**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to administer oral medications following standard infection control practices for 2 of 6 residents observed for medication administration (Resident #6 and Resident #9). The facility reported a census of 59 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Review of the March 2025 Medication Administration Record (MAR) revealed Resident #9 scheduled the following medication in the morning: a. Omeprazole 40 mg (milligram) 1 cap (capsule) PO (by mouth) early every morning. b. Cetirizine 10 mg 1 tab (tablet) PO early every morning. c. Tamsulosin 0.4 mg 1 cap PO early every morning. d. Vitamin B-12 500 mcg (microgram) 1 tab PO every morning. e. Vitamin C 500 mg 1 cap every morning. f. Acetaminophen 325 mg 2 tabs PO TID (three times a day). During an observation on 3/25/25 at 7:56 AM, Staff A, RN (Registered Nurse) popped out the morning tablets/capsules out of the bubble pack into his bare hands. Between each pill he picked up another card. Staff A stuck his fingers into the stock acetaminophen bottle and took 2 pills out of the bottle. Staff A popped the Vitamin B-12 tablet into his hand and as he went to put it into the medication cup, it fell onto the clipboard on the medication cart. Staff A picked it up and placed it in the cup. Staff A then proceeded to administer the medications to Resident #9. 2. The MDS assessment dated [DATE] revealed Resident #6 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. Review of the March 2025 MAR revealed Resident #6 scheduled the following medications in the morning: a. Levothyroxine 75 mcg 1 tab early every morning. b. Acetaminophen 500 mg 2 tabs PO TID c. Celecoxib 200 mg 1 tab PO every morning. d. Clopidogrel 75 mg 1 tab PO every morning. e. Cranberry con cap- 500 mg 1 cap PO every morning. f. Finasteride 5 mg 1 tab PO every morning. g Digoxin 0.125 mg 1 tab PO every morning h. I-Vite tab 1 tab PO every morning. i. Metoprolol Suc 50 mg ER (extended release) 1 tab PO every morning. j. Docusate 100 mg 1 cap PO BID (twice daily). k. Senna 8.6 mg 1 tab PO every morning. During an observation on 3/25/25 at 8:05 AM, Staff A, RN popped Resident #6's medication out of a bubble pack into his bare hands. Between each tablet/capsule Staff A picked up another medication card. Staff A stuck his fingers in the stock acetaminophen bottle and pulled out 2 tablets, then popped the cranberry concentrated capsule out of the bubble cap into his hand, tipped his hand towards the medication cup, and the capsule rolled onto the clipboard, Staff A proceeded to pick up the capsule and put it in the medication cup. Staff A also stuck his fingers into the stock docusate bottle and pulled out a capsule and stuck his fingers in the senna stock bottle and took out a tablet. During an interview on 3/25/25 at 1:41 PM, Staff A stated he did touch the tablets/capsules when he administered the medications for Resident #9 and Resident #6. Staff A stated he should not have touched the medications with his bare hands, and he usually tried to pop the medications in a cup. Staff A stated he washed his hands between residents and that was why he felt more confident in doing it that way. During an interview on 3/27/25 at 9:59 AM, Staff B, LPN (Licensed Practical Nurse) stated tablets and/or capsules should not be touched when they are taken out of the bubble pack or stock bottle during medication administration. During an interview on 3/27/25 at 10:45 AM, the DON (Director of Nursing) stated she expected staff to not touch tablets/capsules with their bare hands during medication administration. Review of the policy titled, Medication Administration , dated 4/28/23 directed staff, if hands are contaminated or soiled at any time during the medication pass wash your hands.

