2. Observation on 10/09/2024 at 10:22 AM revealed Nurse Aide in Training (NAT) 3 and STNA13 used the Hoyer Ascend lift to assist R21 to the toilet. They secured a cloth sling around R21's back and together assisted her to stand. They then moved R21 to the toilet. The strap to the sling fell on R21's abdomen and upper perineal area. They then assisted R21 to the wheelchair. They removed the sling and put the sling on the lift. STNA13 then took the Hoyer Ascent lift to the shower room on the 1100 Hall. She left the shower room and failed to clean the lift. During interview with STNA13 on 10/09/2024 at 10:42 AM in the hallway after she left the shower room, she stated she forgot to clean the lift. She stated she should have cleaned the lift with disinfectant wipes. Registered Nurse (RN) 1 appeared during the interview with STNA13. He had the Hoyer Ascent lift and stated he was going to clean the lift with disinfectant wipes, which were kept in the locked room adjacent to the shower room. However, when RN1 came out of that room, he stated there were no disinfection wipes in the room, and he was going to get some wipes. He then placed the lift back in the shower room and left to get wipes. During interview with STNA13 on 10/09/2024 at 10:44 AM, she stated she did not have a key to the locked room adjacent to the shower room. During interview with RN1 on 10/09/2024 at 11:02 AM, he stated disinfectant wipes were not kept in the shower room because staff was concerned a resident might use the wipes in an inappropriate way. He stated the disinfectant wipes were always in a locked room. During interview with RN7, the Wound Care/Infection Preventionist, on 10/09/2024 at 12:54 PM, she stated the facility did not audit the cleaning of multiuse resident equipment. She stated staff was educated on cleaning the multiuse equipment with bleach wipes. She stated the multiuse wipes were available on the treatment carts and were usually in the shower room. During interview with the DON on 10/10/2024 at 10:07 AM, he stated staff was to clean the lifts after each use and was to use disinfectant wipes. He stated staff was educated in orientation and yearly on infection control. During interview with the Administrator on 10/11/2024 at 10:11 AM, she stated she relied on the Infection Preventionists and the DON to assure the equipment was cleaned appropriately. Based on observation, interview, record review, review of the manufacturer's instructions for use, and review of the facility's policies, the facility failed to maintain infection prevention and control measures to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents sampled for transmission- based precautions (Resident (R) 36 and R107) and 1 of 3 residents reviewed for use of sit-to-stand mechanical lifts (R21). The findings include: Review of the facility's policy titled, Infection Control: Transmission Based Precautions, dated 9/2024, revealed the facility was to implement contact precautions for residents known or suspected to be infected with microorganisms that could be transmitted by direct or indirect contact with the resident or the resident's environment. Further review revealed infections indicating use of contact precautions included multi-drug resistant organisms. Per the policy, staff was to wear gloves and gown for interactions that involved contact with the resident. Review of the facility's policy titled, Standard Precautions, revised 09/2023, revealed reusable equipment used for resident care was not used for the care of another resident until it had been appropriately cleaned and reprocessed. Review of the manufacturer's instruction for use of the Hoyer Ascent lift, not dated, revealed the lift should be cleaned using a damp cloth and to wipe clean with ordinary soap and water and/or using any hard surface disinfectant. 1. a. Review of R36's admission Record revealed the facility admitted the resident on 09/08/2023 with diagnoses including unspecified dementia and type 2 diabetes. Review of R36's Care Plan, not dated, revealed the facility identified the resident had an infection with a multi-drug resistant organism and included the intervention of placing the resident in contact precautions. Review of R36's Order Details, dated 10/02/2024, revealed the physician ordered the resident to be in contact precautions for extended-spectrum beta-lactamase (ESBL-a multi-drug resistant organism) in her urine. Observation on 10/10/2024 at 10:59 AM revealed the facility posted a sign on the personal protective equipment (PPE) container outside R36's room, indicating the resident was in contact precautions. Further observation revealed the sign indicated staff was to don (put on) a gown and gloves prior to entering R36's room. Continued observation revealed Licensed Practical Nurse (LPN) 6 entered R36's bed space without donning PPE, including a gown and gloves. Per additional observation, LPN6 administered R36's insulin (medication given to reduce blood glucose level with a subcutaneous route) without donning gown or gloves. In an immediate interview, LPN6 stated she never wore PPE for insulin administration. She further stated she believed PPE was only required in contact precaution rooms when aides were providing incontinence care or helping a resident get dressed, and she was not expected to wear PPE when administering insulin. In an interview on 10/10/2024 at 11:14 AM, the 100 Unit Manager stated staff was to don PPE prior to entering a room for a resident in contact precautions, especially if the staff member came into direct contact with the resident. b. Observation on 10/11/2024 at 9:03 AM revealed State Tested Nurse Aide (STNA) 18 carried a food tray into R107's room without donning PPE. Per observation, she put the tray on R107's bedside table, exited the room, and applied hand sanitizer. Further observation revealed the sign on the door frame indicated for visitors to check at the nurse's desk. Additional observation revealed a container of PPE located to the right of the doorway had a sign on the top for contact precautions. In an interview on 10/11/2024 at 9:13 AM, STNA18 stated, When residents are in enhanced barrier precautions we do not need to put on PPE. If they are in contact precautions, we should put on PPE before bringing the tray into the room. Did I not do that? After the State Survey Agency (SSA) Surveyor told her she did not wear PPE and R107 was in contact precautions, STNA 18 responded, I am sorry. In an interview on 10/11/2024 at 9:09 AM, the 200 Unit Manager stated if a resident was in contact precautions, staff was required to don PPE for tray delivery and remove PPE before exiting the room. In an interview on 10/10/2024 at 4:12 PM, the Assistant Director of Nursing/Infection Preventionist stated she expected all nurses to don a gown and gloves prior to entering the resident room to administer insulin when the resident was in contact precautions. In an interview on 10/11/2024 at 10:58 AM the Director of Nursing (DON) stated he expected staff to don a gown and gloves prior to coming in contact with a resident in contact precautions, including for insulin administration. In an interview on 10/11/2024 at 9:37 AM, the Administrator stated staff were to don PPE, including gown and gloves, prior to entering a room of a resident in isolation.

