Based on observation, interview, and record review the facility failed to ensure a multi-dose vial was labeled when opened and failed to ensure controlled medications were double locked. This has the potential to affect all residents in the facility. The findings include: The CMS 671 form dated 9/10/24 showed six residents reside in the certified unit of the facility. 1. On 9/12/24 at 9:05 AM, the facility medication room was reviewed. The unit refrigerator had an opened vial of multi-dose tuberculin (TB) solution inside, and it was approximately half dispensed. The vial was not dated or labeled with an open or expiration day. V9 (Registered Nurse) was present and verified the vial was half used and there was no labeling. On 9/12/24 at 10:52 AM, V2 (Director of Nurses) stated the vial should have been dated when it was opened. It should show the date, time, and initials of the nurse that opened it. The information is important to ensure the solution is not used past the expiration day. There is no way of knowing if it is still effective if the date it was opened is missing. The facility's Maintenance of Medication Inventory policy last review dated 8/23 states: Opened multi-dose bottle such as TB solution should have a date opened sticker, if expires in 24 hours or less order replacement (expires in 30 days after opened). 2. R3's face sheet printed on 9/12/24 showed an admission date of 8/6/24. R3's physician order report showed an order start dated 9/2/24 for alprazolam (anxiety medication) at 0.25 milligrams every 24 hours as needed for sleeplessness. The same report showed an order start dated 8/7/24 for pregabalin (convulsion medication) at 50 milligrams two times a day for anticonvulsant. R57's face sheet printed on 9/12/24 showed and admission date of 8/31/24. R57's physician order report showed an order start dated 9/1/24 for pregabalin at 100 milligrams three times a day for anticonvulsant. On 9/12/24 at 9:05 AM, the facility medication cart was reviewed. The bottom drawer of the cart contained the narcotics box, and the lid was unlocked. R3's alprazolam and pregabalin medication cards where in the box. R57's pregabalin medication cards were in the box. V9 (Registered Nurse) stated the lid tends to catch on the top of the medication cards and block it from locking. It happens a lot. It should not be unlocked like that. On 9/12/24 at 10:52 AM, V2 (Director of Nurses) stated narcotics need to be under a double lock system at all times. They have a high risk of misuse and need extra close monitoring. V2 said staff need to be checking the lock even more closely knowing the medication cards cause an issue with it locking correctly. The facility's Medication Administration policy last review dated 8/23 states: 8. Medication room/Narc box/tx (treatment) cupboard is never left unlocked when unattended and the medication room/cart/cupboard key will be in the possession of authorized personnel at all times.

Based on observation, interview, and record review the facility failed to store frozen items off the floor. This failure has the potential to affect all residents in the facility. The findings include: The CMS 671 dated 9/10/24 showed 6 residents reside in certified beds. On 9/11/24 at 11:15 AM and 12:30 PM (One hour and fifteen minutes) a box of lemon and cream cakes was stored on the floor of the walk-in freezer. On 9/11/24 at 11:15 AM, V7 Kitchen Manager stated the facility did not receive a food delivery that day. On 9/11/24 at 12:43 PM, V7 stated the lemon cake was the desert for dinner that evening. V7 stated food should not be stored on the floor; it should be on a shelf. On 9/11/24 at 12:45 PM, V8 Director of Food and Nutrition stated the lemon shortcake was only stored on the floor momentarily. V8 stated food should be stored six inches off the floor. V8 stated, the purpose of storing food off the floor is to prevent pests from getting into food and floor chemicals getting on food. V8 stated, storing food off the floor also allows proper airflow around food to prevent spoilage. V8 stated, she would consider momentary to be five minutes. The facility Storage of Frozen Foods policy (Revision 2017) showed, .Appropriate storage procedures are followed: First-in-first-out. Food is stored six inches above the floor. Food is stored to allow air circulation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have a Legionella (bacteria) prevention and mitigation program in place. The facility also failed