Based on observation, interview, review of the website https://www.accessdata.fda.gov, and review of the facility's policy, the facility failed to ensure all drugs used in the facility were labeled in accordance with professional standards and used prior to the expiration date for 2 of 7 medication carts, C1 Hall and C2 Hall Medication Carts. The findings include: Review of the facility's policy titled, Storage of Medications, revised date 11/2023, revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. In addition, the policy stated some drugs had a shelf life that was different from the expiration date after opening (i.e. insulin). Per the policy, those drugs shall be labeled with the date opened to ensure that no outdated or deteriorated drugs were stored. Review of the website https://www.accessdata.fda.gov under Instructions for Use, for a Novolog insulin vial, revised 12/2012, revealed opened Novolog vials should be thrown away after 28 days, even if they still have insulin left in them. 1. Observation on 10/16/2024 at 2:50 PM revealed the medication cart, located on C1 Hall, contained a multi-dose vial of Novolog insulin, which was opened on 09/10/2024 and had exceeded the 28 day use date by eight days. This insulin was still in the medication cart and available for use. Further observation revealed the cart contained the following medications that were opened and not dated: Pro-Air multi-use inhaler (rapid relief inhaler); guaifenesin syrup (expectorant); and milk of magnesia (laxative). 2. Observation on 10/17/2024 at 8:22 AM revealed the medication cart, located on C2 Hall, contained an unopened epinephrine pen (medication and hormone used to treat an allergic reaction) which expired in 07/2024. During an interview on 10/17/2024 at 8:22 AM with an agency nurse, Licensed Practical Nurse (LPN) 12, she stated she would question how effective the epinephrine pen would be since it had expired. She stated it was the responsibility of the nurse to verify that the medications should be checked and used before the expiration date and to replace them as needed. During an interview on 10/16/2024 at 3:10 PM with LPN6, she stated the risk of giving expired medications could be that they would not be as effective. She stated it was the nurse's responsibility to ensure medications given were not past the expiration date, to obtain refills as needed, and to place the opened date on the label of the medication. She also stated without identifying the date opened, it would be difficult to determine if the medication was still appropriate to use. During an interview on 10/16/2024 at 3:35 PM, a pharmacist with the facility's contracted pharmacy stated it was possible that any medication given past its expiration date could decrease the effectiveness and adversely affect the resident. During an interview on 10/17/2024 at 3:29 PM with the Assistant Director of Nursing (ADON), she stated it was the responsibility of the nurse and Unit Coordinator to monitor the carts for expired medications. She stated she expected all nursing staff to add an opened date to any medication that had the potential to be used more than once. During an interview on 10/18/2024 at 9:27 AM with the Administrator, she stated she expected the nursing staff to always follow the facility's policies.

Based on observation, interview, and review of the facility's policy, the facility failed to serve hot food at a proper and palatable temperature. Observation of the test tray on 10/16/2024 revealed the scrambled eggs were 114 degrees Fahrenheit (F) and tasted warm for 3 of 25 sampled residents (Resident (R) 43, R59, and R66). The findings include: Review of the facility's policy titled, Food Temperatures at Point of Service, not dated, revealed the food temperatures at the point of service included the dining room and room tray, which shall meet the palatability requirement of the resident community. Per the policy, hot foods would be served as hot as safely possible to meet the palatability requirement of the resident community. Observation revealed the breakfast test tray for the 200 Unit arrived on 10/16/2024 at 8:27 AM. Test tray results on 10/16/2024 at 8:39 AM, revealed oatmeal was at 153 degrees (F), scrambled eggs were at 114 degrees (F), milk was at 47 degrees (F), and Orange Juice (OJ) was at 40 degrees (F). The milk and OJ were cold and tasted cold; the oatmeal was hot and tasted hot; the scrambled eggs tasted room temperature and did not taste warm; and the hot plate was room temperature to the touch. In an interview with the Dietary Manager on 10/16/2024 at 8:30 AM, he stated the plates were placed in the warmer. Review of the facility's form Dietary Meal Temperature Log revealed the beginning food temperature for scrambled eggs was 172 degrees (F) at 7:30 AM and at 8:15 AM was 170 degrees (F). In an interview with R59 on 10/14/2024 at 3:00 PM, he stated the food tasted bad and cold. He stated he asked for food to be warmed, staff became frustrated, and he ate cold food. In an interview with the Dietary Supervisor on 10/17/2024 at 2:27 PM, he stated the plates were turned on for warming after the cook entered the kitchen. He stated, if the plates were not all heated in the warmer, they would not stay hot, and the scrambled eggs would not be acceptable to the residents. In an interview with the Dietary Manager on 10/17/2024 at 2:43 PM, he stated the plates were stacked high in the warmer and not hot. He stated the scrambled eggs were not hot and would not taste good to the residents. In an interview with the Assistant Director of Nursing (ADON) on 10/17/2024 at 3:30 PM, she stated she expected food to be served at the proper standard temperature. In an interview with the Administrator on 10/17/2024 at 3:50 PM, she stated if the resident's hot food was cold, the staff would provide a new tray.

