Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert, oriented and able to make his/her needs known, the Facility failed to ensure he/she was treated in a dignified and respectful manner by staff, when on 06/02/25 a staff member witnessed Certified Nurse Aide (CNA) #1 interact with Resident #1 in a rude, disrespectfully manner, which included CNA #1 yelling at Resident #1 to shut up. Findings include: The Facility's Policy titled, Resident Rights, undated, indicated that employees shall treat all residents with kindness, respect, and dignity. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Resident #1 was admitted to the Facility in December 2020, with diagnoses that included quadriplegia (loss of movement and sensation in all four limbs) unspecified, displaced fracture of sixth cervical vertebra sequela, chronic respiratory failure, tracheostomy, and dependence on respirator ventilator. Review of Resident #1's most recent Minimum Data Set Assessment, dated 04/08/25, indicated his/her cognitive patterns were intact, and he/she was able to make his/her needs known to staff. The MDS also indicated that Resident #1 required assistance from staff members to meet his/her care needs. The Facility's Internal Investigation, dated 06/02/25, indicated that on 06/02/25 at 12:45 P.M., Resident # 1 reported that a staff member told him/her to shut up. The Internal Investigation indicated that Resident #1 was able to identify the staff member as Certified Nurse Aide (CNA) #1, and the staff member was removed from the schedule and suspended immediately. The Investigation indicated that another staff member was present (later identified as CNA #2) and stated that CNA #1 told Resident #1 to shut up forcefully. The Investigation indicated that the Facility concluded CNA #1 told Resident #1 to shut up, which was considered verbal abuse. During an interview on 06/25/25 at 1:15 P.M., Resident #1 said that on 06/02/25, he/she was asking a question of Certified Nurse Aide (CNA) #1, that she dismissed his/her question and that CNA #1 responded to him/her by saying Shut up, shut up. Resident #1 said it was disrespectful and wrong for CNA #1 to say what she said, and that it had not made him/her feel very good. During an interview on 06/25/25, at 2:33 P.M., Certified Nurse Aide (CNA) #2 said she was feeding Resident #1 in the TV room area when CNA #1 came to speak to her (CNA #2), and Resident #1 was attempting to talk to her (CNA #1). CNA #2 said that CNA #1 did not care what Resident #1 was saying, and instead responding kindly to him/her, CNA #1 was rude and disrespectful to Resident #1 and forcefully said to him/her, Shut up, I am not talking to you. During an interview on 06/25/25 at 4:30 p.m., the Director of Social Services (DSS) said that Resident #1 reported CNA #1 was rude and disrespectful. The DSS said Resident #1 felt disrespected during interaction with CNA #1 and emphasized the importance of being treated with respect. During a telephone interview on 06/26/25, at 11:16 A.M., Certified Nurse Aide (CNA) #1 denied speaking loudly or telling Resident #1 to Shut up, but acknowledged that when Resident #1 was trying to speak to her, that she did not respond to him/her. During a telephone interview on 07/01/25 at 12:11 P.M., Nurse #1 said that Resident #1 was upset and reported he/she was asking CNA #1 a question, that CNA #1 dismissed him/her and told him/her to shut up. During an interview on 06/25/25 at 4:00 P.M., the Director of Nursing (DON) said he interviewed CNA #1, and she denied the allegations. The DON said the interaction between CNA #1 and Resident #1, was witnessed by CNA #2, who reported that CNA #1 responded by yelling Shut up, shut up, when Resident #1 asked her a question. The DON said that based on the Facility's Investigation and CNA #1's behavior, they terminated CNA #1's employment at the Facility. On 06/25/25, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 06/02/25, Resident #1 was immediately assessed for any signs of injury or emotional distress, none were noted, and he/she continues to be monitored by staff, with support provided as needed. B. On 06/02/25, all residents on CNA #1's assignment were immediately assessed for the potential to be adversely affected by the Facility's identified area of concern. C. On 06/02/25, clinical and management staff conducted resident interviews to ensure their safety and determine if there were any other concerns identified (there were none). D. 06/03/25 through 06/10/25, re-education was provided to all the facility staff by the Director of Nursing (DON), Assistant Director of Nursing (ADNS), Staff Development Coordinator (SDC), and Nursing Supervisor on the following: - The definition of the Abuse Prohibition, Resident Rights, and Customer Services: - Interaction with residents should be appropriate and professional. E. During the June 2025 monthly QAPI meeting, the committee reviewed and discussed the incident and area of concern. F. The QAPI committee will continue to review the issue for a period of two months to ensure substantial compliance. G. The Director of Nursing and/or designee are responsible for overall compliance.

