Based on observation, interview, facility policy review, and review of manufacturer's instructions, the facility failed to ensure drugs and/or biologicals used in the facility were current for use and/or labeled in accordance with currently accepted professional principles, including the expiration date when applicable. A review of one medication storage room and one of two medication carts revealed that a Tuberculin vial stored in the medication storage room refrigerator was opened but not labeled with a date so as to calculate its discard date. The findings include: Review of a facility policy titled, Label/Store Drugs and Biologicals Standard of Practice, reviewed 10/2020, revealed drugs and biologicals must be labeled in accordance with currently accepted professional principles, including the expiration date when applicable. The policy further stated if a multi-dose vial was opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specified a different date for the specific vial. Observation on 04/04/2025 at 10:30 AM of the medication storage room on Hall 2 revealed a house stock multi-dose vial of Aplisol tuberculin 5TU/0.1milliliters (ml) that was opened but was not dated. Review of manufacturer guidelines from PAR Pharmaceuticals (the manufacturer listed on the box containing the vial) revealed that vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. During an interview with Licensed Practical Nurse (LPN) 2 on 04/04/2025 at 10:40 AM, she stated when vials were opened, they should be dated with the date opened and then should be discarded in 30 days. LPN2 stated since the vial was not dated, it should be discarded, adding that if it was used, it may not be as effective. During an interview with the Interim Director of Nursing/Regional Quality Manager (DON) on 04/04/2025 at 2:51 PM, she stated the expectation was that any vial or box be dated immediately upon opening, then it should be monitored for the appropriate discard date. She stated the drug may not be as effective and she would worry about infections, organisms, and growth. During an interview with the Administrator on 04/04/2025 at 3:21 PM, she stated she expected staff to follow facility policy to ensure proper protocols related to vials being dated when opened were followed, as the facility did not want to do things outside of the manufacturer's guidance.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for four (Resident (R)31, R37, R50, and R155). of 14 sampled residents. Staff failed to perform hand hygiene when indicated during wound care and medication administration, as well as clean multi-resident use equipment as indicated. The findings include: 1. Review of an undated facility policy titled, Hand Hygiene, revealed hand hygiene should be by using either handwashing, antiseptic hand wash, or antiseptic hand rub. and should be performed before and after glove use. The policy further stated gloves should be changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care. Record review of an admission Face Sheet revealed the facility admitted R50 on 02/06/2025 with diagnoses including an unstageable pressure ulcer of the right buttock and type 2 diabetes mellitus. An observation of wound care for R50's pressure ulcer of the right buttock was conducted with Licensed Practical Nurse (LPN) 2 on 04/04/2025 at 9:31 AM. LPN 2 donned gloves prior to performing wound care; however, she failed to perform hand hygiene after removing soiled gloves three separate times. During an interview with LPN 2 on 04/04/2025 at 11:30 AM, she stated she should have washed her hands between glove changes, indicating that this failure could have contaminated R50's wound. During an interview with the Infection Prevention (IP) Nurse on 04/04/2025 at 2;00 PM, she stated she expected staff to always wash their hands between glove changes. She stated handwashing and having precautions in place would help prevent infections and stop the spread of infections. During an interview with the interim Director of Nursing/Regional Quality Manager (DON) on 04/04/2025 at 2:51 PM, she stated she expected staff to follow handwashing guidelines and infection control guidelines and protocols for all care including wound care. She stated if the guidelines were not followed, it would increase the risk for infection and that would be her concern, adding R50's wound could have been contaminated. During an interview with the Administrator on 04/04/2025 at 3:21 PM, she stated she expected staff to perform proper handwashing because that is the best prevention of contamination. 2. Review of the facility policy titled, Medication Administration Standard of Practice, with a review date of 10/2020, revealed that staff shall follow established infection control procedures for the administration of medications, as applicable. a. Observation on 04/03/2025 at 8:20 AM revealed LPN1 preparing medications for R31. While removing R31's Calcium Carbonate/Vitamin D3 from the multi-dose blister card, the tablet fell onto the top of the medication cart. LPN1 then, with a bare hand, picked up the tablet and placed it into the medication cup for administration. Additionally, LPN1 removed a Clonazepam 1 milligram (mg) tablet from the multi-dose blister card into her bare hand and placed the tablet into the medication cup, then proceeded to administer it to R31. b. Continued observation of LPN1, while preparing medications on 04/03/2025 at 8:35 AM, revealed LPN1 dropped R155's 1/2 tablet of Entresto out of the multi-dose blister card onto the top of the medication cart. LPN1 then used a bare hand to place the tablet into the medication cup for R155. Ongoing observation revealed LPN1 also used a bare hand to place R155's Sinemet tablet into the medication cup. c. After administering medication to R31, LPN1 then returned to the medication cart. At 8:48 AM, LPN1 failed to perform hand hygiene and began to prepare medications for R37. In an interview with LPN1 on 04/03/25 at 9:01 AM, she stated she received one or two days of training as an LPN at the facility. LPN1 stated the top of the medication cart is wiped off at the start of the shift, but she probably should get another pill if one is dropped on the top of the medication cart when preparing medications. LPN1 related that hand hygiene would be important to do between residents to prevent the spread of infection. 