2. Observation on 10/16/2024 at 2:29 PM revealed two used breakfast trays and one used lunch tray left in the C Unit/COVID kitchenette on the sink against the pump of the thickened liquids container. Review of the facility's form Tray Cart Times, not dated, revealed Breakfast was at 8:30 AM and Lunch was at 12:30 PM. In an interview with State Trained Nurse Aide (STNA) 18 from the C Unit on 10/18/2024 at 8:34 AM, she stated she called dietary for a cart to load the trays into. She stated the soiled trays were not placed in the kitchenette to prevent cross-contamination. In an interview with the C Unit Supervisor, who was also LPN1, on 10/18/2024 at 9:44 AM, she stated the tray cart was not available for late trays. She stated staff called the kitchen and asked for a tray cart for the C Unit. She stated staff placed used trays into the kitchenette until the tray cart returned. She stated soiled trays were picked up after meals. She stated there was possibly an infection control concern about storing soiled trays and dishes in the kitchenette. In an interview with the ADON on 10/18/2024 at 9:52 AM, she stated the tray cart was not available for trays of residents who got up late. She stated some residents took longer to eat than others. She stated staff placed these used trays in the kitchenette. She stated dietary staff cleared out the soiled trays, and patient care took priority over the trays with floor staff. She stated there was no problem with cross-contamination because the food was contained in packages in the kitchenette. She stated floor staff would call dietary staff for the trays to be picked up. In an interview with the Dietary Manager on 10/18/2024 at 9:58 AM, he stated floor staff called dietary for a tray cart. He stated the Dietary Aide, after the last cart went back to the main dining room, was responsible for bringing the used/soiled trays back. He stated there was no concern because the kitchenette was not a food prep area, and the food was prepackaged. In an interview with the Administrator on 10/18/2024 at 10:12 AM, she stated used/soiled trays were put in the kitchenette, and staff called the kitchen to pick up the extra trays. She stated there was no cross-contamination issue or concern. She stated some residents took longer to eat or wake up and had trays from a meal after the tray cart was returned to the kitchen. She stated there usually were not more than three trays left after meals, and dietary checked often to see if there were any to pick up. Based on observation, interview, record review, and review of the facility's policies, the facility failed to identify and correct problems related to infection prevention practices for 2 out of 25 sampled residents (Resident (R) 73 and R35). This failure placed the residents at increased risk for healthcare-associated infections (HAI). In addition, observation revealed two used breakfast trays and one used lunch tray left on the sink against the pump of thickened liquids container in the C Unit/COVID Unit kitchenette. The findings include: Review of the facility's policy titled, Medication Administration, revised 11/2023, revealed the individual administering medications would follow the infection control procedures including hand hygiene, aseptic technique, and isolation precautions during the administration of medications. Review of the facility's policy titled, General Infection Control, revised 03/2024, revealed all staff was expected to perform hand hygiene before and after resident contact, after removing gloves or other personal protective equipment (PPE), before eating, drinking, or handling food, and whenever hands became visibly soiled. 1. a. Observation of medication administration by Licensed Practical Nurse (LPN) 12 on 10/15/2024 at 8:09 AM revealed she did not wash or otherwise disinfect her hands and did not apply gloves before administering medications, including eye drops, to R73. LPN12 also had an opened bottle of iced coffee on the top of her medication cart. During an interview on 10/15/2024 at 8:12 AM with LPN12, she stated the hand sanitizer on her cart would be an appropriate method of cleaning her hands between residents and gloves would have been appropriate for the administration of eye drops. b. Observation on 10/15/2024 at 8:13 AM revealed Activity Assistant (AA) 2 assisted R73 with her breakfast tray. AA2 had not washed or otherwise sanitized her hands, nor did she wear gloves. AA2 then picked up bacon and toast with her bare hands and made a sandwich for R73 to eat. During an interview with AA2 at the time of observation, she stated she should have washed her hands and used gloves before handling the resident's food, and she was in a hurry and was not paying attention. c. Observation of medication administration on 10/15/2024 at 8:15 AM by LPN12 revealed she failed to wash or otherwise disinfect her hands before administering medications to R35. During an interview on 10/17/2024 at 3:29 PM with the Assistant Director of Nursing (ADON), she stated she expected nursing staff to use alcohol based hand sanitizer between residents' medication administration, unless hands were visibly soiled, and then to use soap and water. During an interview on 10/18/2024 at 9:27 AM with the Administrator, she stated she was not clinical, but she expected the nursing staff to follow the facility's policies and the directions of the Director of Nursing (DON).

Based on the observation, interview, and record review, the facility failed to store food safely. Observation on 10/14/2024, during the initial kitchen tour, revealed the refrigeration storage log was incomplete for eight out of 14 days. The findings include: Review of the facility's document Monthly Temperature Logs, revealed it was used to record daily temperatures for the refrigerator, freezer, and dry storage. Further review revealed a notation on the bottom of the document which stated, Please notify Food Service Director if proper temperature is not held in any unit; Fridge 32-41 F [Fahrenheit]; Freezer-Below 0 F; and Dry Storage 50-70 F. Observation on 10/14/2024 at 4:30 PM, during the initial kitchen tour, revealed the posted Monthly Temperature Log, dated 10/2024, for refrigeration equipment revealed the dates for 10/01/2024, 10/02/2024, 10/03/2024, 10/04/2024 and 10/07/2024 were documented. However, no refrigeration equipment temperatures were documented for 10/05/2024, 10/06/2024, 10/08/2024, 10/09/2024, 10/10/2024, 10/11/2024, 10/12/2024, and 10/13/2024. In an interview with the Dietary Supervisor on 10/17/2024 at 2:27 PM, he stated it was important to ensure food was at the proper temperature to prevent the growth of bacteria. He stated equipment temperatures were recorded to ensure they were working properly. In an interview with the Dietary Director on 10/17/2024 at 2:43 PM, he stated the Dietary Supervisor covered many shifts and forgot to record the equipment temperature on the temperature log. He stated it was important to check the temperatures to ensure equipment was working properly because if they were not, the food could thaw and refreeze, and the food quality could change, allowing bacteria to grow. In an interview with the Assistant Director of Nursing (ADON) on 10/17/2024 at 3:30 PM, she stated there was a potential for spoilage of food if the refrigeration equipment was not working properly. In an interview with the Administrator on 10/17/2024 at 3:50 PM, she stated she expected