Based on observation, record review, and interview, the facility failed to assess for self-administration of medication for 1 Resident (#11) out of a total sample of 24 residents. Findings include: Review of the Self-Administration of Medication policy (undated) indicated residents in the facility who wish to self-administer medication may do so, if it is determined they are capable of doing so. It indicates that staff and/or a practitioner will assess each resident's mental and physical abilities to determine whether a resident is capable of self-administering medications. Resident #11 was admitted to the facility in June 2023 with diagnoses including congestive heart failure and chronic atrial fibrillation. Review of Resident #11's physician orders dated 6/28/23, indicated an order for albuterol inhaler, to be used every six hours, as needed. On 9/12/23, at 9:22 A.M., the surveyor observed an albuterol inhaler on Resident #11's over the bed table. No staff were present in the room. On 9/13/23, at 8:32 A.M., the surveyor observed an albuterol inhaler on Resident #11's over the bed table. No staff were present in the room. During an interview on 9/13/23 at 2:07 P.M., Resident #11 said he/she usually self-administers his/her albuterol inhaler, that was observed on bedside table. Review of Resident #11's Self Administration of Medication Assessment and Consent form indicated Resident #11 did not request or consent to self-administer any medications nor was he/she assessed for self-administration of medications. During an interview on 9/13/23 at 2:15 P.M., Nurse #2 said she was not aware Resident #11 self-administered an inhaler. Nurse #2 said if a resident wished to self-administer then a Self-Administration of Medication Assessment and Consent form should be completed. Nurse #2 said and signed by the resident and staff. Nurse #11 reviewed Resident #11's Self-Administration of Medication Assessment and Consent form and said this form does not indicate that Resident #11 consented self-administration or could safely self-administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow a physician's order; specifically related to parameters for cardiac medications, for 1 Resident (#62) out of a total sample of 24 residents. Findings include: Resident #62 was admitted in December 2020 with diagnoses including hypertension. Review of the Minimum Data Set (MDS) dated [DATE], indicated Resident #62 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated Resident #62 was totally dependent on staff for all activities of daily living. Review of Resident #62's physician's orders for August 2023 indicated Resident #62 was prescribed the following medications: * Amlodipine 5 milligrams - at 9:00 A.M. Give 1 tablet and hold if SBP (systolic blood pressure) is less than 110 * Hydrochlorothiazide 25 milligrams- at 9:00 A.M. Give 1 tablet and hold if SBP is less than 110 Review of the blood pressure vitals for August 2023 indicated Resident #62's systolic blood pressure was below 110 on 8/20/23, 8/21/23, and 8/23/23. Review of the Medication Administration Record (MAR) for August 2023 indicated Resident #62 received the amlodipine on 8/23/23 and the hydrochlorothiazide on 8/21/23 and 8/23/23, despite his/her blood pressure being outside the ordered parameters. Review of Resident #62's physician's orders for September 2023 indicated Resident #62 was prescribed the following medications: * Amlodipine 5 milligrams - at 9:00 A.M. Give 1 tablet and hold if SBP (systolic blood pressure) is less than 110 * Hydrochlorothiazide 25 milligrams- at 9:00 A.M. Give 1 tablet and hold if SBP is less than 110 * Metoprolol Tartrate 25 milligrams - at 9:00 A.M. Give 1 tablet and hold if SBP is less than 110 Review of the blood pressure vitals for September 2023 indicated Resident #62's systolic blood pressure was 102 on 9/6/23 and 90 on 9/7/23. Review of the medication administration record for September 2023 indicated Resident #62 received the amlodipine and hydrochlorothiazide on 9/6/23 