to implement enhanced barrier protections (EBP) for a resident with an indwelling catheter. These failures have the potential to affect all residents in the facility. The findings include: The CMS 671 dated 9/10/22 showed 6 residents reside in certified beds. 1. On 9/11/24 at 1:04 PM, V2 Director of Nursing stated V6 Facility Director was responsible for the Legionella program (a bacteria that can cause pneumonia). The facility's Legionella policies for prevention and mitigation were requested from V2. On 9/11/24 at 2:09 PM, V6 stated he has been the maintenance director for 8 months. V6 stated he does not have a legionella mitigation and prevention program for the facility. On 9/12/24 at 8:55 AM, V2 stated Legionella bacteria live in the water in pipes with little to no flow. V2 said the elderly are more susceptible to Legionnaires infection. V2 was uncertain regarding the consequences of a resident contracting Legionella. The Centers for Disease Control (CDC) website About Legionnaires; Disease (dated 1/29/24) showed, Legionnaires' disease is a serious type of pneumonia caused by Legionella bacteria. Certain people are at increased risk for the infection, but it's treatable with antibiotics. People can get Legionnaires' disease by breathing in mist containing Legionella bacteria. To prevent Legionnaires' disease, reduce the risk of Legionella growth and spread . The CDC website How Legionella Spreads (dated 1/29/24) showed .People at increased risk of getting sick include: Current or former smokers. People 50 years or older . 2. R 57's admission record shows he was admitted to the facility on [DATE]. His order summary report for September 12, 2024, documents admission orders for indwelling catheter care. The 8/31/24 care plan for R57 shows him to be placed on EBP (Enhanced Barrier Precautions) due to having an indwelling urinary catheter and wounds. On 9/10/24, R57's room and doorway were found to have no signs indicating EBP, or gowns available for staff to enter his room. On 9/11/24 at 9:55 AM, V5 CNA (Certified Nursing Assistant) was observed performing catheter care, and placing the leg drainage bag around R57's leg. She was not wearing any gown. After placing the leg bag, she assisted R57 to get dressed, then placed a gait belt around him and ambulated him to the recliner. On 9/11/24 at 1:04 PM, V2 DON (Director of Nursing) stated EBP is an added layer of protection for residents who have a heightened risk of infection. It is put in place for residents with chronic wounds, PICC lines (peripheral inserted central catheter), and indwelling catheters to prevent the spread of infection. EBP is required for those residents, it is not an option. Placing residents in EBP is the responsibility of the nurses on the floor and then I would be a backup when I do my 24 hour charting review. On 9/11/24 at 2:02 PM, V4 LPN (Licensed Practical Nurse) said EBP should be in place for residents with open wounds and indwelling catheters. V4 said she does realize she messed up and R57 should be on EBP due to his open wounds and catheter. She said staff should be wearing a gown and gloves when providing care and dressing changes. The facility's 5/24 policy for Enhanced Barrier Precautions documents it to be an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing home. EBP involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (for example: residents with wounds or indwelling medical devices). Staff should perform hand hygiene before entering the resident's room and applying gown/gloves and immediately upon removal.

Based on interview and record review the facility failed to have a PRN (as needed) psychotropic medication stop date to 1 of 5 residents (R59) reviewed for unnecessary medications in the sample of 5. The findings include: R59's Physician Order Sheet (POS) dated 8/2023 show, R59 has an order of: start date- 8/10/23 Risperdal Oral Tablet 0.25 MG (Risperidone) Give 0.25 mg by mouth every 12 hours as needed (PRN) for agitation and insomnia. On 8/15/23 at 9:15 AM, V2 (Director of Nursing-DON) said all psychotropic as needed medications should have a 14 day stop date unless the physician renews the PRN meds. V2 said we will be working on this and ensure all PRN psychotropic medications have a 14 day stop date. The facility policy on Psychotropic Medications with a review date of 8/2023 show, all PRN psychotropic medications will have an automatic stop date of 14 days unless specified by the medical provider.