refrigeration/freezer equipment temperatures to be taken and documented to ensure the equipment worked properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to revise the Comprehensive Care Plan (CCP) for one (1) of forty-seven (47) sampled residents (Resident #141). Per record review and staff interview, staff witnessed Resident # 141 outside in front of the building unaccompanied by staff on 05/31/19. After the event, the facility implemented an intervention for a Wander Guard; however, the facility failed to revise the CCP to reflect the event that occurred on 05/31/19 and to reflect the intervention for the Wander Guard. The findings include: Review of the facility's Elopement Policy and Procedures revised 11/2018, revealed it is the responsibility of all personnel to report any resident attempting to leave the premises or suspect of being missing to the charge nurse immediately. Further, a resident who wanders out of the facility door and remains on the grounds/premises should not be considered an elopement. The charge nurse and supervisor will assure that all interventions are in place and that an elopement assessment is done and care plan updated. Review of the facility's Care Planning-Interdisciplinary Team Policy, dated 05/08/19, revealed the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized Comprehensive Care Plan for each resident. Additionally, a Comprehensive Care Plan should be updated on an ongoing basis as changes in the resident's treatment plan and preferences for care occur. Per Policy, the interventions will be available to direct care staff via the resident's Care Plan or [NAME]. Review of Resident #141's clinical record revealed the facility admitted the resident on 10/23/18 with multiple diagnoses including, but not limited to Unspecified Dementia with Behavioral Disturbance, Cognitive Communication Deficit, Symptoms and signs Involving cognitive Functions and Awareness, and Age-Related Physical Debility. Review of Resident #141 Progress Note, dated 5/31/19 at 3:30 PM, revealed the resident was outside in front of the building unaccompanied by staff. Per the Note, staff brought the resident back inside the facility, and notified the Physician and the resident's Power of Attorney (POA) of the event. Continued review of the Note, revealed staff placed a Wander Guard on Resident #141 to alert staff by the sound of an alarm, if the resident attempted to exit the facility without staff's assistance. Review of Resident #141's Treatment Administration Record (TAR), dated 05/31/19 at 7:00 PM, revealed staff placed a Wander Guard on the resident's ankle as an intervention to help alert staff when the resident attempted to exit the facility doors. Additionally, there was an intervention on the TAR, for the Certified Nurse Assistants (CNAs) to monitor the Wander Guard every shift, both day and night to ensure it was in place to assist with keeping the resident from leaving the facility. Review of Resident #141's Comprehensive Care Plan (CCP), initiated 10/22/19, revealed a focus of alteration in thought processes related to Dementia. The goals stated the resident would accept others decisions and cooperate with care and would be calm in secure environment with safety maintained. The interventions included assess for internal/external contributors to delirium, and praise positive behavior and watch for signs of increasing anxiety and/or agitation. However, there was no documented evidence the CCP was revised to indicate staff placed a Wander Guard as an elopement intervention to help alert staff when the resident was attempting to exit the facility doors. Interview with Licensed Practical Nurse (LPN) # 1, on 07/24/19 at 9:58 AM, revealed Resident # 141 had exiting seeking behaviors and had to be redirected and monitored when up and about in the facility. LPN #1 further stated Resident #141 exited the facility through the front doors and staff returned him/her back inside. Continued interview revealed after this event a Wander Guard was placed on the resident to alert staff by the sound of an alarm if the resident attempted to exit the doors unattended. LPN #1 stated the CCP should have been updated with the Wander Guard intervention. Interview on 07/25/19 at 3:45 PM, with the Director of Nursing (DON), revealed she did not find any documented evidence Resident #141's CCP was updated/revised to reflect the resident exited the building on 05/31/29 or to reflect the interventions put in place regarding the Wander Guard on 05/31/19. Further interview revealed it was her expectation Resident #141's CCP was revised according to policy. Per interview, a possible outcome of failure to revise the CCP could be failure to effectively monitor and maintain the resident's safety and implement care needs.

Based on interview and record review, it was determined the facility failed to ensure the Ombudsman was notified of transfers from the facility to acute care settings for two (2) of thirty (30) sampled residents (Resident #3 and Resident #98). Resident #3 and Resident #98 were transferred to acute care facilities without notification to the Ombudsman. The findings include: Review of the facility's policy titled, Emergency Transfer to Hospital, revised 11/28/17, revealed when necessary to meet the needs of the resident, the facility will assist the resident with emergency transfer or a hospital or related institution. A List of emergency hospital transfers will be sent to the State Ombudsman on a monthly basis. Review of a facility spreadsheet- Acute Care Transfers, undated, revealed although Residents #3 and #98 were listed on the spreadsheet, there was no documented evidence or verification an email or other notification was sent to notify the Ombudsman of the acute care transfers. 1. Review of Resident #3's medical record revealed the facility admitted the resident on 01/25/17 with diagnoses to include: Chronic Obstructive Pulmonary Disease, Heart Disease, Peripheral Vascular Disease, Chronic Ulcer of the Right Ankle, Non-pressure Chronic Ulcer of the Right Heel and Midfoot, Cognitive Communication Deficit, Anxiety Disorder, Cerebral Infarction, and Major Depressive Disorder. Continued review revealed the facility transferred Resident #3 to an acute care setting on 02/11/18 for evaluation and treatment of Hypoxia. Further review revealed there was no documented evidence the Ombudsman was notified of the transfer. 2. Review of Resident #98's medical record revealed the facility admitted the resident on 07/18/17 with diagnoses to include: Parkinson's Disease, Dementia, Non-Pressure Chronic Ulcer of the Buttock, and Major Depressive Disorder. Continued review revealed the facility transferred Resident #98 to an acute care setting on 05/26/18 for evaluation and treatment of abdominal distention. Further review revealed there was no documented evidence the Ombudsman was notified of the transfer. Interview with the Ombudsman, on 06/14/18 at 3:10 PM, revealed the Ombudsman had not received notification of an acute care transfer for Resident #3 in February 2018 or Resident #98 in May 2018. She further stated the Administrator had called her on 06/14/18, to confirm she had received the notifications. The Ombudsman stated, she told the Administrator no acute care notifications were received for the February transfer of Resident #3 nor for the May transfer for Resident #98. Interview with the Director of Nursing, on 06/14/18 at 4:00 PM, revealed the facility should send notification to the Ombudsman of all resident transfers and discharges. Further interview revealed the facility computer system was not operating correctly and she could not retrieve the email sent to the Ombudsman to verify the acute care transfer notifications for Resident #3 and Resident #98.