and 9/7/23, and the metoprolol tartrate on 9/7/23, despite his/her blood pressure was outside the ordered parameters. During an interview on 9/14/23 at 8:57 A.M., Nurse #1 said she knows to obtain the blood pressure before administering the medication and records it in the vitals section of the chart, which shows up on the MAR. During an interview with the Director of Nursing (DON) on 9/14/23 at 12:02 P.M., he said the Nurse Practitioner (NP) told nursing staff to give Resident #62 the amlodipine, hydrochlorothiazide and metoprolol tartrate even though Resident #62's blood pressure was outside the parameters. The DON said he did not provide any documentation to indicate the Nurse Practitioner approved of this administration. Review of the clinical record did not indicate that any of the orders had been changed or that the NP was notified. During an interview on 9/14/23 at 12:30 P.M., the NP said if a resident's blood pressure was outside the ordered parameters he would expect nursing staff to contact him and to not have given the medication unless he gave approval. The NP said the professional standard of care is to obtain a blood pressure before administering these medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review, and staff interviews, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. The surveyor observed 2 of 3 licensed nurses (Nurse #3, Nurse#2) make errors while administering medications on 2 of 3 units. Two medication errors were observed out of 32 opportunities, resulting in a medication error rate of 6.25%. This affected two Residents (#21, #398), out of a total of four residents observed. Findings include: Review of the facility policy titled Administering Medications, undated, indicated the following: -medications shall be administered in a safe and timely manner, and as prescribed. -the individual administering medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medications. For Residents #21 and #398, the facility staff failed administer the correct form of aspirin (anti-platelet medication) as ordered. 1. Review of Resident #21's Physician's Orders, dated September 2023 indicated: -Aspirin Delayed Release (enteric coated) 81 mg, give 1 tablet by mouth daily. During an observation of the medication pass on 9/13/23 at 8:59 A.M., on the [NAME] House, Nurse #3 prepared and administered the following medications for Resident #21: -Aspirin chewable 81 mg, 1 tablet -Omeprazole (a medication used to treat gastroesophageal reflux disease) 20 milligrams (mg), 1 tablet. -Trazadone (a medication used to treat depression) 25 mg, 1 tablet. -Tylenol 500 mg, 2 tablets -Lisinopril (a medication used to treat high blood pressure), 1 tablet. During an interview on 9/13/23 at 10:50 A.M., Nurse #3 said she would look into getting the order for the chewable Aspirin 81 mg to be changed to enteric coated (delayed release) Aspirin 81 mg. 2. Review of Resident #398's September 2023 Physician's Orders indicated: -Aspirin Chewable 81 mg, give 1 tablet by mouth daily. During an observation of the medication pass on 9/13/23 at 9:41 A.M., at the [NAME] House, Nurse #2 prepared and administered the following medications for Resident #398. -Aspirin Enteric coated 81 mg, 1 tablet. -Omeprazole 20 mg, 1 tablet. -Amlodipine (a medication used to treat high blood pressure), 2.5 mg, 1 tablet. -Vitamin B-12 500 micrograms (mcg), 2 tablets. -Ferrous sulfate (a medication used to treat/prevent low level of iron in blood) 325 mg, 1 tablet. -Lasix (a medication used to treat fluid retention) 10 mg, 1 tablet. -Metformin (a medication used to treat diabetes)1000 mg, 1 tablet. -Lisinopril 30 mg, 1 tablet. -Lamotrigine (a medication used to seizure/bipolar) 100 mg, 1 tablet. -Magnesium Oxide (a medication used to treat digestive problems )400 mg, 1 tablet. -Vitamin D3 1000 international unit (IU), 1 tablet. During an interview on 9/13/23 at 10:45 A.M., Nurse #2 said she did not notice that chewable Aspirin 81 mg was administered instead of enteric coated Aspirin 81 mg.

