse the scissors before entering the room and placed them in her pocket. V4 said, she did place the dirty scissor in her pocket when she was exiting the room. V4 stated, she did not perform hand hygiene in between gloves changes when she removed the old dressing and applied the new dressing. On 04/24/2024 at 03:00 pm, V3 (Infection Preventionist/IP) stated that after you remove a dirty dressing with scissors you should clean the scissor and then wash your hands. V3 stated that you should always wash your hands or sanitize them in between glove changes. V3 stated that should be common practice. V3 stated that all dressing changes are expected to be done according to Professional Standards of Practice. V3 stated that a resident who is on enhanced barrier precautions is at a higher risk of infection. V3 stated that it is very important to maintain proper infection control practices for all residents. The facility policy titled Isolation Precautions/ Enhanced Barrier Precautions (EBP) dated 4/1/24 documents the following under Guidance: EBP is used in conjunction with standard precautions and expand the use of PPE (Personal Protective Equipment) to donning of gown and gloves during high-contact resident care activities that provide the opportunities for transfer of MDRO's (multi drug resistant organisms) to staff hand and clothing . EBP ae indicated for residents with any of the following: .Wounds and/ or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO .Facilities should ensure PPE and alcohol based hand rub are readily accessible to staff. The facility policy titled Dressing, Dry/Clean dated January 2018, documents in part under procedures 2. Place the clean equipment on the bedside stand. Arrange the supplies so they can be easily reached. 8. Put on clean gloves, loosen tape and remove soiled dressing 9. Pull glove over dressing and discard into plastic or biohazard bag. 10. Wash and dry your hands thoroughly. 11. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 14. Put on clean gloves.