3. Review of the facility policy titled, Policies and Practices - Infection Control, with a revision date of 10/ 2018, revealed that an objective of the infection control policies and practices are to provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. No policy that described the actual processes for cleaning of specific resident-care equipment was provided prior to exit from the facility. Observation revealed that during the medication pass for R155 which began on 04/03/2025 at 8:35 AM, LPN1 used a reusable electronic wrist blood pressure cuff to perform a blood pressure check for both R31 and R155 without cleaning the equipment between residents. In an interview with LPN1 on 04/03/25 at 9:01 AM, she stated the blood pressure cuff probably should be cleaned between residents but no one explained that. In an interview with the IP Nurse on 04/04/25 at 2:03 PM, she stated she would expect the nurses to complete hand hygiene and clean reusable equipment to prevent the spread of infection. The IP Nurse indicated that that in-services on handwashing are provided yearly and as needed, adding that nursing staff are educated on infection prevention during the quarterly nursing meetings. In an interview with the interim DON on 04/04/25 at 2:53 PM, she stated it was her expectation to follow handwashing and infection control and protocols for all tasks including wound care and medication administration. In an interview with the Administrator on 04/04/25 at 3:56 PM, she stated that it was her expectation for staff to follow infection control and prevention policies to prevent the spread of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents had assistive devices to maintain hearing abilities for one (1) of thirteen (13) sampled resident (Resident #34). The findings include: Review of a facility policy titled, Resident Rights, undated, revealed a resident had the right to a dignified existence, self-determination, and communication which included access to persons and services inside and outside the facility. Review of Resident #34's medical record revealed the facility admitted the resident on 10/13/2023, with diagnoses which included mild cognitive impairment of uncertain or unknown etiology; sensorineural hearing loss bilateral; and altered mental status, unspecified. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #34 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact and interviewable. Review of Resident #34's Comprehensive Care Plan revealed the facility care planned the resident for Communication on 01/13/2024, related to his/her diagnosis of sensorineural hearing loss, bilateral upon admission. Interventions included: allow adequate time for the resident to comprehend and respond when speaking, be aware/responsive to nonverbal communication such as facial gestures, moaning, pointing and eye movement, face resident when speaking, notify the medical director or responsible party of changes as needed, refer for audiology as needed, refer to speech therapy as needed, remove as much background noise as possible when speaking to the resident and speak near the resident, focus resident's attention, speak clearly and slowly, rephrase as indicated and ckeck for understanding. However, continued review revealed the facility had not implemented the care plan until 01/13/2024. The care plan was not implemented until after the State Surveyor interviewed Resident #34. Review of a audiology note for Resident #34 dated 12/07/2023, revealed hearing aids were not indicated for the resident. Continued review revealed however, a personal amplifier or a pocket talker amplifier could be ordered for the resident if requested. During an interview with Resident #34 on 01/13/2024 at 11:51 AM, he/she stated he/she could not hear well out of either ear. The resident stated he/she saw a doctor a while ago and was supposed to get hearing aides but had not heard anything else about them. Resident #34 did not state if he/she had questioned staff about hearing aids. During an interview with Certified Nursing Assistant (CNA) #8 on 01/14/2024 at 4:30 PM, she stated Resident #34 was hard of hearing and she had to speak louder to him/her because of that. CNA #8 further stated Resident #34 had no hearing devices she was aware of. During an interview with Licensed Practical Nurse (LPN) #2 on 01/14/2024 at 4:35 PM, she stated Resident #34 had trouble hearing which had worsened over the past few months. LPN #2 stated Resident #34 did not have any hearing devices; however, his/her brother had stated he was going to look into that for the resident. LPN #2 further stated Resident #34 would benefit from some type of hearing device so he/she could communicate easier. The LPN further stated she communicated with Resident #34 by standing right in front of him/her and ensuring the lighting was adequate, then spoke right into the resident's ear. In addition, LPN #2 stated she would even use pen/paper to communicate with the resident if needed. During an interview with the MDS Coordinator on 01/14/2024 at 10:00 AM, she stated she forgot to hit the sign option after reviewing a resident's care plan a lot of times. The MDS Coordinator stated there was no way to know a care plan had been reviewed if it had not been signed off on. She further stated, the facility was in the process of updating its Electronic Medical Records system to make the process easier for staff to follow and be more compliant During an interview with the Social Services Director (SSD) on 01/14/2024 at 10:12 AM, she stated she was responsible for following up after three hundred and sixty (360) Physician care visits which were an in house provided service, however, had not received the audiology visit note for Resident #34. The SSD stated once she received a visit note, she followed up and if recommendations had been made for a device she looked at the resident's coverage or what options the resident might have. The SSD stated she had not spoken to Resident #34 about his/her hearing because she was not aware the audiology note was complete but it was her responsibility to follow up on physician visit notes. She further stated if follow up was not done the resident's condition might worsen, and he/she could have trouble communicating and socializing with other residents, peers and family. The SSD stated Resident #34's audiology visit should have been followed up on and the recommendations made by the audiologist should have been checked to see if the services recommended would have been covered. During an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated she expected nursing to follow up on any Physician recommendations. She further stated the recommendations should also be followed up on during Interdisciplinary (IDT) meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents' grievances were thoroughly investigated to include a statement of findings with corrective actions taken for one (1) of thirteen (13) sampled residents (Resident #56). Review of a Grievance/Concern Form dated 10/14/2022, for Resident #56, revealed the grievance process was not implemented. The findings include: Review of the facility policy titled, Grievances Standard of Practice, revised 05/2020, revealed the residents and their family members might voice grievances in writing or verbally to the facility, or another entity that heard grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Per policy review, the facility was to make prompt efforts to resolve grievances. Continued review revealed the time frame that a resident would reasonably expect completion of the review of their grievance, and a written decision regarding his/her grievance, was to be within seventy-two (72) hours). Review further revealed with the Administrator's approval, the timeframe might be extended with communication to the resident, family or individual making the grievance. Closed record review for Resident #56 revealed the facility admitted the resident on 04/30/2020, with diagnoses to include Alzheimer's disease, unspecified; dementia in other diseases classified elsewhere with behavioral disturbance; and mood disorder due to known physiological condition with major depressive-like episode. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #56 to have a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) of fifteen (15) indicating the resident was severely cognitively impaired. Review of Resident #56's Care Plan titled, Impaired Bowel and Bladder Elimination, dated 06/15/2020, revealed the resident was at risk for impaired bowel and bladder elimination; incontinence of bowel and bladder frequently with impaired mobility; impaired cognition; and impaired communication. Continued review revealed the Care Plan included an intervention to provide and/or assist Resident #56 with incontinence care as needed. Review of a Grievance/Concern Form dated 10/14/2022, for Resident #56, revealed a family member of the resident had filed a grievance regarding him/her having been left soaked with urine, which included the sheet on his/her air mattress. However, further review of the Grievance/Concern Form revealed there was no documented evidence those concerns were ever investigated or had a resolution. Further review of the form revealed the Business Office Manager completed the grievance form and the Former Administrator completed the investigation and resolution sections of the form. During an interview with Resident #56's Family Members #4 and #5 on 01/10/2024 at 7:20 PM, they stated the resident was often soaked with urine when they visited and they thought it was due to the resident not being turned or changed as he/she should have been. Both Family Members #4 and #5 stated a grievance had been filed but nothing had ever changed. During an interview with the Social Services Director (SSD) on 01/14/2024 at 10:12 AM, she stated she was responsible for addressing grievances. The SSD stated the grievance made by Resident #56's family members should have been addressed and resolved; however, it did not look like that was ever done. The SSD further stated staff should have been re-educated and the issue should have been discussed with the Director of Nursing (DON). During an interview with the Former Administrator (FA) on 01/14/2024 at 1:40 PM, he stated he could not recall a grievance related to Resident #56 being left soiled or soaked in urine; however, if he signed off on the grievance then he must have seen it and would have been responsible for ensuring it was resolved completely. The FA stated he was responsible for signing off on the grievances as they were resolved. He stated if the issue regarding Resident #56 was not resolved, the resident could have more skin breakdown. The FA further stated if a concern was noted on a grievance form, then it should have been addressed and clinical staff re-educated on providing incontinent care. During an interview with the Director of Nursing (DON) on 01/15/2024 at 2:15 PM, she stated if there was a concern on the grievance, it should have been addressed and immediate correction made. During an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated she expected grievances to be investigated, completed, and resolved as soon as possible. The Administrator stated clinical staff should be re-educated on incontinent care and if that were not done, skin breakdown could occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure a care plan was developed to and implemented for two (2) of thirteen (13) sampled residents, Residents #34 and #44. The facility failed to develop Resident #44's care plan to include the resident's need for Hemodialysis. In addition, the facility failed to develop Resident #34's care plan to include his/her communication needs as the resident had a diagnosis of sensorineural hearing loss. The findings include: Review of the facility policy titled, Comprehensive Care Plans Standard of Practice dated 10/2020, revealed the policy's purpose was, for an individualized comprehensive care plan to be developed. Continued review revealed the individualized comprehensive care plan was to be developed to include measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs. 1. Review of Resident #44's medical record revealed the facility admitted the resident on 10/24/2022, with diagnoses that included: unspecified cirrhosis of liver; chronic systolic heart failure; and chronic kidney disease stage 4, severe. Continued review of Resident #44's medical record revealed the resident began receiving hemodialysis on 12/19/2023. Review of the Significant Change in Status Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/25/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated no cognitive impairment. During an interview with Resident #44 on 01/13/2024 at 11:40 AM, the resident stated he/she had started hemodialysis in December while in the hospital. Review of Resident #44's Physician Order dated 12/28/2023, revealed a treatment order to monitor the resident's right chest Perma Cath (a special catheter used for short-term dialysis treatment) for signs and symptoms of infection or bleeding. Continued review of the Order revealed if bleeding was noted, the first step was to confirm the clamps were closed. Further review revealed if bleeding continued to apply pressure and notify the Physician or Nurse Practitioner (NP). Further review of the orders revealed the resident had hemodialysis on Monday, Wednesday, and Friday. Review of Resident #44's Comprehensive Care Plan, dated 12/23/2022, revealed the resident had no plan of care in place to guide facility staff on his/her care should there be complications related to his/her hemodialysis. In an interview with the MDS Coordinator on 01/15/2024 at 12:46 PM, she stated she was responsible for residents' care plans. She stated the purpose of the care plans were to guide staff on caring for the residents safely. The MDS Coordinator stated she thought she had developed a dialysis care plan for Resident #44; however, had not done so. She stated she would finish the resident's care plan today. During an interview with the Director of Nursing (DON) on 01/15/2024 at 2:30 PM, she stated her expectations were for care plans to be person centered and when things came up, those should also be addressed on the care plan. She stated Resident #44 should have had a dialysis care plan developed upon return from the hospital. In an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated her expectation was for care plans to be developed, reviewed, and revised as needed when changes occurred. She stated the care plan was a guide staff on what kind of care residents needed. 2. Review of Resident #34's medical record revealed the facility admitted the resident on 10/13/2023, with diagnoses to include mild cognitive impairment of uncertain or unknown etiology; sensorineural hearing loss, bilateral; and altered mental status, unspecified. Review of the admission MDS assessment dated [DATE], revealed the facility assessed Resident #34 to have a BIMS score of fifteen (15) of fifteen (15) indicating he/she was cognitively intact and interviewable. Review of Resident #34's Comprehensive Care Plan for Communication revealed it had not been developed or implemented until 01/13/2024, even though the resident had a diagnosis of sensorineural hearing loss, bilateral upon admission. During an interview with the MDS coordinator on 01/15/2024 at 12:46 PM, she stated she was responsible for the comprehensive care plans and the floor nurse was responsible for implementing the baseline care plans. The MDS coordinator stated the purpose of care plans were to guide staff on caring for residents safely and how to take care of the residents. She stated she was unsure why Resident #34 did not have a care plan initiated but should have had one when admitted due to her hearing impairment. During an interview with the DON on 01/14/2024 at 2:30 PM, she stated care plans should be person centered and specific to address the resident's needs and conditions. The DON stated the MDS coordinator is the final check to review and compile the comprehensive care plans. The DON stated Resident #34 should have had a care plan initiated upon admission due to having hearing loss. During an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated she expected care plans to be implemented, revised, and reviewed. She stated this should be done during IDT meetings and when issues are identifed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, it was determined the facility failed to review a resident's Comprehensive Person Centered Care Plan for one (1) of thirteen (13) sampled residents, Resident #43. Review of Resident #43's care plan revealed the care plan had not been reviewed since 08/10/2022. . The findings include: Review of the facility policy titled, Comprehensive Care Plans Standard of Practice dated 10/2020, revealed its purpose was for an individualized comprehensive care plan be developed for each resident. Continued review revealed the residents' individualized comprehensive care plans were to include measurable objectives and timetables to meet the residents' medical, nursing, mental, and psychosocial needs. Further review revealed the care plans were to be reviewed and updated when: there was a significant change in the resident's condition; when the desired outcome was not met; or when the resident had been readmitted to the facility from a hospital stay and at least quarterly. Review of Resident #43's medical record revealed the facility admitted the resident on 07/07/2022, with diagnoses which included: Type II diabetes mellitus with diabetic neuropathy unspecified; muscle weakness (generalized); and chronic kidney disease, stage 4 (severe). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #43 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15) indicating he/she was cognitively intact and interviewable. Review of Resident #43's Comprehensive Care plan for Falls dated 07/07/2022, revealed the last review date was 08/10/2022, and it had been signed by the MDS Coordinator. During an interview with the MDS Coordinator on 01/14/2024 at 10:00 AM, she stated she forgot to hit the sign option after reviewing a resident's care plan a lot of times. The MDS Coordinator stated there was no way to know a care plan had been reviewed unless it had been signed off on. She further stated the facility was in the process of updating their Electronic Medical Records (EMR) system to make the process easier for staff to follow and be more compliant. During an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated she expected residents' Care Plans to be updated, revised and reviewed during the Interdisciplinary Team (IDT) meetings. She stated an example of a potential outcome if revisions/updates were not completed, would be a resident could develop a pressure ulcer or have a pressure ulcer worsen. She further stated the care plan was a guide for staff on what kind of care residents needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policies, it was determined the facility failed to ensure one (1) of thirteen (13) sampled residents, (Resident #53) was not administered a psychotropic medication without an appropriate diagnosis. Resident #53 was administered an antipsychotic, Ziprasidone medication for a diagnosis of Dementia with Agitation. However, Ziprasidone was not approved by the Food and Drug Administration [FDA] for the treatment of behavior problems in older adults with dementia. The findings include: Review of the facility policy titled, Behavior and Psychoactive Medication Protocol dated 11/2020, revealed the facility strived to enhance the Quality of Life and Quality of Care of residents experiencing behaviors and were receiving psychoactive medications through the Behavior and Psychoactive Medication review process. Continued review revealed each resident was to receive individualized care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Per review, the facility's Interdisciplinary Team (IDT) was to work with the Physician to determine the appropriate diagnosis associated with a resident's symptoms, so the underlying causes of the symptoms were recognized and treated appropriately. Further review revealed the Physician orders and pharmacy reviews were to clinically support the diagnosis and the reason for the medication. According to policy review, an evaluation of risk versus benefits of the medication was to be shared with the resident and/or responsible party, and a gradual dose reduction of medications was to be attempted as recommended and as applicable. In addition, policy review further revealed the facility was to contract with psychiatric services to add to the Interdisciplinary Team's (IDT) approach in providing individualized support for applicable residents. Review of Resident #53's record revealed the facility admitted the resident on 12/08/2023, with diagnoses to include dementia; unspecified severity with agitation; hallucinations unspecified; major depressive order; and generalized anxiety disorder. Review of Resident #53's admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/14/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) of fifteen (15) indicating he/she had moderate cognitive impairment. Further review revealed Resident #53 received antipsychotic medication in the past seven (7) days and an indication was noted that an anti-psychotic was received. Review of Resident #53's Comprehensive Care Plan established on 01/02/2024, with an onset date of 12/08/2023, revealed the facility care planned the resident for Psychotropic Drug Use related to: having been admitted to the facility with psychoactive medications: Celexa, Diazepam, Ambien, Amitriptyline, and Trazadone. Further review revealed the interventions included: Address side effects as needed to promote/maintain dignity, gradual dose reduction as clinically appropriate, psych referrals as warranted, IDT to review effectiveness of medication regimen at least quarterly and as needed, observe for adverse effects of antipsychotic, antidepressant. Review of the hospital record dated 11/19/2023, for Resident #53 revealed he/she was admitted to the hospital on [DATE], after a fall at home. Continued review revealed Resident #53's admitting diagnoses included dementia and confusion. Further review revealed on 11/20/2023, Ziprasidone (antipsychotic medication) twenty (20) milligrams (mg) by mouth twice daily was initiated. Review of the facility's admission orders for Resident #53 dated 12/8/2023, revealed the orders included Ziprasidone twenty (20) mg by mouth twice daily to be administered for diagnosis of Dementia, with unspecified severity and agitation. Review of the Consultant Pharmacist Report dated 12/18/2023, revealed a medication regimen review (MMR) was completed on admission with no recommendations made. Review of the Consultant Pharmacist Report dated 12/28/2023, revealed an MMR was completed with no recommendations. Review of the progress note dated 12/29/2023 at 2:02 PM, signed by the Advanced Practice Registered Nurse (APRN), revealed an order to increase Resident #53's Ziprasidone to twenty (20) mg three (3) times a day. Review of Electronic Health Record (EHR) for Resident #53 revealed no