**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of facility policy, and the facility's initial investigation documentation, it was determined the facility failed to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of three (3) sampled residents (Resident #2). Interview with the Administrator on 12/01/2022 at 11:14, revealed on 11/27/2022 at 6:40 PM, Resident #2, proceeded to his/her room after a supervised smoke break with staff and went passed his/her room. Resident #2 approached door #1 on the northside of the building on Wing Two (2), where he/she pushed on the door until the magnetic locking system automatically disengaged. Resident #2 then exited the building without staff's knowledge. The findings include: Review of the facility's policy titled, Wandering and Elopement, revised 03/2019, revealed the facility was to identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting, revised 07/2017, revealed all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the premises were to be investigated and reported to the Administrator. Review revealed the Nurse Supervisor or the department director were to promptly initiate and document investigation of the accident or incident. Per review, the Report of Incident/Accident form was to include the date and time the incident/injury took place, the nature of the injury/illness or incident, and the circumstances surrounding the accident or incident. Further review revealed the Report of Incident/Accident form was also to include the names of any witnesses and their account of the accident or incident, the time of Physician notification and response or instructions, and the time of family notification and by whom. In addition, the form was to include the condition of the resident including vital signs, any corrective action taken, and the signature of person completing the report. Review of Resident #2's medical record revealed the facility admitted the resident on 03/09/2021, with diagnoses which included Other Transient Cerebral Ischemic Attacks and related Syndromes, Encephalopathy, and Dementia. Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) indicating severe cognitive impairment. Review of the the facility's Wander/Elopement Risk assessment dated [DATE], revealed the facility assessed Resident #2 as with a score of eleven (11). Review revealed a score of eleven (11) or above indicated a high risk for wandering. Further review revealed the facility additionally assessed Resident #2 as ambulatory with the use of a walker and to have a history of wandering; however, with no reported episodes of wandering in the last six (6) months. Review of the Resident #2's Comprehensive Care Plan initiated 03/09/2021 and revised 11/28/2022, revealed Resident #2 was an elopement risk/wanderer related to family concerns of resident stating multiple times that he/she wished to go home. Resident #2's goal was his/her safety would be maintained through 02/07/2023. Continued review of the care plan revealed interventions which included: placement of a Wander Alert Bracelet, initiated on 03/10/2021; identify patterns of wandering, such as wandering purposeful, aimless, escapist, the resident looking for something or the need for more exercise. Per review, Resident #2's interventions also included distracting him/her from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, initiated on 03/09/2021. Further review revealed on 11/28/2022, every fifteen (15) minute checks were implemented at 6:00 AM on 11/28/2022 and were still in progress at the survey exit date. Review of Long-Term Care Facility - Self Reported Incident Form, dated 11/27/2022 at 10:45 PM, completed by the Administrator, revealed the northeast door alarm sounded, and staff responded and noticed Resident #2 approximately sixty (60) feet from the door in a grassy area of the property. Per review, staff assisted Resident #2 back into the facility and a full body audit and assessment was completed, with no injuries noted. Continued review revealed the facility placed Resident #2 on one to one (1:1) care (supervision) by Licensed Practical Nurse (LPN #1). Further review of the document revealed the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Environmental Director arrived at the facility. Review further revealed the Environmental Director assessed the security functions on all the facility's doors and alarms to ensure they were functioning properly. In addition, MDS staff and the ADON performed assessments of all residents with Wander Guard alarms and their care plans updated and revised if applicable. Review of the Health Status Note dated 11/27/2022 at 6:45 PM, revealed the alarm sounding for the side door by office, and staff responded immediately by going to check the door. Review revealed staff observed Resident #2 walking in the field on the side of the facility property. Continued review revealed staff approached Resident #2, and escorted him/her back to the facility without any injuries noted. Per review one to one (1:1) supervision with staff was initiated and the resident's care plan was updated. Further interview