Based on interview, record review, and review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, it was determined the facility failed to ensure the accuracy and completion of Section K of the Minimum Data Set (MDS) Assessment, for one (1) of twenty-five (25) sampled residents (Resident #94). Review of Resident #94's Quarterly MDS Assessment, dated 06/19/19, Section K0300, revealed the facility assessed the resident as not having a weight loss of ten percent (10%) or more in the last six (6) months; however, record review of the resident's weights revealed the resident sustained an 18% weight loss during the 180 day look back period between 12/06/19 and 06/04/19. In addition, review of Resident #94's Significant Change MDS Assessment, dated 07/17/19, Section K0300, revealed the facility assessed the resident as not having a weight loss of ten percent (10%) or more in the last six (6) months; however, record review of the resident's weights revealed the resident sustained a 15.50 % weight loss during the 180 day look back period between 01/02/19 and 07/02/19. The findings include: Review of the Centers for Medicare and Medicaid Resident Assessment Instrument (RAI) User Manual Version 3.0, dated October 2016, revealed the purpose of this manual is to offer clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care. Further review under section K, revealed for determining weight loss in 180 days, start with the resident's weight closest to 180 days ago and multiply by .90 (or 90%). The resulting figure represents a 10% loss from the weight 180 days ago. If the resident's current weight is equal to or less then the resulting figure, the resident has lost 10% or more body weight. Review of Resident #94's medical record revealed the facility admitted the resident on 07/18/16 with diagnoses including Epilepsy, Alzheimer's Disease, and Dysphagia. Review of the Resident #94's weights reveals the following: 07/02/19- 104.6 pounds 06/04/19- 103.0 pounds 05/03/19- 103.0 pounds 04/07/19- 115.2 pounds 03/18/19- 126.0 pounds 02/03/19- 121.0 pounds 01/11/19- 119.8 pounds 01/02/19- 123.8 pounds 01/01/19- 114.6 pounds 12/06/18- 125.6 pounds 11/02/18- 127.2 pounds Review of Resident #94's Quarterly MDS Assessment, dated 06/19/19, Section K0300, revealed the facility assessed the resident as not having a weight loss of five (5) percent (5%) in the last month or a weight loss of ten percent (10%) or more in the last six (6) months. However, per record review the resident weighed 125.6 pounds on 12/06/18 and weighed 103 pounds on 06/04/19. This would be an 18% weight loss in six (6) months during the 180 day look back period between 12/06/19 and 06/04/19. Review of Resident #94's Significant Change MDS Assessment, dated 07/17/19, Section K0300, revealed the facility assessed the resident as not having a weight loss of five (5) percent (5%) in the last month or a weight loss of ten percent (10%) or more in the last six (6) months. However, per record review the resident weighed 123.8 pounds on 01/02/19 and weighed 104.6 pounds on 07/02/19. This would be a 15.50 % weight loss in the last six (6) months during the 180 day look back period between 01/02/19 and 07/02/19. Interview with the MDS Nurse, on 08/15/19 at 4:15 PM, revealed she did not complete the Nutrition section of the MDS Assessments as the Registered Dietician was responsible for completing section K. Per interview, it was her expectation all sections of the MDS Assessments be completed accurately in order to get a true picture of the residents. Interview with the Registered Dietician (RD), on 08/15/19 04:34 PM, revealed she didn't mark the resident as sustaining a weight loss for the MDS Assessments dated 06/19/19 and 07/17/19. Per interview, this was because the RAI manual was vague in explaining how to complete section K, and therefore she used her clinical judgement when completing the MDS Assessments. The RD admitted to not receiving any formal education related to completing the MDS Assessments. Interview with the Director of Nursing (DON), on 08/15/19 at 5:48 PM, revealed she was not an expert on the MDS Assessments and relied on staff to complete all sections of the MDS Assessments accurately. Interview with the Administrator, on 08/15/19 at 6:18 PM, revealed she thought the RD was completing the MDS Assessments accurately according to the guidelines.