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility's policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to meet the resident's medical needs for one (1) of thirty (30) sampled residents (Resident #3). The facility failed to develop and implement a Comprehensive Care Plan that included prosthetic management interventions to meet Resident #3's medical needs including specific interventions for applying the left leg prosthesis. On 05/17/18, Resident #3's prosthesis was applied incorrectly by a State Tested Nurse Assistant (STNA) to the left Below the Knee Amputation (BKA) site and as a result the resident suffered a wound to the site. Refer to (F-696) The findings include: Review of the facility policy titled, Care Planning-Interdisciplinary Team , revealed the Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident based on the comprehensive assessment. Further review revealed the care plan will be update on an ongoing basis as changes in the resident's treatment plan and preferences for care occur. Review of the Tips for Donning Prosthesis, undated, revealed: 1) skin check was to be done prior to residual limb donning; 2) if bandages, skin tears, or bruising were noted on the residual limb, do not apply the prosthesis and notify the patient's nurse; 3) make sure socket/liner was rubber side out prior to donning (should not be able to see the screw); 4) place the rubber liner/socket onto the end of the residual limb and roll up, white section of socket/liner needs to be centered on top of the leg; 5) the prosthetic leg slides over liner/socket, must hear clicks, if no clicks are heard, the prosthetic leg will fall off; 6) easier to don prosthetic leg in a sitting position as the patient can assist with pushing the leg down to secure fit/hear clicks; 7) once sit to stand transfer was performed, further clicks may be herd indicating more secure fit; 8) always remove prosthesis before bedtime by pressing metal release button and rolling liner/socket off the residual limb 9) when skin integrity was intact, recommend use of prosthesis during all patient transfers to maximize the patient's independence. Review of Resident #3's clinical record revealed the facility admitted the resident on 01/25/17 with diagnoses to include: Cognitive Communication Deficit, Anxiety Disorder, Cerebral Infarction due to Embolism of Left Cerebellar Artery, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Heart Disease, Peripheral Vascular Disease (PVD), Non-Pressure Chronic Ulcer of Right Ankle with Fat layer Exposed, Non Pressure Chronic Ulcer of Right Heel and Midfoot Limited to Breakdown of Skin, and Left Below the Knee Amputation (BKA). Review of Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a five (5) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assist of two (2) staff for transfers; as ambulation not occurring; and as having a limb prosthesis. Review of Resident #3's Visual/Bedside [NAME] Report undated, revealed no information related to Resident #3 having a prosthesis, nor did it provide guidance for application of Resident #3's prosthesis. Interview with the DON, on 06/13/18 at 3:11 PM, revealed this was the Care Plan utilized by State Registered Nursing Assistants (SRNAs) to provide resident care. Review of the Comprehensive Care Plan initiated 10/07/16, with no revision date, revealed Resident #3 had Activities of Daily Living (ADLs) deficit related to left leg Below the Knee Amputation (BKA) cognitive impairment, and debility. The Care Plan goal stated the resident would have maximized independence with ADLs. There were several interventions including extensive assist of one (1) to two (2) with bed mobility, and transfers; and left leg prosthesis due to BKA- use with stump shrinker when out of bed as resident will allow. Further review of the Comprehensive Care Plan initiated 10/07/16, with no revision date, revealed Resident #3 was at risk for impaired skin integrity related to disease process and PVD. The Care Plan goal stated the resident would have no avoidable skin breakdown. There were several interventions including ok to use prosthetic leg with stump shrinker when out of bed, and geri leg to right leg as resident will allow. However, there was no specific guidance for application of Resident #3's prosthesis, or specific guidelines related to who was allowed to apply a prosthesis. Additional review revealed there was no documented evidence Resident #3's person centered comprehensive care plan addressed the safe and correct application or removal of the prosthetic device. Review of the Incident Report, titled, #5817 Skin Tear dated 05/17/18 at 8:11 AM, completed by Licensed Practical Nurse (LPN) #3, revealed the nurse was called to Resident #3's room to assess a wound that occurred when a new nursing assistant incorrectly applied a prosthetic sleeve inside out causing a skin tear on the end of the stump. Per the Report, the Skin tear measured 2.0 centimeters (cm) x 0.5 cm, and the area was cleansed with Normal Saline and Xeroform Guaze and dressing applied. The report revealed there was notification to the family representative and Nurse Practitioner on 05/17/18. Review of Resident #3's Progress Note, dated 05/18/18 at 9:30 AM, revealed a late entry follow up note completed by the Unit Manager. The Note stated a STNA attempted to incorrectly place Resident #3's prosthesis causing a skin tear to the resident's stump, and the area was assessed by the charge nurse. Per the Note, the resident was dependent on staff to don/doff prosthesis. Continued review revealed the Provider was notified and nursing staff were re-educated by therapy staff on the correct application of a prosthesis. Review of Resident #3's Visit Report, Wound Specialists, dated 06/04/18, revealed wound #21 on the left amputation site revealed a full thickness wound without exposed support structure. The wound was described as having no granulation in the wound bed with a large amount of necrotic tissues within the wound. The recommendations for wound care included application of Santyl to the wound with daily dressing changes. Interview on 06/12/18 at 3:59 PM, with Resident #3's daughter, revealed the resident incurred the wound on 05/17/18 when an untrained nursing assistant incorrectly placed the prosthesis. She stated the prosthesis was applied to the resident's leg with a screw protruding which resulted in the leg wound and consequently, the inability of the resident to wear the prosthesis. She further stated the staff did not know how to apply the prosthesis and the resulting wound caused decreased mobility. Interview with Licensed Practical Nurse (LPN) #8 on 06/13/18 at 9:52 AM, revealed Resident #3's prosthesis was applied incorrectly on 05/17/18, by a STNA orientee, who was no longer employed by the facility. She stated due to the prosthesis being applied incorrectly, the resident sustained a wound to the left lower extremity. She further stated she was not involved in the incident as she was not assigned to the resident at the time, but she was assigned to the resident frequently and the wound was progressing with daily dressing changes. LPN #8 revealed