revealed staff attempted to notify Resident #2's Power of Attorney; however, were unable to do so, and left a message. In addition, review further revealed the DON, ADON, the Administrator and the Physician were notified. Review of Certified Nursing Assistant (CNA) #3's witness statement dated 11/27/2022, revealed she had been providing care to another resident when the door alarm went off. Continued review revealed CNA #3 proceeded to the door, looked out the window but did not see anything. Further review of the statement revealed she turned the alarm off and CNA #5 went out the front door to check outside and found Resident #2. Observation of Resident #2 on 11/29/2022 at 2:22 PM, revealed the resident was resting on his/her bed with eyes closed. Continued review revealed a wander alert bracelet was present on his/her left ankle and there was a walker at the bedside. Observation of Resident #2, on 11/30/2022 at 2:18 PM and on 12/01/2022 at 8:46 AM, revealed Resident #2 was ambulating on the hallway on Wing one (1) with a walker attempting to located his/her room. Interview with CNA #3 on 11/28/2022 at 8:30 PM, revealed on 11/27/2022 at approximately 6:40 PM, while providing care to another resident she heard the door alarm, so she went to door #1 on the side of the building and looked out the window, but did not see anything. CNA #3 stated there were no residents near the door or on the hall so she turned the alarm off and asked CNA #5 to go out the front door to see if she saw anyone/anything. Continued interview revealed CNA #5 found Resident #2 outside and brought him/her back inside. According to CNA #3, the nurse was aware of the incident as the nurse heard the alarm. CNA #3 revealed the DON, ADON, Administrator and Environmental Director came to the facility and started an investigation of the incident. The CNA stated Resident #2 was placed on 1:1 supervision and staff took turns sitting with him/her throughout the night until 6:00 AM the following morning. Review of CNA #2's witness statement dated 11/27/2022, revealed she was on the back hall on Wing 2 at the computer completing education when the door alarm went off. stated she checked the alarm panel (located at the nurses' station) which listed all the doors and showed when a door was opened, explain what this panel is, does it list all the doors and show when one has been opened and saw that it was door #1. Further review of the document revealed CNA #2 viewed the security cameras located at the nurse's station and saw CNA #3 and CNA #5 were outside bringing Resident #2 back inside. Interview with CNA #2, on 12/01/2022 2:18 PM, revealed she was on the back hall of wing two (2) completing education on the computer. CNA #2 stated she heard the door alarm sound and checked the alarm panel and saw it was door #1. She stated she viewed the security cameras located at the nurse's station and saw Resident #2 walking in the grass on the side of the building just steps from the sidewalk. Continued interview revealed as CNA #2 viewed the camera she saw CNA #5 come around the corner and escorted Resident #2 back inside the building. Further interview with CNA #2 revealed she had never witnessed Resident #2 at the doors attempting to leave, nor had she ever heard him/her make statements about going home. Review of CNA #5's witness statement dated 11/27/2022, revealed she was providing care to another resident when she heard the door alarm going off. Per review, she started looking at the door and nobody was around. Continued review revealed CNA #3 asked her to look outside and she saw Resident #2 standing on the grass and she escorted him/her back to the building. Interview with CNA #5 on 12/01/2022 at 2:38 PM, revealed she was in another resident's room when she heard the door alarm. She stated she immediately went to check and saw CNA #3 at the side door and CNA #3 asked her to go out the front door to look and see if she saw anything. Continued interview revealed she stepped out and saw Resident #2 standing on the grass at the side of the building. Per CNA #5, Resident #2 had been wearing gray jogging pants, a black or gray hooded sweatshirt and tennis shoes at the time. She stated she escorted Resident #2 back into the facility. Further review revealed administrative staff came to the facility, and did a walk through of the incident. Interview with LPN #1 on 12/02/2022 at 10:46 AM, revealed she was the nurse working when Resident #2 eloped from the facility. She stated she was on the phone with Pharmacy when she heard the alarm sounding. Per LPN #1, CNA #2 checked the panel and saw that it was door #1's alarm sounding, then looked at cameras and saw that Resident #2 was outside. Continued interview revealed when she got to the lobby area staff were bringing Resident #2 back inside the facility. She stated she assessed Resident #2 for injury, and none were observed. LPN #1 stated she called the DON and the DON had informed the Administrator. Further interview revealed they all came to the facility to investigate the situation. LPN #1 further stated Resident #2 was placed on 1:1 