Based on observation, interview, and record review, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible. Observation on 08/13/19 and 08/14/19, revealed an opened tube of Ammonium Lactate Cream 12% ( moisturizer for dry itchy skin) and an opened tube of Remedy Antifungal Cream 2% (Miconazole Nitrate) on the bedside table in Resident #46's room accessible to residents and visitors. In addition, staff interviews revealed Resident #17 was confused and ambulatory and wandered into and out of resident rooms. The findings include: Review of the facility's Medication Storage Policy, dated 08/2018, revealed medications and biologicals, including treatment items, are securely stored in a secured locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. Review of Resident #46's clinical revealed the facility admitted the resident on 05/23/19 with diagnosis to include Major Depression, Chronic Pain, Type 2 Diabetes, and Dementia. Review of Resident #13's Annual Minimum Data Set (MDS) Assessment, dated 05/10/19, revealed the facility assessed the resident as having a Brief Interview for mental Status (BIMS) of a thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Observation on 08/13/19 at 11:49 AM, of Resident #46's room, revealed an opened tube of Ammonium Lactate Cream 12% ( moisturizer for dry itchy skin) and an opened tube of Remedy Antifungal Cream 2% (Miconazole Nitrate) on the bedside table. Interview with Resident #46, at the time of observation, revealed the tubes were kept on the table and the nurse would put the medication on his/her feet. Observation on 08/14/19 at 8:15 AM, of Resident #46's room revealed the opened tube of Ammonium Lactate Cream 12% ( moisturizer for dry itchy skin) and the opened tube of Remedy Antifungal Cream 2% (Miconazole Nitrate) remained ion the resident's bedside table. Review of Resident #46 Monthly August Physician's orders, revealed an order with an original date of 05/23/19 for Ammonium Lactate Cream 12%, apply to feet and legs topically every day and night shift related to congenital ichthyosis; and an order for Remedy Antifungal Cream 2% (Miconazole Nitrate), apply to buttocks topically every day and night for excoriation. However, there were no Physician's Orders regarding self-administration of the medication. Review of the Safety Data Sheet for Ammonium Lactate 12% Moisturizing Lotion revealed this was an eye irritant, as well as required contact with a physician or Poison Control Center if the lotion was ingested. Review of the Safety Data Sheet for Miconazole revealed it could be harmful if swallowed, and if ingested contact a physician or Poison Center if ingested. Interview with Licensed Practical Nurse (LPN) #4, on 08/15/19 at 3:32 PM, revealed all topical medications were to be locked in a cabinet or medication/treatment cart including ointments because wandering residents could get hold of the medication which would be a safety issue. Interview with LPN #5, on 08/15/19 3:32 PM, revealed nurses were to ensure medications, creams, and ointments were locked in the medication or treatment carts or locked in the medication room and not accessible to confused residents. Interview with Licensed Practical Nurse (LPN) #4, on 08/15/19 at 3:32 PM, revealed all topical medications were to be locked in a cabinet or medication/treatment cart including ointments because wandering residents could get hold of the medication which would be a safety issue. Interview with LPN #5, on 08/15/19 3:32 PM, revealed nurses were to ensure medications, creams, and ointments were locked in the medication or treatment carts or locked in the medication room and not accessible to confused residents. Interview on 08/15/19 at 3:33 PM, with State Registered Nurse Aide (SRNA #5), revealed Resident #17 wandered into other peoples rooms. When questioned related to medication storage, SRNA #5 stated resident medications should not be kept at bedside, and all medications should be locked up for the safety of the residents. Further interview revealed if she saw any medications including medicated lotions or creams, she would report it to the nurse right away. Interview on 08/15/19 at 3:45 PM, with SRNA #6, revealed she had seen Resident #17 who was confused and could ambulate, wander into and out of other residents' rooms. Further interview revealed medications should be stored in the medication cart or treatment cart, and should only be stored in a resident's room if the medication was locked in a cabinet. She further stated medications should never be sitting out in open, as any confused resident could take the medications. Interview on 08/15/19 at 3:54 PM, with Licensed Practical Nurse (LPN) #3, revealed Unit 1 did have one (1) confused resident who would go into other residents' rooms which was Resident #17. When questioned about medications being left out in a resident's room, she stated medications should be locked in the medication cart, treatment cart, or medication room and should not be stored out in the open at bedside. Per interview, this was because there were wandering residents who may consume the medication. Interview on 08/15/19 at 4:03 PM, with the Director of Nursing (DON), revealed Resident #17 was a wanderer on the first floor and primarily wandered in the hallways; however, sometimes he/she did go into other residents' rooms. She stated all medications should be secured and not left at the bedside. Per interview, any medicated ointments or lotions should be locked in the treatment cart. Further interview revealed it was important to keep all medications secure so that residents did not have access to the medications. Further, it was her expectation staff lock up medications on the treatment cart. Interview with the Administrator, on 08/15/19 6:07 PM, revealed it was her expectation staff follow the policy regarding medication storage for the safety of the residents.