Based on observation, interview and record review the facility failed to wash hands after providing pericare to prevent the spread of infection to 1 of 5 residents (R58) reviewed for infection control in the sample of 5. The findings include: On 8/14/23 at 9:10 AM, V4 (Certified Nursing Assistant-CNA) toileted R58 and provided peri care after R58 had a bowel movement. V4 (CNA) then removed her soiled gloves but did not wash hands/did not perform hand hygiene. Using her contaminated hands V4 took R58's toothbrush, applied tooth paste then handed the toothbrush to R58 and gave R58 a cup of water. V4 then wheeled R58 and assisted R58 to his recliner all doing these tasks without washing her hands. On 8/15/23 at 8:50 AM, V5 (Registered Nurse) said staff should wash their hands prior to and after giving care. V5 also said every time staff remove their gloves, they should perform hand hygiene to prevent the spread of infection, The facility Policy entitled Hand Hygiene with a revised date of 4/2020 show, it is the policy of this organization to promote use of alcohol sanitizers and handwashing as the single most important means of preventing the spread of infection. Examples of situation when hand hygiene is indicated before and after direct resident contact (care, treatment).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to offer the pneumococcal conjugate vaccines (PCV20) or the pneumococcal polysaccharide vaccine (PPSV23) for 1 of 5 residents (R58) reviewed for vaccinations in the sample of 5. The findings include: R58's face sheet shows he is an [AGE] year-old male admitted to the facility on [DATE] with diagnosis including pneumonitis due to inhalation of food and vomit, atrial fibrillation, hypertension, and presence of cardiac pacemaker. R58's Immunization Report provided on 8/14/23 shows on 10/9/2015 he received Prevnar 13 (PCV13). There were no other pneumococcal vaccinations recorded. On 8/15/23 at 12:03 PM, V3 Assistant Director of Nursing (ADON) said R58 received Prevnar 13 in 2015, he is eligible to receive the 2nd dose of the pneumococcal vaccine. It should've been offered on admission and given if consented. Residents should receive the 2nd dose of the pneumococcal vaccine after one year of receiving PCV13. The CDC (Centers for Disease Control and Prevention) guidelines dated February 2013 shows states, the CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide detailed information .For adults 65 years or older who have only received PCV13, CDC recommends you either: Give 1 dose of PCV20 at least 1 year after PCV13 or Give 1 dose of PPSV23 at least 1 year after PCV13 . The facility's Flu and Pneumonia Vaccines revised 2018, states, All residents living in licensed units will be offered an annual flu vaccine in accordance with the recommendations of the Advisory Committee of the Centers for Disease Control and with the approval of their physician and the resident's consent, (if resident unable to make decision, legally responsible party will be consulted), unless they have had previous reactions to the vaccine, are allergic to eggs, have a history of Guillain Barre Syndrome, or are ill .All residents age [AGE] and older living in a licensed unit will be offered a pneumonia vaccine in accordance with the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control upon admission and with the approval of their physician, and with the resident's consent .Administration of, refusal of, or medical contraindication of a pneumonia vaccine will be documented in the resident's medical record.

Based on observation, interview and record review the facility failed to ensure staff wore N95 face masks when testing residents for COVID-19. This applies to all residents residing in the facility. The findings include: The CMS 672 Resident Census and Conditions report dated September 12, 2022, shows, there is one resident residing in a certified bed in the facility. 1. On September 12, 2022, at 11:17 V5, V6, & V7 all lab technicians were testing residents on the skilled unit for COVID-19. They were wearing a KN95 face mask and not an N95 face mask. On September 13, 2022, at 9:59 AM, V3 Director of Nursing/Infection Preventionist stated, anyone testing residents for COVID-19 should be wearing an N95 face mask. They should not be wearing a KN95 face mask. She also stated, they had enough N95's for staff to wear. The CDC's (Centers for Disease Control and Prevention) Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing last updated July 15, 2022, shows, Collecting and Handling Specimens Safely: For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with SARS-CoV-2 (COVID-19), maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a gown. The facility's COVID-19 staff, and resident testing policy (no date) does NOT show that staff/HCP should wear an N95 when collecting a COVID-19 specimen.