supervision throughout the night, then every fifteen (15) minute checks were initiated. Additionally, she stated she notified the Physician and attempted to notify the POA; however, was unable to and left a message. Interview with Assistant Director of Nursing (ADON) on 12/02/2022 at 2:13 PM revealed she had received a call from LPN #1 about Resident #2 getting out of the side door. She stated she immediately notified the DON who notified the Administrator. Per the ADON, they all went to the facility and started an investigation of the incident. The ADON stated staff education was initiated on 11/27/2022 following the event, regarding door alarms, Wander Guard system, timing of alarms, policy of door alarms. Further interview revealed the education was initiated that night for staff working, and was still in progress. She further stated an elopement assessment was completed for Resident #2 and the resident's care plan was revised. In addition, the ADON revealed Resident #2 was placed on 1:1 supervision and then on every fifteen (15) minute checks. Interview with the DON on 12/02/2022 at 2:36 PM, revealed she was notified by the ADON that Resident #2 had gotten outside. She stated she informed the Administrator and called the facility to obtain the details from LPN #1. The DON stated she had LPN #1 assess Resident #2, obtain written statements from staff, and initiate 1:1 supervision of the resident. Continued interview revealed she went to the facility, and the ADON, Administrator, and Environmental Services also came to the facility that evening and initiated an investigation. The DON further stated the investigation was currently ongoing. Interview with the Administrator on 12/01/2022 at 11:14 AM, revealed Resident #2's elopement investigation was presently ongoing. He stated he had gone to the facility on [DATE], and the DON, ADON and Environmental Director also came to gather witness statements and check all the facility doors. The Administrator stated the facility determined Resident #2 had missed his/her room and had gone out the first door he/she saw. He further stated the facility's Interdisciplinary Team (IDT) was currently reassessing the Wander Guard elopement system and a corrective action plan was being implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policies, it was determined the facility failed to establish a system of records receipt of medications, ensure drug records were in order, and account of all controlled drugs was maintained for two (2) of three (3) sampled residents (Resident #1 and Resident #6). Certified Medication Technician (CMT) #7 and Licensed Practical Nurse #1 failed to follow the facility's policy for counting narcotic medications when they did not count the narcotic medication at change of shift on the evening of 08/16/2022 and again on the morning of 08/17/2022. CMT #7 had Registered Nurse (RN) #1 count with him and they discovered Resident #6 had two (2) missing tablets of his/her Norco (a narcotic pain medication). The facility investigated; however, was unable to determine what happened to the two (2) missing Norco tablets. In addition, the facility failed to secure Resident #1's ninety (90) day supply of Eliquis (an anticoagulant medication) brought to the facility by the resident's daughter at the time of his/her admission. Resident #1's daughter had to obtain the medication for the resident. The findings include: Review of the facility's policy titled, Controlled Substances, dated April 2019, revealed the facility would comply with all laws, regulations and other requirements related to handling and documentation of controlled substances. Per review, controlled substances were to be counted at the end of each shift, by the nurse coming on duty and the nurse going off duty together. Continued review revealed any discrepancies in the controlled substance count were to be documented and reported to the Director of Nursing (DON) services immediately. Further review of the policy revealed the DON investigated all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties and reports the findings to the Administrator. Review of the facility's policy titled, Discrepancies, Loss and or Diversion of Medications, revised 01/2018, revealed all discrepancies, suspected loss and or diversion of medications, irrespective of drug type or class, was to be immediately investigated and a report filed. Continued review revealed immediately upon discovery or suspicion of a discrepancy, suspected loss or diversion, the Administrator, DON, Consulting Pharmacist and/or other determined appropriate parties were notified, and an investigation conducted. Per review, a discrepancy in a drug count, a search for the medication and investigation were to be completed by the designated personnel/staff. The policy review revealed a plan of correction was to be completed by the leadership team or designated personnel. Further review revealed if there was loss of a supply of a medication, a search for the medication and an investigation must be completed by the designated personnel/staff. In addition, the review