Based on interview and record review, it was determined the facility failed to ensure drug irregularities reported by Pharmacy were acted on for one (1) of twenty-five (25) sampled residents (Resident #94). Resident #94 was prescribed Lorazepam (antianxiety medication) PRN (as needed) on 03/18/19 with no end date; however, there was no documented rationale for extending the medication beyond fourteen (14) days nor was there documentation stating the duration for the PRN order. On 04/19/19, the Physician responded to the Consultation Report from Pharmacy documenting the duration was indefinite and the rationale was hospice patient. On 06/03/19, the Consultation Report from the Pharmacist Consultant stated the SOM (State Operations Manual) required a duration of therapy even for hospice patients and indefinite was not allowed per CMS (Centers for Medicare and Medicaid) guidelines. However, there was no indication of the Physician's choice to either accept, decline, or modify the recommendations. This Report was not signed or dated by the Physician and there was no documented evidence the facility acted on this recommendation. Resident #94's Physician's Order for the PRN Lorazepam continued until 08/07/19 without an acceptable duration for the order. (Refer to F-758) The findings include: Review of the facility Pharmacy-Medical Record and Medication Regimen Review Policy, revised 10/2017, revealed medical record and and Medication Regimen Reviews (MRR) are performed monthly by the Consultant Pharmacist and the Pharmacist provides potential recommendations to the Physician/Prescriber for each resident's medication regimen. The Physician/Prescriber should either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. The MRR recommendations are given to the Director of Nursing (DON) on a monthly basis. The Pharmacist will address copies of resident's MRRs to the Attending Physician and the Medical Director. The DON gives recommendations to the Physician/Prescriber to review. The Physician reviews recommendations completes, signs and dates the form. If Physician/Prescriber rejects recommendations they need to document rationale and return to the DON. If recommendations are not completed within sixty (60) days, the Consultant Pharmacist will re-issue the recommendation or DON/designee will contact Physician for review and completion. The facility should alert the Medical Director where MRRs are not addressed by the Attending Physician in a timely manner. Review of the facility's Psychotropic-Anti-psychotic Medication Management Policy, revised 10/2017, revealed PRN orders for psychotropic drugs are limited to fourteen (14) days. Per Policy, except as provided in § 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond the 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of Resident #94's clinical record revealed the facility admitted the resident on 07/18/16 with diagnoses including Alzheimer's Disease, Anxiety and Depression. Review of Resident #94's Physician's Orders, dated 03/18/19, revealed orders for Lorazepam Concentrate 2 Milligrams (MG) /Milliliter (ML), give 0.25 ML sublingually every three (3) hours PRN for Anxiety or Dyspnea AND Give 0.5 ML sublingually every three (3) hours PRN for Anxiety or Dyspnea AND Give 1.0 ML sublingually every three (3) hours PRN for Anxiety or Dyspnea. The medication end date was listed at indefinite and there was no documented evidence of a rationale for extending the medication past fourteen (14) days. Review of Resident #94's Consultation Report from the Consultant Pharmacist, dated 04/09/19, revealed the resident had a PRN order for an anxiolytic, without a stop date: Lorazepam Intensol 0.5 mg - 1 mg-2 mg every three (3) hours as needed for anxiety. Additional review revealed, Please discontinue PRN Lorazepam Intensol. If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy and the extended time period. The Physician replied the duration was indefinite and the rationale was hospice patient. This Report was signed and dated by the Physician on 04/19/19. Review of Resident #94's Consultation Report from Pharmacy, dated 06/03/19, revealed the resident had a PRN order for an anxiolytic, without a stop date: Lorazepam Intensol 0.5 mg - 1 mg-2 mg every three (3) hours as needed for anxiety. Continued review revealed a recommendation stating in all CAPITAL letters, SOM requires a duration of therapy even for hospice patients and indefinite is not allowed per CMS guidelines. In the Physician's Response, there was no indication of the Physician's choice to either accept, decline, or modify the recommendations. This Report was not signed or dated by the Physician. Review of Resident #94's Consultation Report from Pharmacy, dated 08/05/19, revealed the resident had a PRN order for an anxiolytic, without a stop date: Lorazepam Intensol 0.5 mg - 1 mg-2 mg every three (3) hours PRN for anxiety. Additional review revealed a recommendation stating in all CAPITAL letters, SOM requires a duration of therapy even for hospice patients and indefinite is not allowed per CMS guidelines. Continued review of the Physician's Orders revealed orders to discontinue Lorazepam PRN on 08/07/19. Interview with the Consultant Pharmacist, on 08/15/19 at 2:52 PM, revealed he reissued recommendations that had not been acted upon. He stated he sent a Consultation Report to Resident #94's Physician on 04/09/19 asking for documentation related to the indication for use, the intended duration of therapy and the extended time period for the Lorazepam PRN if the medication could not be discontinued. Per interview, the Physician replied he wanted the medication ordered indefinitely because the resident was hospice. Interview further revealed he informed the Physician through a Consultation Report dated 06/03/19, a duration of indefinite was not allowed per CMS guidelines, but he did not receive a response from the Physician. He stated he sent another Consultation Report to Resident #94's Physician on 08/05/19, again reminding the Physician of the need for a duration for the PRN medication. Interview with the Director of Nursing (DON), on 08/15/19 at 5:55 PM, revealed she acknowledged PRN anti-anxiety medications were limited to fourteen (14) days or if the Provider wanted to extend the duration of the medication, the Provider would need to document the rationale in the resident's medical record and also indicate the duration for the PRN order as per the facility Policy. Further, it was her expectation the Physician acknowledge and respond to the Consultation Reports from Pharmacy. Post survey interview with the DON, on 08/29/19 11:47 PM, revealed she received the Pharmacy Consultation Reports and she reviewed the reports before placing them in the Physician's Binder at the nurse's station or in the medical record as per the Prescriber's preference. She stated she checked the Physician's Binder and the medical records three (3) times per week to ensure the Physician/Prescriber had acted on the recommendations. Further interview revealed she was unsure why Resident #94's Pharmacy recommendation dated 06/03/19 related to Lorazepam PRN was not acted on by the facility. Interview with the Administrator, on 08/15/19 at 06:11 PM, revealed it was her expectation the facility follow Policy and regulations related to PRN psychotropic medications. Further, it was her expectation drug irregularities reported from Pharmacy were acted on by the facility.