Resident #3 was not currently wearing the prosthesis because the wound had not yet completely healed. Per interview, currently Resident #3 was a two (2) person transfer with a gait belt based on the resident's instability when transferring on one (1) leg Observation of a wound assessment conducted by LPN #3, for Resident #3 on 06/13/18 at 10:58 AM, revealed the wound at the distal end of the left leg below the knee amputation which was scabbed over in approximately a dime sized area. There was no drainage or slough present and surrounding skin was pink. The nurse cleansed the wound with Normal Saline (NS), dressed the wound with a gauze pad, and elevated the resident's leg on a pillow. Interview with SRNA #3, on 06/13/18 at 3:04 PM, revealed she was orienting STNA #4/orientee at the time Resident #3's prosthesis was applied incorrectly. SRNA #3 revealed STNA #4 had been working at the facility for one (1) week, and this was her first time working with the new orientee as a preceptor. SRNA #3 further stated she and STNA #4/orientee entered the Resident #3's room, and then SRNA #3 left the room to get additional linens. Per interview, she had not attempted to apply nor asked STNA #4/orientee to apply the resident's prosthesis prior to exiting the room. Further interview revealed when she returned to the room and saw STNA #4 applying the resident's prosthesis incorrectly, she stopped her, checked the resident's leg, and notified LPN #3 of the newly acquired wound. Per interview, STNA #4 was new and had not received training or guidance on how to provide prosthetic care for residents. On 06/13/18 at 3:37 PM, a Phone call was made by the State Agency Representative in an attempt to interview STNA #4/orientee responsible for the incorrect application of Resident #3's prosthesis. STNA #4/orientee answered the phone, and stated she no longer worked at the facility, could not recall any residents or care at the facility, and hung up. Interview with LPN #3, on 06/13/18 at 10:34 AM, revealed she was notified by SRNA #3 on 05/17/18, that STNA #4/orientee incorrectly applied the prosthesis to Resident #3. She stated SRNA #3 informed her of the incident and the resulting wound from the prosthetic screw that punctured the skin when STNA #4/orientee incorrectly applied the prosthesis. LPN #3 further stated she checked the resident, provided the necessary immediate care, and notified a family member as well as the Advanced Registered Nurse Practitioner (ARNP) on 05/17/18. Per interview, when she saw the wound on 05/17/18, it looked like a skin tear without a flap, and she cleansed the wound with Normal Saline and applied Xeroform gauze to the wound. Further interview revealed she had continued to care for the wound and the wound was healing slowly. She stated Resident #3 was currently not wearing the prosthetic limb while the wound healed. Interview on 06/13/18 at 2:17 PM, with the Unit Manager, revealed STNA #4 who applied Resident #3's prosthetic incorrectly causing the wound on 05/17/18, was a new trainee who had been working for approximately one (1) week. Per interview, STNA #4/orientee had not received any training in application of a prosthesis prior to the incident. Per interview, Resident #3 now required more assistance to transfer because of balance challenges when using only one (1) leg. Interview on 06/13/18 at 3:11 PM, and post survey phone interview on 06/28/18 at 2:30 PM, with the Director of Nursing (DON), revealed Resident #3's wound from the prosthesis application occurred when a newly hired nursing assistant (STNA #4) who had not been trained by the facility in prosthesis application, incorrectly applied the prosthetic leg to Resident #3. Per interview, STNA #4/orientee applied the prosthetic with the screw protruding outward resulting in a puncture wound to the amputation site. The DON stated STNA #4 was still in training and had not yet received education on how to apply Resident #3's prosthesis and should not have attempted to apply the prosthesis herself. Further interview with the DON, revealed the Comprehensive Care Plan was to be developed from the comprehensive assessment by the Interdisciplinary Team, and was a guide for staff in providing care for the residents. The DON revealed the facility had not developed Resident #3's Comprehensive Care Plan with step by step instructions on how to apply the prosthesis, or how to otherwise manage the prosthesis; however, she stated every prosthesis was individualized for each resident and staff needed to be aware of residents' goals and preferences, to wear and be able to use the prosthetic device and how to safely apply and remove the device. Continued interview with the DON, revealed the Visual/Bedside [NAME] Report which was computerized from the Comprehensive care Plan, was a guide for the SRNAs/STNAs in providing care and SRNAs/STNAs were to review this [NAME] before providing care for the residents. The DON stated Resident #3's [NAME] Report did not have did not have individualized instructions on how to don the prosthesis or provide care and medical management for his/her prosthesis. Post survey phone interview on 06/28/18 at 2:30 PM, with the Administrator, revealed the Comprehensive Care Plan was to have specific interventions to address the residents' wants, needs, choices and preferences as well as interventions for clinical/medical management. He further stated it was important for the Care Plan to be specific in order for the care team to be on the same page. Per interview, Resident #3's Comprehensive Care Plan as well as the [NAME] Report utilized by the Nurse Aides should have had specific instructions related to the care and management of the resident's prosthesis, information regarding donning and removing the prosthesis, and instructions not to attempt to don or remove the prosthesis without training. The Administrator stated STNA #4 should not have attempted to apply Resident #3's prosthesis without being educated on how to properly apply the prosthesis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure that a resident who has a prosthesis is provided care and assistance, consistent with standards of practice for one (1) of thirty (30) sampled residents (Resident #3). On 05/17/18, Resident #3 sustained a wound to the left Below the Knee Amputation (BKA) site as a result of incorrect application of a prosthesis. (Refer to F-656) The findings include: Interview on 06/13/18 at 3:11 PM, with the Director of Nursing (DON), revealed she was not aware of a facility policy regarding application of a prosthesis; however, guidelines were important for staff to ensure the highest functionality for residents. The DON provided information titled, Tips for Donning Prosthesis. Review of the Tips for Donning Prosthesis, undated, revealed: 1) skin check was to be done prior to residual limb donning; 2) if bandages, skin tears, or bruising were noted on the residual limb, do not apply the prosthesis and notify the patient's nurse; 3) make sure socket/liner was rubber side out prior to donning (should not be able to see the screw); 4) place the rubber liner/socket onto the end of the residual limb and roll up, white section of socket/liner needs to be centered on top of the leg; 5) the prosthetic leg slides over liner/socket, must hear clicks, if no clicks are heard, the prosthetic leg will fall off; 6) easier to don prosthetic leg in a sitting position as the patient can assist with pushing the