documented evidence Psychiatric (Psych) Services had been consulted for the resident. During an interview with the Family Nurse Practitioner (FNP) on 01/14/2024 at 12:07 PM, she stated Resident #53 had dementia with agitation as a diagnosis for the Ziprasidone. She stated she increased Resident #53's Ziprasidone medication on 12/29/2023, due to increased the resident's agitation both verbal and physical in the afternoon of 12/29/2023. The FNP stated instead of trying something new she just increased the dose of the Ziprasidone. She stated residents were usually referred to Psych services and she was not sure why Resident #53 had not been referred. The FNP further stated if the pharmacy made recommendations, she was unaware of the recommendations. In addition, she stated she was aware that medications required an indication for use and Resident #53 had episodes of agitation. In an interview with the Clinical Consultant Pharmacist on 01/14/2023 at 2:51 PM, she stated she printed the facility's admissions report weekly and monthly to review ordered medications and complete the Medication Regimen Review (MRR). She stated if a resident was receiving a psychotropic medication and she could not locate a diagnosis for its use, or the resident had an inappropriate diagnosis she would make the facility aware of that information. In an interview with the Director of Nursing (DON) on 01/15/2024 at 2:30 PM, she stated Resident #53 was admitted to the facility with antipsychotic medication and had a diagnosis of dementia with agitation. She stated Resident #53 had episodes of agitation, which included wandering and getting up and down out of his/her chair or bed. The DON stated she could not recall any recommendations related the MRR, and she could not speak to what the FNP did. In an interview with the Administrator on 01/15/2024 at 2:45 PM, she stated residents should have a diagnosis in place for antipsychotic medications; however, it was up to the Physician or FNP to diagnose and treat residents. She stated, I can't answer that when asked about dose reduction and indications on antipsychotic's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and a review of the facility restraint policy it was determined the facility failed to ensure one (1) of fifteen (15) residents (Resident #7) was free from physical restraint. Resident #7's alarming seat belt was not released during the lunch meal on 02/11/2020. The findings include: A review of the facility restraint policy titled Restraint Standard of Practice, dated November 2016, revealed residents were to be free of restraints unless medically necessary and the least restrictive restraint method would be utilized. A review of the medical record for Resident #7 revealed the facility admitted the resident on 07/20/2017 with diagnoses that included Dementia with Behavioral Disturbance, Muscle Weakness, and Lack of Coordination. A review of the most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident was assessed to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three (3). The resident was also assessed to utilize a trunk restraint daily. A review of physician orders dated 04/11/2019 revealed an order for an alarming seatbelt when up in chair to promote safe wheelchair mobility related to poor safety awareness secondary to Dementia. A review of the plan of care developed for Resident #7's restraint use revealed an intervention to release the restraint for meals and supervised activities as deemed safe. Observation of Resident #7 during the noon meal service on 02/11/2020 at 1:25 PM revealed State Registered Nurse Aide (SRNA) #1 who was also a restorative aide assisted Resident #7 to eat; however, the restorative aide did not remove the lap belt restraint while assisting the resident to eat. Interview with SRNA #1 on 02/13/2020 at 3:51 PM revealed the SRNA knew that Resident #7's seatbelt restraint should have been released while the resident was eating lunch but SRNA #1 stated she forgot to remove the belt. Interview on 02/13/2020 at 3:25 PM with the MDS/Restorative Supervisor revealed resident restraints were monitored by observing residents during daily rounds, which were completed 2-4 times per day depending on the workload. The MDS/Restorative Supervisor stated the staff receives yearly training on restraints and she reeducated staff when necessary related to restraint use. The MDS/Restorative Supervisor stated Resident #7's seat belt restraint should be released during meals. Per the MDS/Restorative Supervisor, she was not aware that SRNA #1 failed to release Resident #7's seatbelt restraint during lunch on 02/11/2020. Interview with the Director of Nursing (DON) on 02/13/2020 at 5:59 PM revealed the DON made rounds daily during meal service to ensure staff were following the residents' plan of care. According to the DON, Resident #7's plan of care should have been followed and the seatbelt should have been released when the resident was eating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and a review of the facility care plan policy, it was determined the facility failed to follow the plan of care related to restraint use for one (1) of fifteen (15) sampled residents (Resident #7). Facility staff failed to remove Resident #7's seatbelt restraint during the noon meal on 02/11/2020 per the intervention in the resident's plan of care. The findings include: A review of the facility policy for following the plan of care titled Comprehensive Care Plans Standard of Practice, with a revision date of September 2017, revealed it was the practice of the facility to implement a person-centered care plan for each resident to meet the needs of the resident identified in the comprehensive assessment. In addition, the facility would ensure residents diagnosed with Dementia received treatment and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. A review of Resident #7's medical record revealed the facility admitted the resident on 07/20/2017 with diagnoses that included Dementia with Behavioral Disturbance, Muscle Weakness, and Lack of Coordination. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] completed for Resident #7 revealed the resident was assessed to be severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three (3). Per the MDS, the resident was assessed to utilize a trunk restraint daily. A review of the comprehensive plan of care developed for Resident #7 revealed the facility had addressed the resident's use of a physical restraint in the form of an alarming seat belt. Per the plan of care, the reason for the restraint use was abnormal posture and impaired cognition with poor safety awareness. The goal was listed for the resident to be free from complications associated with the use of a physical restraint. The interventions included application of the restraint seatbelt alarm when the resident was up in a wheelchair and release of the restraint for meals. Observation of Resident #7 during the noon meal service on 02/11/2020 at 1:25 PM revealed State Registered Nurse Aide (SRNA) #1 who was also a restorative aide assisted Resident #7 to eat; however, the restorative aide did not remove the lap belt restraint while assisting the resident to eat. Interview with SRNA #1 on 02/13/2020 at 3:51 PM revealed the SRNA knew that Resident #7's seatbelt restraint should have been released while the resident was eating lunch but SRNA #1 stated she forgot to remove the belt. Interview on 02/13/20 at 3:25 PM with the MDS/Restorative Supervisor revealed residents' restraints were monitored by observing residents during daily rounds, which were completed 2-4 times per day depending on the workload. The MDS/Restorative Supervisor stated staff receive yearly training on restraints and she reeducated staff when necessary related to restraint use. The MDS/Restorative Supervisor stated Resident #7's seatbelt restraint should be released during meals. Per the MDS/Restorative Supervisor, she was not aware that SRNA #1 failed to release Resident #7's seatbelt restraint during lunch on 02/11/2020. Interview with the Director of Nursing (DON) on 02/13/2020 at 5:59 PM revealed the DON made rounds daily during meal service to ensure staff are following the plan of care. According to the DON, Resident #7's plan of care should have been followed and the seat belt should have been released when the resident was eating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility policy review the facility failed to maintain an effective infection control program for three (3) of twenty-nine (29) sampled residents (Resident #4, Resident #14, and Resident #28). The facility failed to follow their policy and physician order related to contact and droplet precautions for Resident #4 and failed to disinfect a blood glucose monitor per manufacturer guidelines for Resident #28. Resident #14 did not receive annual Tuberculin testing. The findings include: 1. Review of the facility policy titled Isolation Categories of Transmission-Based Precautions, not dated, revealed Transmission-Based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others. Further review of the policy revealed residents who require droplet precautions will be placed in a private room if possible and the facility will implement a system to notify staff and visitors of the type of precaution the resident requires. Review of Resident #4's medical record revealed the facility admitted the resident on 05/11/2019 with diagnoses of Chronic Obstructive Pulmonary Disease, Retention of Urine, Cachexia, Anorexia, and Chronic Pain. Further review of the medical record revealed the resident had a Microbiology-Bacteriology report dated 02/07/2020 that indicated Resident #4 had a positive sputum culture for Methicillin-Resistant Staphylococcus Aureus (MRSA). Continued review of the medical record revealed a physician order for respiratory/contact precautions due to MRSA in the sputum dated 02/07/2020. After review by the Nurse Practitioner, an order was written on 02/12/2020 to place the resident in droplet precautions. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] revealed the facility assessed Resident #4 to have a BIMS (brief interview for mental status) score of fourteen (14) indicating the resident is cognitively intact. Review of the comprehensive care plan dated 02/07/2020 revealed an intervention for droplet precautions dated 02/12/2020. Observation of Resident #4's room on 12/11/2020 at 9:33 AM and again at 3:28 PM revealed there was no signage on the door related to isolation precautions or to see a nurse before entering. Interview with Resident #4 on 02/12/2020 at 2:55 PM revealed visitors have not been using personal protective equipment when entering the room. Resident #4 stated he/she has been treated for MRSA several times in the past and is aware that staff and visitors should wear a gown, mask, and gloves when entering the room. Interview with Kentucky Medication Aide (KMA) #1 on 02/11/2020 at 3:37 PM revealed Resident #4 was placed in isolation on 02/07/2020 due to MRSA in his/her sputum. KMA #1 acknowledged there should be signage on the door alerting staff and visitors to the isolation precautions. Observation of Resident #4's room on 02/12/2020 at 9:21 AM revealed signage on the door directing visitors to see the nurse before entering the room. Interview with RN #1 on 02/12/2020 at 2:39 PM revealed staff and visitors should see the nurse prior to entering Resident #4's room. The nurse would instruct staff and visitors on the type of personal protective equipment (PPE) to use when entering the room. Interview with State Registered Nurse Aide (SRNA) #2 on 02/13/2020 at 9:42 AM revealed she is knowledgeable of the type of isolation and the precautions for Resident #4. SRNA #2 acknowledged the signage was not on the door until yesterday, 02/12/2020. Interview with SRNA #3 