Based on interview and record review, it was determined the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to fourteen (14) days, unless the Physician documents the rationale for extending the order and documents the duration of the PRN order for one (1) of twenty-five (25) sampled residents (Resident #94). Resident #94 was prescribed Lorazepam (antianxiety medication) PRN on 03/18/19 with no end date; however, there was no documented evidence of the rationale for extending the medication beyond fourteen (14) days nor was there documented evidence of the duration for the PRN order. On 04/19/19, the Physician responded to the Consultation Report from Pharmacy stating the duration was indefinite and the rationale was hospice patient. However, indefinite was not an acceptable duration for the PRN order. There was no further duration for the medication documented after subsequent requests from pharmacy. The Physician's Order for the PRN Lorazepam continued until 08/07/19. (Refer to F-756) The findings include: Review of the facility's Psychotropic-Anti-psychotic Medication Management Policy, revised 10/2017, revealed PRN orders for psychotropic drugs are limited to fourteen (14) days. Per Policy, except as provided in § 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond the 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of Resident #94's medical record revealed the facility admitted the resident on 07/18/16 with diagnoses including Alzheimer's Disease, Anxiety and Depression. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/19/19, revealed the facility assessed the resident as having both short and long term memory loss. Review of Section N, Medications, revealed Resident #94 had received one (1) antianxiety medication during the seven (7) day look back period. Review of the Physician's Orders dated 03/18/19, revealed orders for Lorazepam Concentrate 2 Milligrams (MG) /Milliliter (ML), give 0.25 ML sublingually every three (3) hours PRN for Anxiety or Dyspnea AND Give 0.5 ML sublingually every three (3) hours PRN for Anxiety or Dyspnea AND Give 1.0 ML sublingually every three (3) hours PRN for Anxiety or Dyspnea. The medication end date was listed at indefinite and there was no documented rationale for extending the medication past fourteen (14) days. Review of Resident #94's Consultation Report from Pharmacy, dated 04/09/19, revealed a comment stating the resident had a PRN order for an anxiolytic, without a stop date: Lorazapem Intensol 0.5 mg - 1 mg-2 mg every three (3) hours as needed for anxiety. Further review revealed a recommendation stating, Please discontinue PRN Lorazepam Intensol. If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy and the extended time period. The Physician replied stating the duration was indefinite and the rationale as hospice patient. The Report was signed and dated by the Physician on 04/19/19. Review of Resident #94's Consultation Report from Pharmacy, dated 06/03/19, revealed a comment stating, the resident has a PRN order for an anxiolytic, without a stop date: Lorazepam Intensol 0.5 mg - 1 mg-2 mg every three (3) hours as needed for anxiety. Further review revealed a recommendation stating in all CAPITAL letters, SOM (State Operations Manual) requires a duration of therapy even for hospice patients and indefinite is not allowed per CMS guidelines. In the Physician's Response, there were was no indication of the Physician's choice to accept, decline, or modify the recommendations. The Report was not signed or dated by the Physician. Review of the Consultation Report from Pharmacy, dated 08/05/19, revealed a comment stating, Resident #94 has a PRN order for an anxiolytic, without a stop date: Lorazepam Intensol 0.5 mg - 1 mg-2 mg every three (3) hours as needed for anxiety. Further review revealed a recommendation stating in all CAPITAL letters, SOM requires a duration of therapy even for hospice patients and indefinite is not allowed per CMS guidelines. In the Physician's Response, there were was no indication of the Physician's choice to accept, decline, or modify the recommendations. The Report was not signed or dated by the Physician. Further review of the Physician's Orders revealed orders to discontinue Lorazepam PRN on 08/07/19. Interview on 08/15/19 at 2:52 PM, with the Consultant Pharmacist, revealed he sent a Consultation Report to Resident #94's Physician on 04/09/19 requesting documentation related to the indication for use, the intended duration of therapy and the extended time period for the Lorazepam PRN if the medication could not be discontinued. He further stated the Physician replied he wanted the medication ordered indefinitely because the resident was hospice. Further, he informed the Physician through a Consultation Report dated 06/03/19, a duration of indefinite was not allowed per