leg down to secure fit/hear clicks; 7) once sit to stand transfer was performed, further clicks may be herd indicating more secure fit; 8) always remove prosthesis before bedtime by pressing metal release button and rolling liner/socket off the residual limb 9) when skin integrity was intact, recommend use of prosthesis during all patient transfers to maximize the patient's independence. Continued review revealed there was no guidelines related to who could apply a prosthesis, or related to the need for training prior to applying a prosthesis. Review of the facility Orientation Sheet for State Tested Nurse Assistant, revision date 04/18/14, revealed no training topic for application of prosthetics. Review of Resident #3's medical record revealed the facility admitted the resident on 01/25/17 with diagnoses to include: Cognitive Communication Deficit, Anxiety Disorder, Cerebral Infarction due to Embolism of Left Cerebella Artery, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, Heart Disease, Peripheral Vascular Disease (PVD), Non-Pressure Chronic Ulcer of Right Ankle with Fat layer Exposed, Non Pressure Chronic Ulcer of Right Heel and Midfoot Limited to Breakdown of Skin, and Left Below the Knee Amputation (BKA). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a five (5) out of fifteen (15) indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assist of two (2) staff for transfers; as ambulation not occurring; and as having a limb prosthesis. Review of the Visual/Bedside [NAME] Report undated, revealed no information related to Resident #3 having a prosthesis, nor did it provide guidance for application of Resident #3's prosthesis. Interview with the DON, on 06/13/18 at 3:11 PM, revealed this was the Care Plan utilized by State Registered Nursing Assistants (SRNAs) to provide resident care. Review of Resident #3's Comprehensive Care Plan initiated 10/07/16, with no revision date, revealed the resident had Activities of Daily Living (ADLs) deficit related to left leg Below the Knee Amputation (BKA) cognitive impairment, and debility. The goal stated the resident would have maximized independence with ADLs. There were several interventions including extensive assist of one (1) to two (2) with bed mobility, and transfers; and left leg prosthesis due to BKA- use with stump shrinker when out of bed as resident will allow. Further review of Resident #3's Comprehensive Care Plan initiated 10/07/16, with no revision date, revealed the resident was at risk for impaired skin integrity related to disease process and PVD. The goal stated the resident would have no avoidable skin breakdown. There were several interventions including ok to use prosthetic leg with stump shrinker when out of bed, and geri leg to right leg as resident will allow. However, there was no specific guidance for the safe and correct application or removal of the prosthetic device or specific guidelines related to who was allowed to apply the prosthesis. Review of the Incident Report, titled, #5817 Skin Tear dated 05/17/18 at 8:11 AM, completed by Licensed Practical Nurse (LPN) #3, revealed the nurse was called into Resident #3's room to assess a wound that occurred when a new nursing assistant incorrectly applied a prosthetic sleeve inside out causing a skin tear on the end of the stump. Skin tear measured 2.0 centimeters (cm) x 0.5 cm. Area cleansed with Normal Saline and Xeroform Guaze and dressing applied. The report included notification of a family representative and Nurse Practitioner on 05/17/18. Review of Resident #3's Progress Notes, dated 05/18/18 at 9:30 AM, revealed a late entry follow up note entered by the Unit Manager. The Note stated a STNA attempted to incorrectly place Resident #3's prosthesis causing a skin tear to his/her stump. Area was assessed by charge nurse. Resident dependent on staff to don/doff prosthesis. Further review revealed the Provider was notified and nursing staff were re-educated by therapy staff on the correct application of a prosthesis. Review of Resident #3's Visit Report, Wound Specialists, dated 06/04/18, revealed wound #21 on the left amputation site was a full thickness wound without exposed support structure. The wound was described as having no granulation in the wound bed with a large amount of necrotic tissues within the wound. Recommendations for wound care included application of Santyl to the wound with daily dressing changes. Interview with Resident #3's daughter on 06/12/18 at 3:59 PM, revealed the resident incurred the wound on 05/17/18 when an untrained nursing assistant incorrectly placed the prosthesis. Per interview, the prosthesis was applied to the resident's leg with a screw protruding which resulted in the leg wound and consequently, the inability of the resident to wear the prosthesis. She stated the staff did not know how to apply the prosthesis and the resulting wound caused decreased mobility. Interview with Licensed Practical Nurse (LPN) #8 on 06/13/18 at 9:52 AM, revealed Resident #3's prosthesis was applied incorrectly on 05/17/18, by a STNA who was an orientee, and was no longer employed by the facility. Per interview, due to the prosthesis being applied incorrectly, the resident sustained a wound to the left lower extremity. She stated she was not involved in the incident as she was not assigned to the resident at the time, but she was assigned to the resident frequently and the wound was progressing with daily dressing changes. Per interview, Resident #3 was not currently wearing the prosthesis because the wound had not yet completely healed. LPN #8 further stated currently Resident #3 was a two (2) person transfer with a gait belt based on the resident's instability when transferring on one (1) leg. Observation of a wound assessment for Resident #3 on 06/13/18 at 10:58 AM, by Licensed Practical Nurse (LPN) #3, revealed the wound at the distal end of the left leg below the knee amputation was scabbed over in approximately a dime sized area. There was no drainage or slough present and the surrounding skin was pink. The nurse cleansed the wound with Normal Saline (NS), dressed the wound with a gauze pad, and elevated the resident's left leg on a pillow. Interview with SRNA #3, on 06/13/18 at 3:04 PM, revealed she was orienting STNA #4/orientee at the time Resident #3's prosthesis was incorrectly applied. SRNA #3 stated STNA #4 had been working at the facility for one (1) week, and this was her first time working with the new orientee as a preceptor. SRNA #3 stated she and STNA #4/orientee entered the Resident #3's room, and then SRNA #3 left the room to get additional linens. SRNA #3 stated she had not attempted to apply nor asked STNA #4/orientee to apply the resident's prosthesis prior to exiting the room. Per interview, when she returned to the room and saw STNA #4 applying the resident's prosthesis incorrectly, she stopped her, checked the resident's leg, and notified LPN #3 of the newly acquired wound. A Phone call was made on 06/13/18 at 3:37 PM, by the State Agency Representative in an attempt to interview STNA #4/orientee responsible for the incorrect application of Resident #3's prosthesis. When contacted by telephone, STNA #4/orientee revealed she no longer worked at the facility, could not recall any residents or care at the facility, and hung up. Interview with LPN #3, on 06/13/18 at 10:34 AM, revealed she was notified by SRNA #3 on 05/17/18, that STNA #4/orientee had incorrectly applied the