Based on observation, record review, and interview, the facility failed to ensure it stored a prescribed albuterol inhaler, located on an over bed table, in a safe and secure manner for 1 Resident (#11) out of a total sample of 24 residents. Findings include: Resident #11 was admitted to the facility in June 2023 with diagnoses including congestive heart failure and chronic atrial fibrillation. Review of Resident #11's physician orders dated 6/28/23, indicated an order for albuterol inhaler, to be used every six hours, as needed. On 9/12/23, at 9:22 A.M., the surveyor observed an albuterol inhaler on Resident #11's over the bed table. No staff were present in the room. On 9/13/23, at 8:32 A.M., the surveyor observed an albuterol inhaler on Resident #11's over the bed table. No staff were present in the room. Review of the facility's Administering Medications policy (undated) indicated the medication cart will be kept closed and locked when out of sight of the nurse or aide and no medications are kept on top of cart. It indicates that residents who are capable of self-administering medications can keep some medications, like inhalers, at bedside when in a private room. Review of Resident #11's medical record failed to indicate the facility assessed Resident #11 to determine if he/she was capable of safely administering prescribed medications, or if he/she consented to self-administer medications. During an interview on 9/13/23 at 2:15 P.M., Nurse #2 said she was not sure why or how the albuterol inhaler was left at bedside but that it should not have been without an assessment for self-administration of medication or consent by Resident #11. Nurse #2 said Resident #11 had not consented or been assessed for self-administration of the albuterol inhaler.

Based on observation and interview, the facility failed to maintain a functioning call system for 1 Resident (#52) out of a total sample for 24 residents. Findings include: Resident #52 was admitted to the facility September 2023 with diagnoses including a left arm fracture. Review of Resident #52's medical record did not indicate he/she had a cognitive disorder. During an interview on 9/12/23 at 9:45 A.M., Resident #52 said his/her call light cord has been broken since her admission to the facility, approximately one week ago. Resident #52 said the call light cord worked only half of the time and he/she reported it every day to nursing staff. On 9/12/23 at 9:45 A.M., the surveyor observed Resident #52 did not have an alternative way to alert staff if he/she needed help. On 9/12/23 at 9:47 A.M., the surveyor pressed the button on the call light cord and it did not work. During an interview on 9/13/23 at 1:21 P.M., Nurse #2 said the call light cord was replaced with a functioning cord the previous night (9/12/23). Nurse #2 said staff were aware on 9/10/23 and over the weekend that the call light cord was not functioning and she thought it would be fixed, but that it was not. During an Interview with Maintenance Director on 9/13/23 at 2:11 P.M., he said he was not aware that Resident #52's call light cord had not been functioning over the past week. Review of the Maintenance Log for dates from March 2023 to current date failed to indicate any call light concerns for Resident #52.