CMS guidelines, but he did not receive a response from the Physician. Per interview, he sent another Consultation Report to Resident #94's Physician on 08/05/19, again reminding the Physician of the need for a duration for the PRN medication. Interview with the Director of Nursing (DON), on 08/15/19 at 5:55 PM, revealed she acknowledged PRN anti-anxiety medications were limited to fourteen (14) days or if the Provider wanted to extend the duration of the medication, the Provider would need to document the rationale in the resident's medical record and indicate the duration for the PRN order as per facility Policy. Per interview, it was her expectation the facility policy be followed related to PRN psychotropic medications. Interview with Administrator, on 08/15/19 at 06:11 PM, revealed it was her expectation the facility follow facility Policy and regulations related to PRN psychotropic medications.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure proper storage of drugs and biologicals for one (1) of twenty-five (25) sampled residents (Resident #46). Observation on 08/13/19 and 08/14/19, revealed Resident #46 had an opened tube of Ammonium Lactate Cream 12% ( moisturizer for dry itchy skin) and an opened tube of Remedy Antifungal Cream 2% (Miconazole Nitrate) on the bedside table in his/her room. The findings include: Review of the facility's Medication Storage Policy, dated 08/2018, revealed medications and biologicals including treatment items are securely stored in a secured locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. Review of Resident #46's medical record revealed the facility admitted the resident on 05/23/19 with diagnoses to include Major Depression, Chronic Pain, Type 2 Diabetes, and Dementia. The facility assessed Resident #13, in an Annual Minimum Data Set (MDS) Assessment, dated 05/10/19, as having a Brief Interview for Mental Status (BIMS) of a thirteen (13) out of fifteen (15) indicating the resident was cognitively intact. Observation on 08/13/19 at 11:49 AM, revealed an opened tube of Ammonium Lactate Cream 12% ( moisturizer for dry itchy skin) and an opened tube of Remedy Antifungal Cream 2% (Miconazole Nitrate)on the bedside table in Resident #46's room. Interview with Resident #46, on 08/13/19 at 11:49 AM, revealed the tubes were kept on the table and the nurse would put the medication on his/her feet. Observation on 08/14/19 at 8:15 AM, of Resident #46's room, revealed the opened tube of Ammonium Lactate Cream 12% ( moisturizer for dry itchy skin) and the opened tube of Remedy Antifungal Cream 2% (Miconazole Nitrate) was still on the resident's bedside table. Review of Resident #46 Monthly August Physician's orders, revealed a current order with an original date of 05/23/19 for Ammonium Lactate Cream 12%, apply to feet and legs topically every day and night shift related to congenital ichthyosis; and an order for Remedy Antifungal Cream 2% (Miconazole Nitrate), apply to buttocks topically every day and night for excoriation. However, there were no orders regarding self-administration of the medication. Review of the Safety Data Sheet (SDS) for Ammonium Lactate 12% Moisturizing Lotion, revealed this product was an eye irritant, as well as required contact with a physician or Poison Control Center if the lotion was ingested. Review of the SDS for Miconazole, revealed it could be harmful if swallowed, and to contact a physician or Poison Center if ingested. Interview with Licensed Practical Nurse (LPN) #4, on 08/15/19 at 3:32 PM, revealed all topical medications were to be locked in a cabinet or medication/treatment cart including ointments. Per interview, it was important to keep all medications locked and inaccessible to residents and visitors. Interview with LPN #5, on 08/15/19 3:32 PM, revealed nurses were to ensure medications, creams, and ointments were locked in the medication or treatment carts or locked in the medication room. Per interview, leaving topical medications, or any medications accessible to confused residents created the potential for danger as the medications could be ingested. Interview 08/15/19 04:09 PM, with the Director of Nursing (DON), revealed, We wouldn't want opened tubes of medication kept at the bedside. We have kept resident's medication in their locked drawer in the past, but current practice is to lock up the medications in the medication cart. The DON further stated unlocked medication could be hazardous to residents and it was her expectation staff lock up any medication. Interview with the Administrator, on 08/15/19 6:07 PM, revealed if the resident did not have an order to keep medications or medicated creams at the bedside, then the medication should be kept in the medication cart. Per interview, it was her expectation staff follow the facility policy regarding medication storage.