prosthesis to Resident #3. Per interview, SRNA #3 informed her of the incident and the resulting wound from the prosthetic screw that punctured the skin when STNA #4/orientee incorrectly applied the prosthesis. LPN #3 stated she checked the resident, provided the necessary immediate care, and notified a family member on 05/17/18 at 9:23 AM as well as the Advanced Registered Nurse Practitioner (ARNP) on 05/17/18 at 10:23 AM. LPN #3 stated when she saw the wound on 05/17/18, it looked like a skin tear without a flap, and she cleansed the wound with Normal Saline and applied Xeroform gauze to the wound. LPN #3 further stated she had continued to care for the wound and the wound was healing slowly. Per interview, Resident #3 was currently not wearing the prosthetic limb while the wound healed. Interview on 06/13/18 at 2:17 PM, with the Unit Manager, revealed STNA #4 who applied Resident #3's prosthetic causing the wound was a new trainee who had been working for approximately one (1) week. Per interview, STNA #4/orientee had not received any training in application of a prosthesis at the time of the event. He further stated he did not discuss the event with STNA #4/orientee and she was no longer an employee at the facility. He further stated Resident #3 now required more assistance to transfer because of balance challenges when using only one (1) leg. Interview on 06/13/18 at 3:11 PM, and post survey phone interview on 06/28/18 at 2:30 PM, with the Director of Nursing (DON), revealed each time a resident received a new brace or prosthesis, therapy would inservice all SRNAs and nurses related to the prosthesis. She stated Resident #3's wound from the prosthesis application occurred when a newly hired nursing assistant (STNA #4) who had not been trained by the facility in prosthesis application, attempted to apply the prosthetic leg to Resident #3. Per interview, STNA #4/orientee applied the prosthetic with the screw protruding outward which resulted in a puncture wound to the amputation site. Further interview with the DON, revealed newly hired nursing assistants would receive classroom time if they were a brand new STNA, but if not would generally receive two (2) weeks of orientation on the units with a preceptor. Per interview, the training time was customized to each new staff member and could exceed two (2) weeks if opportunities were identified. She stated STNA #4/orientee was not a brand new STNA and did not receive classroom time, but was placed with a preceptor on the unit. She stated all STNAs were given a check off list of skills to be checked off by their preceptor when hired and were told not to attempt to independently care for the resident themselves. The DON stated STNA #4 was still in training and had not yet received education on how to apply Resident #3's prosthesis. She stated STNA #4 should not have attempted to apply the resident's prosthesis before being trained related to how to correctly apply the prosthesis. Post survey phone interview on 06/28/18 at 2:30 PM, with the Administrator, revealed STNA #4 should have received instruction on how to apply Resident #3's prosthesis prior to attempting to apply the prosthesis herself. Per interview, it was important the facility have a system in place to ensure new staff were safe in providing care to prevent injury to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to ensure PRN (as needed) Physician's orders for psychotropic drugs were limited to fourteen (14) days unless renewed by the attending physician or prescribing practitioner with documentation for the rationale with indication of the duration for the PRN order in the resident's medical record for one (1) of thirty (30) sampled residents (Resident #54). Resident #54 was prescribed Ativan 0.5 milligrams (mg) three (3) times a day (tid) PRN on 04/14/18, which remained in effect through review date of 06/14/18. The findings include: Review of the facility Psychotropic Drugs Policy, effective 11/28/17, revealed PRN Psychotropic drugs are limited to fourteen (14) days. If the attending Physician or prescribing practitioner believes that is is appropriate for the PRN psychotropic drug order to be extended beyond fourteen (14) days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of Resident #54 medical record revealed the facility re-admitted the resident post hospitalization for psychiatric management on 04/13/18 with diagnoses to include Vascular Dementia Without Behavioral Disturbance, Alzheimer's Disease Unspecified, and Anxiety Disorder Unspecified. The facility assessed Resident #54, in a Quarterly Minimum Data Set (MDS) assessment dated [DATE], as having a Brief Interview for Mental Status (BIMS), of a five (5) out of fifteen (15) indicating severe cognitive impairment. Review of Resident #54's Physician's orders, revealed Telephone orders dated 04/14/18 for Ativan 0.5 mg tid PRN (anti-anxiety medication) prescribed by the resident's primary care provider, Physician #1. Review of Resident #54's Provider's Progress Notes dated 04/20/18, 05/04/18, and 05/25/18, signed by Advanced Registered Nurse Practitioner (APRN) #1, revealed recommendations for continuation of current psychiatric orders to include Ativan 0.5 mg tid PRN initiated on 04/14/18. Review of Resident #54's Medication Administration Record (MAR) dated April 2018, revealed Resident #54 received Ativan 0.5 mg PRN fourteen (14) times in April. Review of Resident #54's MAR dated May 2018, revealed the resident received Ativan 0.5 mg PRN three (3) times in May. Review of Resident #54's MAR dated June 2018, revealed the resident did not receive Ativan .5 mg PRN in June. Interview on 06/14/18 at 1:01 PM, with the Unit Manager on the Unit in which Resident #54 resided, revealed she was in charge of reviewing monthly orders and ensuring the diagnoses were correct and regulations were being followed. Per interview, in addition to her monthly review, the practitioner also reviewed psychotropic medications. She stated orders for PRN psychotropic medications were to be written for fourteen (14) days only and then were to be reviewed by the practitioner on or before the fourteenth day to evaluate if the medication should continue. She further stated in the case of Resident #54, the resident had a need for PRN Ativan prior to the psychiatric nurse practitioner (APRN #1) being available, so the order was placed through the primary care provider (Physician #1). She stated she should have caught the 0.5 mg Ativan tid PRN order for Resident #54 was not written for just fourteen (14) days and there was no re-evaluation by a practitioner for the continued need for the medication during her audits. Interview with APRN #1, on 06/14/18 at 4:24 PM, revealed Resident #54 was not stable when he/she returned to the facility from the hospital for psychiatric management, and needed an order prior to her being able to see Resident #54, and as a result the PRN order for Ativan 0.5 mg tid PRN was ordered through Physician #1. She stated she prescribed Resident #54 a low dose of Risperdal (antipsychotic medication), and the resident responded well to the medication. Per interview, the resident did not need the continued order for Ativan after the initial fourteen (14) days. Interview with Physician #1, on 06/14/18 at 5:00 PM, revealed it was his expectation staff contact him or the ARNP or whoever was on call at the end of a fourteen (14) day PRN psychotropic medication order to review and determine if the order needed to be renewed at that time. Interview with the Director of Nursing (DON), on 06/14/18 at 4:37 PM, revealed it was her expectation PRN psychotropic medication orders be written for only fourteen (14) days. She revealed there were continuous audits being done to check for this, and it should have been caught and corrected. Interview with the Administrator, on 06/14/18 at 4:34 PM, revealed psychotropic medications should be written for no longer than fourteen (14) days, and then the resident should be re-assessed at the end of the fourteen (14) days to determine if another order needed to be written for PRN psychotropic medications at that time.