Based on record review and interview, the facility failed to ensure for one Resident (#67), out of a total sample of 27 residents, that he/she participated with interdisciplinary team to review his/her person-centered goals. Findings include: Resident #67 was admitted to the facility in July 2022 with diagnoses that include amyotrophic lateral sclerosis (ALS) and chronic obstructive pulmonary disease. Review of the Minimum Data Set Assessment (MDS), with an assessment reference date of 7/23/22, indicated Resident #67 scored a 14 out of 15 on the Brief Interview for Mental Status assessment, which indicated intact cognition. Further review of the MDS indicated Resident #67 participated in the MDS assessment and was expected to remain in the facility. During an interview on 8/22/22 at 8:03 A.M., Resident #67 said he/she was admitted to the facility a few weeks ago. Resident #67 said he/she was concerned about getting a particular ALS medication that is taken intermittently and had concerns about staffing. When asked by the surveyor, if he/she had an interdisciplinary team meeting to discuss his/her goals of care with his/her care team, he/she replied no, but said he/she did express concerns last week to a social worker. Review of the medical record indicated care plans were initiated on 7/14/22 and on 7/28/22 to address Resident #67's care. Although the care plans were developed on 7/14/22 and 7/28/22, there was no evidence within the medical record to indicate that a care plan conference with Resident #67 was conducted. During an interview on 8/23/22 at 1:51 P.M., Social Worker (SW)#1 said care plan meetings are conducted routinely within a few days of admission and every three months along with the MDS schedule. SW #1 said notes of the meeting are in the medical record. She said she was not aware if Resident #67 had a care plan meeting and would look into it. During a subsequent interview on 8/23/22 at 3:07 P.M., SW #1 said that Resident #67 wanted his/her family invited to the care plan meeting. SW #1 said Resident #67's family did not respond and she never returned to Resident #67 to ask if he/she would want a meeting without family present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain a pulse prior to administration of a cardiac medication with a special instruction, during observations of 1 of 4 nurses (#4) on 1 of 4 nursing units. Findings include: On 8/23/22 at 9:50 A.M., the surveyor observed Nurse #4 administer medications to Resident #72 in the [NAME] house which included metoprolol (cardiac medication) 25 milligrams (mg) extended release. The surveyor did not observe vital signs being obtained prior to administration. Review of medication administration record for August of 2022 indicated that there was a physician's order for metopolol 25 mg extended release. Call MD/NP for pulse greater than 100. During an interview, immediately after the administration, Nurse #4 said that there were no parameters that required vital signs to be taken for the metoprolol. When she further reviewed the order, she said that she had forgotten to take a pulse before administering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #67, the facility failed to discontinue a peripherally placed IV per the facility policy. Review of the facility's policy entitled, Removal of a Peripheral IV (over the needle, peripheral short) Catheter, not dated, indicated at General guidelines: 3. The peripheral IV catheter is also removed when therapy is discontinued. Resident #67 was admitted to the facility in July 2022 with diagnoses which included amyotrophic lateral sclerosis (ALS) and chronic obstructive pulmonary disease. Review of the Minimum Data Set Assessment (MDS), with an assessment reference date of 7/23/22, indicated Resident #67 scored a 14 out of 15 on the brief interview of mental status, which indicated he/she has intact cognition. During an interview on 8/22/22 at 8:01 A.M., Resident #67 was observed with an intravenous access in his/her left lower arm. Resident #67 said he/she had dehydration last week and the IV was put in for fluids, but that he/she was never was administered the fluids. On 8/23/22 at 11:36 A.M., Resident #67 was observed without the intravenous access line. He/she said nursing staff removed it. Review of the physician's order summary report indicated the following: -place a peripheral line in patient for IV rehydration one time only for IV rehydration for one day. Active date 8/13/22 end date 