revealed the appropriate agencies, required by state and federal law, were also to be notified, and the facility would assume financial responsibility for the loss. Review of Resident #6's medical record revealed the facility admitted the resident on 06/17/2020 with diagnosis which included Chronic Kidney Disease, Spinal Stenosis and Pain in Left Leg. Review Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated 09/17/2022, revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating Resident #6 was cognitively intact. Review of Resident #6's Physician order dated 08/11/2022, revealed an order for Norco 10/325 (Hydrocodone 10 milligrams [mg] and Acetaminophen 325 mg) one (1) tablet by mouth three (3) times a day for pain. Review of the facility provided, Long-Term Care-Self Reported Incident Form, Initial Report dated 08/17/2022, at 8:55 PM, revealed the CMT counted medications and found two (2) narcotics missing for Resident #6. Per review, Resident #6 did not miss any ordered pain medication and a pain assessment was completed with no complaints of pain from the resident. Continued review revealed LPN #1 and CMT #7 failed to count the controlled substances at change of shift on the evening of 08/16/2022 and again on the morning of 08/17/2022 (as per the facility's policy). Review revealed the Pharmacy, Medical Director, and resident's family were aware of the issue. According to review of the facility's Initial Report, the investigation was completed with no further discrepancies identified, and the resident's missing medication was replaced at no charge to him/her. Further review revealed education was initiated for all CMT's and nurses. Review further revealed an Action Plan was in progress for approval by the facility's Quality Assurance Performance Improvement (QAPI) team to include weekly audits performed by the DON and Assistant Director of Nursing (ADON) to rule out any further discrepancies. In addition, review revealed the facility included the implemented education in the new hire packets for all new nurses and med technicians (techs) regarding the proper medication count procedure. Review of the Controlled Drug Use Record revealed on 08/09/2022 the facility received thirty (30) tablets of Norco 10/325 for Resident #6. Continued review revealed that on 08/17/2022, tablets #20 and #21 had been recorded as missing and a line had been drawn through the date and signature lines. Review of the facility's Corrective Action Report, first warning, dated 08/17/2022, and signed by the former DON, revealed she counseled CMT #7 and LPN #1 for not counting the controlled drugs on the medication carts together before and after change of shift on the evening of 08/16/2022, and on the morning of 08/17/2022. Review of the facility's Performance Improvement (PI) Action Plan dated 08/17/2022, signed by the former DON, revealed the DON and the ADON were to initiate chart audits and count narcotics daily for one (1) week, then weekly for one (1) week, then monthly for one (1) month. However, interview with the ADON on 12/01/2022 at 4:18 PM, revealed the facility was unable to provide evidence the audits were performed and the narcotic counts had been completed as per the PI Action Plan. Interview with Resident #6 on 11/30/2022 at 3:40 PM, revealed she recalled the facility made her aware some time back that a couple of his/her pain tablets were missing. Resident #6 stated it had not bothered him/her, he/she had not missed any medication doses. Interview with CMT #7 on 11/29/2022 at 3:58 PM, revealed he and LPN #1 had not counted the medication cart at the end of the shift on 08/16/2022 or the beginning of the shift on 08/17/2022. He stated he had Registered Nurse (RN) #1 count with him and that was when it was discovered that Resident #6 had two (2) tablets missing. CMT #7 stated the former DON had a meeting that day with the nurses and other CMT's about counting the narcotics together and accepting the medication cart. Further interview revealed CMT #7 stated it was a lesson learned. Interview with RN #1 on 12/01/2022 at 3:05 PM, revealed CMT #7 asked her to count the controlled substances on the medication cart on 08/17/2022, and they discovered Resident #6 was missing two (2) of his/her Norcos. She stated she did not know why CMT #7 had not counted the controlled drugs with LPN #1 that morning and LPN #1 had already left the building. Per RN #1, she reported the missing Norco tablets to the former DON. RN #1 stated all controlled drugs were to be counted at change of shift, and she did not know what happened to the missing doses of the medication. Interview with LPN #1 on 12/02/2022 at 10:46 AM, revealed that on 08/16/2022 and 08/17/2022, she and CMT #7 had not counted the narcotics on the medication cart at change of shift. She stated the former DON called her and informed her that two (2) tablets were missing from Resident #6's Norco card. Continued interview revealed she had no idea what happened to the Norco tablets. According to LPN #1, Resident #6 had an order to receive the medication three (3) times a day and she had administered a