Based on observations, clinical record review and staff interviews, the facility failed to provide adequate supervision to ensure resident safety and to mitigate risk for elopement for 1 of 2 residents reviewed. (Resident #2) The facility reported census was 49. Findings include: According to a Minimum Data Set (MDS) with a reference date of 12/26/23, Resident #2 had a Brief Mental Status (BIMS) score of 5 indicating a severely impaired cognitive status. Resident #2 required limited assistance with transfers, mobility and extensive assistance with dressing, toilet use and personal hygiene needs. Resident #2's diagnosis included Alzheimer's and an aortic aneurysm. According to Resident #2's plan of care dated 1/3/23, Resident #2 is an elopement risk related to wandering behavior with interventions which included monitoring location frequently across all shifts, document wandering behavior if observed, the use of a wander guard, and staff to ensure it is in place and functioning properly each shift and to replace it as needed. In an interview on 2/20/24 at 10:04 a.m. Staff B, Registered Nurse, stated she heard the door alarm on the north hall sound (10/16/23 at 2:25 p.m.) and responded immediately. Staff B stated she looked out doors through the window and did not see anyone, so she returned to the nurse's station without verifying the cause for the alarm or initiating elopement protocols which included doing a head count to ensure all residents were accounted for. Staff B stated shortly after returning to the nurse's station, someone said that someone (Resident #2) was outside and was being escorted back into the facility. Staff B stated Resident #2 was an elopement risk and was wearing a wander guard at the time of the event. In an interview on 2/20/24 at 10:45 a.m. the Director of Nursing (DON) stated on 10/16/23, Resident #2 exited the building through the North door setting off the alarm. The DON stated Resident #2 was wearing a wander guard bracelet at the time and was discovered on the East side of the building by their maintenance guy 5-10 minutes later and escorted back into the building. The DON stated her expectations upon a door alarm sounding would be that staff immediately respond to determine the cause for the alarm which may include stepping outside to check for residents. If a resident is not seen and the cause of the alarm cannot be determined, staff are to complete a resident headcount to ensure all residents are accounted for. If a resident is missing, elopement protocols are to be initiated. Observations on 2/20/24 at 10:45 a.m. found the North hall exit alarmed and functioning properly. The door sits on the other side of double doors (not alarmed) leading off of the long term care unit. The North door alarm does not have a wander guard monitor. According to a Disciplinary Notice dated 10/25/23, Staff B given a verbal warning for failing to go outside and check for residents when responding to a door alarm and failing to alert staff and account for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interview and facility document review the facility failed to supervise 2 out of 3 random observations of medication administration. The facility reported a census of 52 residents. Findings included: 1. The Annual Minimum Data Set (MDS) Assessment for Resident # 6 dated 12/30/22, reflected diagnoses of heart failure, hypertension and osteoporosis. The MDS indicated a Brief Interview for Mental Status score of 15 (intact cognition). The Care Plan for Resident # 6 dated 9/15/21, identified she wanted to remain as independent as possible and wanted to continue to do things for herself, even if it tires her out. The Care Plan failed to identify Resident #6 as independent in administering her own medication. Resident #11's Significant Change MDS dated [DATE], reported diagnoses of Alzheimer's disease and hypertension. The MDS listed Resident # 11's BIMS as 6 (severe cognitive impairment). On 03/22/23 at 8:18 AM, Staff A, Certified Medication Aid (CMA), sat a cup of medication in front of Resident # 6 with a second medication cup that held apple sauce and a spoon at the table. Resident # 6 sat across from Resident #11 The Staff B walked away from the table and failed to come back. She stood at her medication cart in the hall with her back to the residents in the dining room. On 03/22/23 at 8:21 AM, Staff B CMA, administered medication to Resident # 11. Staff A left the dining room area. On 03/22/23 at 8:29 AM, Resident # 6 moved the medication cup in front of her. Resident #6 added 1 pill at a tip to spoon with apple sauce and put the medication in her mouth. Resident #6 repeated this 4-5 times. The CMA's failed to observe Resident # 6 take the medication. 2. On 03/22/23 at 12:11 PM, Staff B, carried 2 medication cups to Resident # 6 and set them on the table to the left of her. Staff B stood and talked with a family across the table. On 03/22/23 at 12:12 PM, Staff B, walked to her med cart with her back to R #6. On 03/22/23 at 12:17 PM, Staff B, walked back over at the table and administered Resident # 11 medications and went back to the medication cart. On 03/22/23 at 12:22 PM, Staff B, left the dining room and took the medication cart back the the nurses station at the center of the building. On 03/22/23 at 12:39 PM, Resident #6 moved the medication cup in front of her as she pushed her plate away. Resident # 6 took the medications from the medication cup and placed them in her mouth. Staff B failed to provide supervision as Resident # 6 took medications. On 03/23/23 at 9:02 AM, Staff C, Registered Nurse (RN) stated none of the resident's on Hall two took medications independently. She confirmed, she supervised residents as they took medications. On 03/23/23 at 9:06 AM, the MDS Coordinator, stated all the resident's at the facility required supervision while they took medication. On 03/23/23 at 9:09 AM, the Acting Director of Nursing (DON), reported all of the current residents take medication with supervision. The Acting DON revealed she expected is the staff stay with the residents until all the medications are administered. The Acting DON stated it is the standard of practice, she stated the facility failed to have a policy on Medication Administration. The facility provided an audit tool titled Medication Pass undated, directed at point # 9 Administered medication and certified consumption.