Based on observation, interview, and review of facility policy, it was determined the facility failed to prepare and serve food under sanitary conditions. Observation on 08/14/19 of the second floor Unit 2 dining room, revealed Dietary Aide #5 held four (4) saucer plates against her clothing and put her ungloved thumb and other fingers into the middle and over the rim of the saucers prior to placing the saucers into the middle of the table. In addition, observation on 08/14/19, revealed Dietary Staff #4 was wearing gloves while talking on a cell phone and did not wash hands and change gloves after putting the phone away and prior to continuing to work in the kitchenette. Furthermore, observation of the second floor kitchenette on 08/14/19, revealed Dietary Aide #1 was working during tray service from 5:08 PM to 6:15 PM, without wearing a beard net to cover his beard. Dietary #1 was also observed to use gloved hands to pull up and readjust his scrub top; however, failed to wash hands and don new gloves prior to continuing to work in the kitchenette. The findings include: Review of the facility Policy titled Meal Service, dated 02/2017, revealed hands are washed and gloves changed if the Dietary Aide touches any unclean surface. Staff are to serve meals using proper handling techniques while preventing contact of eating surfaces with staff's clothing. Review of the facility Policy, titled Dress Code dated 08/2016, revealed hair and beard nets were to be worn by kitchen staff and serving staff. Review of the facility policy titled Cell Phone Use dated 08/2016; revealed personal cell phones are not to be used while on the clock. Cell phones are used in designated areas, break room or outside the facility. Review of the facility Policy, titled Hand Hygiene dated 04/2017, revealed all team members will follow hand hygiene guidelines to reduce the incidence of health care associated infections. Ensure Hand hygiene after removing gloves. Observation on 08/14/19 at 2:20 PM, of the second floor Unit 2 dining room, revealed Dietary staff was setting up tables for dinner service. Dietary Aide #5 held four (4) saucer plates against her clothing and put her ungloved thumb and other fingers into the middle and over the rim of the saucers prior to placing the saucers into the middle of the table. Observation on 08/14/19 at 5:20 PM, of Dietary staff setting up the second floor kitchenette, revealed Dietary Staff #4 was wearing gloves while talking on a cell phone and did not change his gloves or wash his hands after putting the phone away and prior to continue working in the kitchenette. Also, observation of the second floor kitchenette on 08/14/19 at 5:20 PM, revealed Dietary Aide #1 was working during tray service from 5:08 PM to 6:15 PM, without wearing a beard net to cover his beard. Dietary #1 was also observed to use gloved hands to pull up and readjust his scrub top. However, the Dietary Aide failed to wash hands and don new gloves prior to continuing to work in the kitchenette after adjusting his clothes. Interview on 08/15/19 at 1:40 PM, with Dietary Aide #1, revealed he did not always wear his beard net when working with food or working in the kitchenette. However, he stated beard nets should be worn to prevent hair from getting into residents' food and to prevent cross contamination. Further interview revealed he should have washed his hands after adjusting his clothes while working during tray service. Interview on 08/15/19 at 1:49 PM, with the Chef, revealed cell phones were not allowed during meal service. Per interview, staff hairnets and beard nets were to be worn at all times to prevent cross contamination. The Chef stated Dietary staff should have washed hands after touching their clothes and the cell phone. Further interview revealed dishware should be handled properly and not held against clothing and ungloved fingers should not touch the plates to be served in order to prevent cross contamination. Interview on 08/15/19 at 2:42 PM, with the Director of Nursing (DON), revealed there was an infection control issue if staff used the cell phone and then failed to wash hands and don new gloves prior to continuing to serve food. Further, if staff adjusted their own clothing, they were to wash hands prior to continuing to work with serving food. Continued interview revealed plates or saucers should not be held against clothing and ungloved hands should not touch the plates or saucers. Additional interview revealed staff should wear beard nets when working in the kitchenettes to prevent hair from falling into food. Interview on 08/15/19 at 3:00 PM, with the Administrator, revealed staff was to wear beard nets in the kitchen and kitchenettes to prevent cross contamination. Further, if staff touched objects such as the phone or their own clothing, they should wash hands, and don new gloves before working in the kitchenettes or with food. Continued interview revealed dietary staff should take the cart to each table, instead of carrying saucer or dishware against their clothing to prevent cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility Policy, it was determined the facility failed to ensure it's medication error rates are not five (5) percent or greater. Observation of medication pass on 7/18/18, revealed twenty-eight (28) medication opportunities with eight (8) medication errors resulting in a medication error rate of 28.5 percent. Observation of medication administration for Resident #470, on 07/18/19, revealed medications were given via Percutaneous Endoscopic Gastrostomy Tube (PEG tube) without water flushes in between medications for eight (8) medications. The findings include: Review of the facility Medication Administration Via Gastric/Jejunostomy Tubes Policy, revised 02/2012, revealed tubing was to be flushed before and after medications were given using thirty (30) to sixty (60) milliliters (ml) of water and multiple medications to be given at the same time should be given individually and flushed individually. Review of Resident #470's medical record revealed the facility admitted the resident on 07/09/18, with diagnoses of Unspecified Mood Disorder, Post Traumatic Stress Disorder, Hypokalemia, Mixed Incontinence, Other Symptoms Involving the Musculoskeletal System, and Dysphagia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be severely cognitively impaired and unable to be interviewed for a Brief Interview for Mental Status Score. Review of Resident #470's Physician's Orders dated July 2018, revealed orders to crush the resident's medications