dose at bedtime on 08/16/2022. Further interview revealed the DON counseled her and she had also been educated along with the other nurses and medication techs on counting narcotics. LPN #1 further revealed she didn't really have a reason as why she failed to do a count. Interview with the former DON on 12/02/2022 at 11:01 AM, revealed that on 08/17/2022, RN #1 informed her that Resident #6 was missing two (2) doses of his/her narcotics. She stated she spoke with CMT #7 and he admitted to not counting the narcotics at shift change on 08/16/2022 with LPN #1, and again at shift change on 08/17/2022. Continued interview revealed she placed a call to LPN #1 who also admitted to not counting the controlled drugs at shift change. The former DON stated she provided written disciplinary action to CMT #7 and LPN #1 on 08/17/2022. She revealed she and the ADON performed chart audits and counted the narcotics daily, and she left the investigation information in the DON office when she resigned. Further interview revealed she was unable to determine what happened to the two (2) missing narcotic tablets, did not know if the Administrator had notified law enforcement or not. Interview with the ADON on 12/01/2022 at 4:18 PM, revealed she was unable to locate the documentation for the chart audits and the daily narcotic audits she and the former DON had completed. Interview with the former Administrator on 12/02/2022 at 1:44 PM, revealed she could not recall if she reported the missing narcotics to law enforcement or not. She stated the former DON and ADON provided staff education and performed audits of the narcotics after the missing narcotic medication was discovered. Further interview revealed she expected staff to follow the facility's policy and procedures related to counting narcotics. Interview with the current Administrator on 12/02/2022 at 3:28 PM, revealed he had not been the Administrator at the time of the incident; however, he would expect the nurses to follow the facility's policy and count the controlled drugs at change of shift. He further stated he would expect the DON to investigate and also follow the facility's policy. 2. Review of the closed record revealed the facility admitted Resident #1 on 07/27/2022, with diagnoses which included Paroxysmal Atrial Fibrillation, Chronic Kidney Disease, Stage Three (3), and Unspecified Dementia. Review of Resident #1's admission MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of seven (7) out of fifteen (15) which indicated severe cognitive impairment. Further review of the MDS Assessment revealed Resident #1 was admitted to the facility under Hospice Services and was discharged from the facility on 10/18/2022. Review of Resident #1's Physician order dated 07/27/2022, revealed an order for Eliquis 2.5 mgs to be administered two (2) times daily for anticoagulation. Review of Resident #1's Medication Administration Record (MAR) dated July 2022, revealed the resident had not missed any doses of Eliquis since his/her admission to the facility. Interview with Resident #1's daughter on 11/29/2022 at 8:04 PM, revealed Resident #1 had the medication Eliquis (a blood thinner) ordered from Veterans Affairs (VA). She stated Resident #1 had been under Hospice Care since February 2022 and that Hospice Services had not provided the medication. Resident #1's daughter stated when Resident #1 was admitted to the facility on [DATE], she took a ninety (90) day supply of the Eliquis medication to the facility and gave it to RN #1. Further interview revealed the following day she was made aware by RN #1 that the Eliquis medication could not be found. Further interview revealed as a result of that she had to drive to the VA and obtain another prescription. She additionally stated the facility never found the Eliquis medication Review of a Hospice Visit Note dated 08/11/2022, revealed RN #1 had called a Hospice nurse and stated when Resident #1 was admitted to the facility the family had provided the facility with a bag full of medications including a ninety (90) day supply of Eliquis and the Eliquis medication could not be found. Continued review revealed RN #4 was present when Resident #1 arrived at the facility and recalled RN #1 taking a bag of medications, and saying the facility would take the medications, in case medication did not arrive from the facility's Pharmacy. Per review, RN #4 spoke with the former DON regarding the medications which had not been found. Further review of the Note revealed Hospice Nurse #1 informed the DON that Eliquis was not a covered drug under Hospice. Review further revealed the Hospice team met and felt the facility was ultimately responsible for finding or replacing Resident #1's missing Eliquis medication. Interview with Registered Nurse (RN) #1 on 12/01/2022 at 3:05 PM, revealed she was the nurse working when Resident #1 was admitted to the facility. She stated Resident #1's daughter had brought a ninety (90) day supply of Eliquis to the facility, and she had been the person who accepted the medication. RN #1 revealed she thought she put the Eliquis in the medication