on 02/13/2020 at 9:50 AM revealed she is aware of the type of isolation Resident #4 is in and the type of Personal Protective Equipment (PPE) to use when entering the room. SRNA #3 reported the signage that directs staff and visitors to see the nurse prior to entering the room was not posted on the door the entire time Resident #4 was in isolation. SRNA #4 stated she has seen visitors enter the room without using PPE. Interview with the Director of Nursing (DON) on 02/13/2020 at 5:52 PM revealed the nurse who takes the order for isolation is responsible for placing signage on the door directing staff and visitors to see the nurse prior to entering the room. The DON stated she made rounds daily to monitor resident care. The DON stated she was not aware of any concerns with isolation precautions and correct use of PPE. 2. Review of the facility policy titled, Cleaning and Disinfecting Blood Glucose Machines, undated, revealed it is the policy of the facility to clean/disinfect the blood glucose monitor machines after each use to prevent the spread of infection. Further review of the policy revealed staff were to clean the glucometer with an approved wipe, ensuring it is visibly wet for the recommended time. Review of the medical record for Resident #28 revealed the resident was readmitted to the facility on [DATE] with diagnoses including Diabetes Mellitus Type II, Paranoid Schizophrenia, Hypertension, and Hyperlipidemia. Further review of the medical record revealed the resident had physician orders for blood glucose monitor checks before meals, at bedtime, and as needed for signs and symptoms of hypo/hyperglycemia. Review of the resident's care plan revealed the resident was to receive blood glucose monitoring as ordered by the physician. Observation of blood glucose monitoring for Resident #28 on 02/13/2020 at 12:54 PM revealed Licensed Practical Nurse (LPN) #1 sanitized hands, donned gloves, obtained a blood specimen from Resident #28, and obtained a blood glucose monitor reading of 301 milligrams per deciliter (mg/dl). LPN #1 exited the room, placed the blood glucose monitor on a dry paper towel on a hard surface, removed gloves, sanitized hands, donned gloves, and proceeded to wipe the blood glucose machine with a Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipe for approximately thirty (30) seconds. LPN #1 then placed the blood glucose machine on a new clean dry paper towel on a hard surface to air dry. The blood glucose machine was dry within thirty (30) seconds after being placed on the paper towel. Review of the label on the Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipe container revealed to disinfect the surface it should be thoroughly wiped and kept wet for two (2) minutes using as many wipes as necessary to keep the surface wet for the entire contact time and allow to air dry. Interview with LPN #1 on 02/13/2020 at 3:38 PM revealed she was employed by an agency outside of the facility. LPN #1 further revealed she was taught and performed competency checks by the outside agency for the blood glucose monitoring procedure. LPN #1 revealed she was taught with a different type of cleaning wipe and it only required thirty (30) seconds contact to the device for it to be disinfected. LPN #1 also revealed that when she came to work at the facility she signed a contract that she had been trained in blood glucose monitoring including cleaning of the device. LPN #1 further revealed she was not aware this was a different type of disinfecting wipe and required longer contact with the blood glucose monitor. Interview with the Director of Nursing (DON) on 02/13/2020 at 6:01 PM revealed staff employed from an outside agency received two (2) to three (3) shifts of training at the facility before being assigned duties. The DON further revealed staff were trained and performed competency checks annually and as needed throughout the year. The DON revealed the blood glucose monitor required two (2) minutes of cleaning with a wet wipe to disinfect the device and was to be placed on a clean surface to allow to air dry. The DON further revealed she conducted random auditing of staff to monitor for correct cleaning of the blood glucose monitor and had not identified any concerns. 3. A review of the facility policy for tuberculosis skin test titled Administration and Interpretation of Tuberculin Skin Test, with a revision date of June 2010, revealed the facility will administer and interpret tuberculin skin tests in accordance with recognized guidelines and pertinent regulations. A review of the medical record for Resident #14 revealed the facility admitted the resident on 12/12/2018 with diagnoses of Dementia, Anxiety, and Chronic Obstructive Pulmonary Disease. Further review of the record revealed no evidence that annual required tuberculin skin testing was conducted for Resident #14 in 2019. According to the medical record the most recent tuberculin skin testing conducted for Resident #14 was completed on 12/12/2018 when the resident was admitted to the facility. Interview with the facility Infection Control Preventionist on 02/13/2020 at 5:39 PM revealed she had recently assumed the duties of infection control in January 2020 and was responsible for ensuring residents received tuberculin skin testing. The Infection Control Preventionist stated she was not aware that Resident #14 had not received annual tuberculin skin testing in 2019 as required. Interview with the Director of Nursing (DON) on 02/13/2020 at 5:50 PM revealed the DON was aware that Tuberculin Skin Testing was to be completed annually and had a monthly binder to track each resident. The DON stated residents were listed in a binder with the due date of the PPD (purified protein derivative). The DON stated she reviewed this binder every couple of months; however, she had not identified any problems and was not aware Resident #14 had not received Tuberculin Skin Testing in 2019.