8/14/22. -sodium chloride solution 0.9% use 125 milliliters (ml) intravenously every 4 hours for decreased fluid intake, d/c (discontinue) order after admission of 2 liters. Review of the Treatment Administration Record (TAR) indicated the following: -sodium chloride solution 0.9 % use 125 ml intravenously every 4 hours for decreased fluid intake d/c order after admission of 2 liters. Hold date from 8/13/22 to 8/17/22 dc date 8/18/22. Further review of the TAR indicated the following: dates 8/12/22 at 1600 hours (4:00 P.M.), coded as other, 8/13/22, 8/14/22, 8/16/22, 8/17/22 all timed areas were coded as H (hold) 8/18/22 was coded at 0000 hours as other, the remainder times were coded as H (hold.) The TAR indicated that the administration of the sodium chloride solution 0.9 % was not administered and was placed on hold. Review of the TAR indicated the IV access site remained in place 6 days beyond the discontinue date of 8/18/22. During an interview on 8/23/22 at 5:06 P.M., with Nurse #6, who was caring for Resident #67 on this date, said that Resident #67 had an IV recently for dehydration and she believed he/she was administered 2 liters of fluids. Nurse #6 said she was not aware if the IV was pulled (taken out.) Based on record review, observation and interview, the facility failed to ensure that management of peripherally inserted central catheters (PICC) was followed in regard to PICC line dressing changes, in accordance with the physicians' order, for 2 of 2 residents (#143 and #144) with PICC lines, and failed to ensure an intravenous (IV) access line was discontinued timely for 1 resident (#67) out of a total sample of 27 residents. Findings include: 1. For Resident #143, facility staff failed to change the resident's PICC line dressing on admission per the physician's order. Resident #143 was admitted to the facility in 8/2022, with diagnoses which included cellulitis of the right lower leg, sepsis (a blood infection) and diabetes. Review of a physician's order, dated 8/16/22, indicated to change the catheter site dressing and catheter securement device on admission, weekly and as needed. On 8/22/22 at 10:45 A.M., during observation on the [NAME] House, the surveyor observed Resident #143 sitting on the side of his/her bed. The surveyor observed a transparent dressing covering intravenous tubing on Resident #143's right upper arm. The upper portion of the dressing had lifted away from Resident #143's arm and was marked with the date 8/11/22. During an interview on 8/22/22 at 10:55 A.M., Resident #143 said that he/she got the PICC line put in when he/she was in the hospital, and the hospital staff put the dressing on. Resident #143 said the staff here haven't changed the dressing yet. During an interview on 8/23/22 at 8:20 A.M., after observation of Resident #143's right upper arm transparent PICC line dressing, Nurse #1 said that the PICC line dressing should have been changed the day Resident #143 was admitted to the facility from the hospital. Nurse #1 said the PICC line dressing was dated 8/11/22, which was prior to the resident's admission to the facility. 2. For Resident #144, facility staff failed to change the resident's PICC line dressing on admission per the physician's order. Resident #144 was admitted to the facility in 8/2022, with a diagnosis of an infection and inflammatory reaction due to internal left knee prosthesis, requiring intravenous antibiotic therapy. Review of a physician's order, dated 8/18/22, indicated to change the catheter site dressing and catheter securement device on admission, weekly and as needed. On 8/22/22 at 12:15 P.M., during observation on the [NAME] House, the surveyor observed Resident #143 sitting in his/her bed. The surveyor observed a transparent dressing covering intravenous tubing on Resident #144's right upper arm. The transparent dressing was marked with the date of 8/12/22. During an interview on 8/22/22 at 12:20 P.M., Resident #144 said he/she had a PICC line placed while he/she was in the hospital. Resident #144 said the staff will change the dressing at some point. During an interview on 8/23/22 at 8:20 A.M., after observation of Resident #144's right upper arm transparent PICC line dressing, Nurse #2 said that he was new and wasn't sure of when the PICC line dressing should be changed and he would check with the supervisor. Nurse #2 said the dressing was dated 8/12/22. Nurse #2 said he wasn't aware of the physician's order to change the dressing on admission.