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure proper labeling of drugs and biologicals in accordance with currently accepted professional principles. Observation of the Unit A Short Hall Medication Cart, on 06/13/18 revealed one (1) opened twenty (20) milliliter (ml) bottle of Albuterol Sulfate Inhalation Solution five (5) milligrams (mg)/ml without the opened date written on the bottle; and one (1) opened multi-dose twenty (20) ml vial of Xylocaine HCL injection 1%, 200 mg/20 ml without the opened date written on the bottle. Also, observation of the Unit A Medication Storage Room, on 06/14/18, revealed one (1) opened vial of Tuberculin Purified Protein Derivative 5TU/0.1 ml, without the opened date written on the vial. The findings include: Review of the facility policy, titled Storage of Medications, dated 11/2017, revealed some drugs have a shelf life that is different than the expiration date after opening. These drugs shall be labeled with the date opened to ensure that no outdated or deteriorated drugs were stored. 1. Observation of the Unit A Short Hall Medication Cart, on 06/13/18 at 4:31 PM, revealed one (1) twenty (20) milliliter (ml) bottle of Albuterol Sulfate Inhalation Solution (five (5) milligrams (mg)/ml), which was open without the opened date written on the bottle, and one (1) multi-dose twenty (20) ml vial of Xylocaine HCL injection 1%, 200 mg/20 ml, which was open without the opened date written on the bottle. 2. Also, observation of the Unit A Medication Storage Room, on 06/14/18 at 12:48 PM, revealed one (1) vial of Tuberculin Purified Protein Derivative 5TU/0.1 ml, one (1) ml vial, with an expiration date of 10/2019, which was opened with one-fourth (1/4) of the vial remaining, with no opened date written on the vial. Interview with Licensed Practical Nurse (LPN) #5, on 06/13/18 at 4:44 PM, revealed when medications were opened, the opened date should be written on the bottle or vial. Additional interview revealed if a medication was not dated when opened, it was policy to discard that medication. She stated it was important to date medications when opened so as not to administer outdated/expired medications. Continued interview revealed night shift nurses usually checked for expiration dates of medications. Interview with LPN #6, on 06/13/18 at 5:12 PM, revealed it was all nurses' responsibility to date medications when they were opened, check for expiration dates, and remove medications when discontinued. Continued interview revealed it was important to date medications when opened so you know if they are safe to use and they are not outdated. Interview with LPN #7, on 06/14/18 at 12:51 PM, revealed nurses should write the date opened on medications when opened because some medications have a different expiration date after opening than what was listed by the manufacturer. She stated any liquid medication was good for thirty (30) days after they were opened. She further stated if she found a medication that had been opened, but not dated, she would discard the medication and call the pharmacy to reorder the medications. Per interview, there could possibly be a negative outcome from giving a medication that was outdated, such as the medication could be ineffective. LPN #7 stated it was the nurses' responsibility to check the expiration dates on medications in the storage room and medication carts and discard medications which were opened with no open date written on the bottle or vial. Continued interview revealed Unit Managers and/or the Director of Nursing (DON) performed audits monthly on medication carts and medication storage rooms. Interview with the Unit A Manager, on 06/14/18 at 2:02 PM, revealed nurses should be dating the bottles and vials of medication with the open date. She stated if nurses found medications that were opened and not dated with the open date, the medication could be used as long as it had not been over thirty (30) days since received from pharmacy. Per interview, the Pharmacist came to the facility monthly and checked the residents' medications and looked through the residents' charts and then signed off on a form in the chart that the medications had been reviewed. Continued interview revealed if the nurses found expired medications, they were responsible for sending the medications back to the pharmacy. Further interview revealed the supervisors audited the medication carts at times, maybe monthly, but the nurses checked the medication carts mainly because they were on the carts daily passing medications. Additional interview revealed the nurses were responsible for checking the medications in the medication storage rooms also for expired medications. Interview with the facility's Registered Pharmacist, on 06/14/18 at 3:36 PM, revealed her job was to review the charts and to evaluate for standards of practice. She stated she would recommend nurses use the manufacturer's expiration date of a medication unless the manufacturer mandated a shorter expiration date caused by the medication being opened. She further stated she would expect the nurses to date medications when opened. Additional interview with the Registered Pharmacist, revealed the pharmacy periodically went through the medication carts to check medication expiration dates, but mostly focused on any medications that contained shorter expiration dates like insulin and eye drops. She stated there was no scheduled time for pharmacy to check the medication carts, but the medication carts were checked more frequently when it was time for survey. She further stated she did not check all the carts with each visit. Per interview, she was in the building up to four (4) days per month. Further interview revealed if nurses had questions about expiration dates of medications, the pharmacy had a twenty-four (24)-hour phone line for them to call. She stated she occasionally provided inservices to staff regarding medication expiration dates, do not crush lists, and medication storage, with the last inservice being in March 2018. Interview with the DON, on 06/14/18 at 4:41 PM, revealed she would not want to give any medication that was expired. Continued interview revealed medication should be dated when opened because once opened, the manufacturer's expiration date may be compromised as some medications were only good for a certain amount of days once opened. Additional interview revealed if a medication was used after the expiration date, it could potentially be less effective. She stated it was her expectation that staff follow policies regarding medication storage. Interview with the Administrator, on 06/14/18 at 4:48 PM, revealed it was his expectation staff follow the facility policy related to medication storage to ensure efficacy and safety for in administration of medications.