cart; however, the next day the CMT #7 informed her the Eliquis was not present in the cart in order for it to be given. Further interview revealed RN #1 called the resident's daughter and informed her and the daughter was upset after being told that. She further stated the resident's daughter worked with the VA to get the medication refilled. In addition, RN #1 revealed she did not know what happened to the Eliquis medication. Interview with the former Director of Nursing (DON) on 12/02/2022 at 11:01 AM, revealed she had been aware of the missing Eliquis medication for Resident #1. She stated the facility had looked for the medication; however, had not performed a formal investigation related to the missing medication. Continued interview revealed the facility should have completed an investigation to attempt to determine what happened to the medication. The former DON further stated the family was able to provide the facility with a refill of the Eliquis medication, and Resident #1 had not missed any doses of the medication. Further interview revealed the facility had covered the cost of the Eliquis. Interview with the former Administrator on 12/02/2022 at 1:44 PM, revealed she expected staff to follow the facility's policy and procedures related to missing medications. She stated the Eliquis medication should have been accounted for on the resident's admission.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of nine (9) sampled residents (Resident #9). Observation on 12/01/2022, revealed Certified Nurse Aide (CNA) #1 failed to wash her hands when providing care to Resident #9. The findings include: Review of the facility's policy titled, Handwashing, undated, revealed handwashing and hand antisepsis should be regarded by the facility as the single most important means of preventing the spread of infection. All personnel should follow the established hand washing and antisepsis procedures to prevent the spread of infection and disease to residents, and visitors. If staff's hands were not visibly soiled, they were to use an alcohol-based hand rub for routinely decontaminating their hands in all other clinical situations; before having direct contact with residents, after contact with inanimate objects in the immediate vicinity of the resident, and after removing gloves. Review of the medical record revealed the facility admitted Resident #9 on 04/02/2022, with diagnoses which included Cerebral Infarction, Unspecified, Hemiplegia and Hemiparesis affecting Right Dominant Side and Muscle Weakness. Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 10/20/2022, 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. Interview with Resident #9, on 12/01/2022 at 9:41 AM, revealed he/she did not pay much attention when staff washed their hands, but thought they usually wore gloves. Observation on 12/01/2022 at 9:12 AM, revealed CNA #1 entered Resident #9's room and donned gloves without washing her hands, and assisted the resident to the bathroom. Continued observation revealed CNA #1 exited the bathroom with Resident #9 in his/her wheelchair, removed her gloves and tossed them in the trash and did not wash her hands. CNA #1 then assisted Resident #9 to the nurses' station without washing her hands. Interview with CNA #1 on 12/01/2022 at 9:21 AM, revealed she should have washed her hands prior to her gloves on. She stated she should have also washed her hands when she removed the gloves after caring for Resident #9. CNA #1 further stated handwashing helped prevent the spread of infections. Interview with the Assistant Director of Nursing (ADON) on 12/02/2022 at 2:13 PM, revealed she expected all staff to wash their hands before and after resident care and as indicated by the facility policy. She stated all staff had been educated numerous times on handwashing since the COVID pandemic. Interview with the Administrator on 12/02/2022 at 3:10 PM, revealed he expected staff to follow infection control guidelines and wash their hands before and after patient care. He stated handwashing was important to prevent resident infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the care plan for one (1) of twenty (20) sampled residents (Resident #66). The facility care planned for Resident #66 to receive proper peri-care; however, observation of peri-care for Resident #66 by Certified Nurse Aide (CNA) #1 revealed CNA #6 failed to wash her hands when gloves were removed/prior to applying new gloves, and prior to touching items in the resident's room. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, last revised December 2016, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical well being. Also, will reflect treatment goals. Record review revealed the facility admitted Resident #66 on 06/14/16 with diagnoses which included frequent Urinary Tract Infections (UTI's) and Urinary/Bowel Incontinence. Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #indicated the resident was interviewable. Further review of the MDS assessment revealed the resident was always incontinent of urine and required extensive assist of two (2) persons for toileting. Review of Resident #66's Comprehensive Care Plan for Potential for Urinary Tract Infection (UTI), dated 05/29/18, revealed an intervention to provide proper peri-care. However, observation of peri-care provided by CNA #1, on 06/20/19 at 8:46 AM, revealed she failed to wash her hands between glove changes during peri-care. Further observation revealed she also did not wash her hands after removing her gloves prior to touching the bedding, the resident's privacy curtain, or after placing the resident's skin cream in the cabinet. Interview with CNA #1, following the observation, revealed she should have washed her hands between glove changes and prior to touching the bedding, privacy curtain and skin cream. She stated the resident's Comprehensive Care Plan included using proper peri-care and should be followed. Interview with the Director of Nursing (DON), on 06/20/19 at 1:30 PM, revealed the staff should follow the facility policy regarding proper hand washing and hand hygiene. She stated she expected all staff to follow the Comprehensive Care Plans as written. She revealed all CNA's have a copy of the resident's care plans available, and she expected all staff to follow the facility policy and care plans as written with no exceptions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility failed to label/date drugs used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, related to one (1) vial of 70/30 Novolin Insulin, with an expiration date of 03/2019, found in the Emergency Drug Kit refrigerator box on Wing 2. The findings include: Interview with the Director of Nursing (DON), on [DATE] at 3:30 PM, revealed she was unable to provide a policy regarding expiration dates of medications. Observation on [DATE] at 2:43 PM, revealed an unopened vial of 70/30 Novolin insulin which had an expiration date of 03/2019. Interview with the Unit Manager (UM), on [DATE] at 2:43 PM, revealed the insulin should have been removed with the weekly delivery of medications by Pharmacy. Interview (Post Survey) with the current Pharmacist from the facility Pharmacy Company, on [DATE] at 2:15 PM, revealed their Pharmacy took over in [DATE]. He stated the insulin was actually medication from the former Pharmacy used prior to [DATE]. The Pharmacist revealed, our Pharmacists go into the facility monthly to check for outdates of medications. He stated, since that medication was in a storage container belonging to the former Pharmacy, we did not check that medication, since it was in the former Pharmacy's container, and therefore, was not dispensed by us. He further revealed the customer service representative had spoken with the facility on the day the surveyor found the expired medication, and the facility was reminded the medications were from the former Pharmacy, and the current Pharmacy does not have any responsibility for those medications. Further interview with the DON, on [DATE] at 3:30 PM, revealed the Pharmacy was responsible to check all medications in the Emergency Drug Kit and remove medications which had expired. She stated the medication should have been discarded before the end of [DATE]. Additionally, she revealed licensed nurses were responsible to ensure no outdated medications were in the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections related to handwashing/gloving technique during peri-care, for one (1) of two (2) residents (Resident #66). During observation of peri-care, on 06/20/19, Certified Nurse Aide (CNA) #1 failed to wash her hands between glove changes and prior to touching resident's personal items. The findings include: Review of the facility policy Handwashing/Hand Hygiene, last revised August 2015, revealed the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: before and after coming on duty; before and after direct contact with residents; and after removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for prevention healthcare-associated infections. Record review revealed the facility admitted Resident #66 on 06/14/16 with diagnoses which included frequent Urinary Tract Infections (UTI's) and Urinary/Bowel Incontinence. Review of the Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #66's cognition as intact with a Brief Interview for Mental Status Score (BIMS) score of fourteen (14), which indicated the resident was interviewable. Observation of peri-care provided by CNA #1, on 06/20/19 at 8:46 AM, revealed she failed to wash her hands between glove changes during peri-care and she did not wash her hands after removing her gloves prior to touching the bedding, the resident's privacy curtain, or after placing the resident's skin cream in the cabinet. Interview with CNA #1 after she provided Resident #66's peri-care revealed she should have washed her hands between glove changes and prior to touching the bedding, privacy curtain, and skin cream. Interview with the Director of Nursing (DON), on 06/20/19 at 1:30 PM, revealed the staff should follow the facility policy regarding proper hand washing and hand hygiene. She stated she expected all staff to follow the facility policy with no exceptions.