Based on observation, interview and record review, the facility failed to ensure physician's orders were in place relative to the use of oxygen therapy for one Resident (#1), out of a total of 27 sampled residents. Findings include: Resident #1 was admitted to the facility in August, 2022 with diagnoses which included chronic obstructive pulmonary disease, heart failure and shortness of breath. Review of the 8/2022 Physician's Orders, indicated that there was no order which would determine the oxygen flow rate for Resident #1. Review of the 8/2022 Treatment Administration Record, indicated to obtain oxygen saturations with oxygen every shift, but did not indicate what the oxygen flow rate should be. During an observation on 8/22/22 at 2:02 P.M., the surveyor observed Resident #1 sitting up in bed with oxygen nasal prongs in place. The oxygen concentrator indicated the oxygen flow rate was set at 3 liters per minute. During an observation on 8/23/22 at 2:34 P.M., the surveyor observed Resident #1 sitting up in bed with oxygen nasal prongs in place. The oxygen concentrator indicated the the oxygen flow rate was set at 3 liters per minute. During an interview on 8/23/22 at 2:35 P.M., Nurse #1 said that Resident #1 uses oxygen at all times. Nurse #1 said she reviewed the physician orders and there wasn't one in place. Nurse #1 said she would obtain a doctor's order for the oxygen flow rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure that medications were properly stored and labeled in 2 of 5 medication drawers observed on 2 of 4 nursing units. Findings include: Review of the facility's undated Storage and Labeling of Medication policy, included the following: * Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. 1. On 8/23/22 at 8:03 A.M., the surveyor observed Nurse #5 administer medications to a resident in the [NAME] house. There was a medication cup in the drawer with unidentified pills in it and there was a loose pill in the bottom of the drawer. During an interview on 8/23/22 at 8:06 A.M., Nurse #5 said the pills in the cup looked like Tums and the pill on the bottom of the drawer looked like vitamin D. She said pills should not be left loose and unlabeled in the medication drawer. 2. On 8/23/22 at 9:13 A.M., the surveyor observed Nurse #2 administer medications to a resident in the [NAME] house. There was a loose pill in the bottom of the drawer. During an interview on 8/23/22 at 9:16 A.M., Nurse #2 was not sure what the pill was, but said it should not be there and should be thrown away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure that appropriate hand hygiene was performed to reduce the risk of spread of infection during observation of medication administration with 1 of 4 nurses (Nurse #5) on 1 of 4 nursing units. Findings include: Review of the undated, facility Infection Control Guidelines for All Nursing Procedures, included the following: * In most situations, the preferred method of hand hygiene is with an alcohol based hand rub. If hands are not visibly soiled, use an alcohol based hand rub or wash hands. * Employees must wash their hands or use antimicrobial or non-antimicrobial or non-antimicrobial soap and water under the following conditions: before preparing or handling medications. On 8/23/22 at 8:03 A.M., the surveyor observed Nurse #5 administer medications to a resident in the [NAME] house. During administration, one of the pills fell onto the floor. Nurse #5 picked the pill up from the floor, contaminating her hand. Without performing hand hygiene, Nurse #5 prepared and administered an appropriate replacement pill. During an interview, immediately after the observation, Nurse #5 said she should have washed her hands before preparing the medication to replace the pill that had fallen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that they were free from a medication error rate of 5% or greater. There were 2 errors in 29 opportunities for a medication error rate of 6.9%, during observations made on 2 of 4 houses with 2 of 4 nurses (#3 and #4); 2 residents (#48 and #72) were involved. Findings include: 1. On 8/23/22 at 8:21 A.M., the surveyor observed Nurse #3, on the [NAME] house, administer medications to Resident #48, including Magnesium Oxide 240 milligram(mg) tablet, 1 tablet. Review of Resident #48's medication administration record for August of 2022 indicated that the order for Magnesium Oxide was for 400 mg, not 240 mg as observed. During an interview on 8/23/22 at 8:25 A.M., Nurse #3 said that he thought the tablets were 400 mg tablets. When he reviewed the medication bottle again he said one tablet was 240 mg and the manufacturer listed a serving size as 2 tablets which compares to 400 mg. He said he should have given two tablets. 2. On 8/23/22 at 9:50 A.M., the surveyor observed Nurse #4, on the [NAME] house, administer medications to Resident #72, including calcium plus vitamin D 600/400 mg, 2 tablets. Review of Resident #72's medication administration record for August of 2022 indicated that the order for calcium plus vitamin D was for 600/200 mg, not 600/400 mg as observed. During an interview on 8/23/22 at 11:32 A.M., Nurse #4 said that she administered the calcium plus vitamin D that was available. She said it is not the strength that is ordered.