and to administer medications including Culturelle, Duloxetine, Digoxin, Folic Acid, Seroquel, Ranitidine, Alprazolam and Potassium Chloride via Peg-Tube. (A PEG/Percutaneous Endoscopic Gastrostomy is an endoscopic medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) Observation on 7/18/18 starting at 10:45 AM, revealed Licensed Practical Nurse (LPN) #1 checked the Medication Administration record (MAR) and retrieved Culturelle Capsule, probiotic supplement (probiotic supplement) from the medication cart; took the medication to Resident #470's room; dissolved the medication in thirty (30) ml's of water; and then administered the medication to Resident #470 per PEG tube after checking for placement of the tube. However, the nurse failed to flush the resident's PEG tube with water after administration of the medication. Further observation revealed LPN #1 then went back to the medication cart in the hallway and retrieved Duloxetine 60 milligram capsule (antidepressant medication); brought the medication back into the resident's room; opened the capsule and mixed it with thirty (30) ml's of water; and administered the medication per PEG tube. However, the nurse failed to flush the resident's PEG tube with water after administration of the medication. Continued observation revealed LPN #1 then went back to the medication cart in the hallway and retrieved Digoxin 0.25 mg tablet (medication used to treat Atrial Fibrillation, an abnormal heart rhythm); crushed the medication, and placed it in a cup. The nurse brought the cup of crushed medication back into the resident's room; added thirty (30) mls of water to the cup; and administered the medication via the resident's PEG tube. However, the nurse failed to flush the resident's PEG tube with water after administration of the medication. Additional observation revealed LPN #1 then went back to the medication cart in the hallway and retrieved Folic Acid one (1) mg (a vitamin to treat Iron Deficiency Anemia) two (2) tablets; crushed the tablets; then brought the cup of medication back to the room and dissolved the medication in thirty (30) ml of water. The nurse then administered the medication via the PEG tube. However, the nurse failed to flush the resident's PEG tube with water after administration of the medication. Further observation revealed LPN #1 then went back to the medication cart in the hallway and retrieved Seroquel (antipsychotic) twenty-five (25) milligrams, one (1) tablet and crushed the tablet. She then brought the cup of crushed medication back to the room and dissolved the medication in thirty (30) mls of water and administered the medication via the PEG tube. However, the nurse failed to flush the resident's PEG tube with water after administration of the medication. Interview with LPN #1, on 07/18/18 at 11:00 AM, revealed normal procedure for giving medications through a PEG tube would be to take all crushed medications in the resident room at the same time and then dissolve the medications in individual cups prior to administering the medications. Upon prompts for further procedures related to medication administration, LPN #1 could not name anything else she would do differently related to administration of medication via PEG tube. Continued observation on 7/18/18 at 11:05 AM, revealed LPN #1 retrieved Resident #470's medication from the medication cart including Alprazolam (anti-anxiety medication) 0.5 mg - two (2) tablets; Ranitidine (antacid) 150 mg; and Potassium chloride (for Hypokalemia) 20 mg/15 milliliters (ml) liquid which she measured for a dose of 7.5 ml. The nurse crushed the Alprazolam and placed the medication in a cup, then crushed the Ranitidine and placed the medication in a separate cup, and then returned to the resident's room. Once in the resident's room, LPN #1 mixed thirty (30) mls of water in the medication cup with the Alprazolam and also mixed 30 mls of water in the medication cup with the Ranitidine. She then administered the Alprazolam and next the Ranitidine through the PEG tube, but failed to flush the PEG tube with water between administration of the Alprazolam and Ranitidine and failed to flush the PEG after administering the medications. LPN #1 then proceeded to dilute the Potassium Chloride with eight (8) ounces of water and administered it through the PEG tube. The PEG tube was flushed with sixty (60) mls of water after the Potassium Chloride. Interview with LPN #1, on 7/18/18 at 3:30 PM, revealed per facility policy and also per standards of practice, when administering medication through a PEG tube, the tube should be flushed with water after each medication unless there was Physician's orders not to flush with water between medications. Continued interview revealed it was important to flush the PEG tube after each medication was administered to make sure the full amount of medication was given and to ensure the tube did not get occluded. Per interview, LPN #1 had been employed by the facility for ten (10) months and had received training on medication administration through a PEG tube. Interview with LPN #1's Unit Manager, on 7/19/19 at 11:20 AM, revealed nursing staff was to flush PEG tubes with water after administration of each individual medication. Per interview, this was important for the absorption of medication and to make sure the medication did not get clumped up in the tube. Per interview, there may be times when there was not as many residents on the unit with PEG tubes and therefore the nurses may not be as familiar with administration of the medication per PEG tube. Continued interview revealed the Corporate Educator was available for any staff member who needed assistance with skills. Interview with Director of Nursing (DON), on 7/19/19 at 11:30 AM, revealed it was her expectation nursing staff performed water flushes after administration of each medication through PEG tubes per policy and nursing standards. Per interview, the flushes were important to ensure the tube was patent and to ensure full administration of the medication. Continued interview revealed this skill was part of the annual competency for nurses. Interview with the Administrator, on 7/19/19 at 11:35 AM, revealed staff was to follow policies and procedures related to administration of medications. Continued interview revealed policies were developed to ensure staff delivered medications through proper procedure. Per interview, this was important for the safety and well being of the resident. Continued interview revealed this skill was an annual competency for the nursing staff.