**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, record reviews, and facility policy review the facility failed to verify the documented advance directives signed by the Resident Representative (RR) were the preferences of a cognitively intact resident for one (1) of 16 Advance Directives reviewed. Resident #148. Findings Included: Review of the facility policy, titled Advanced Directives, revealed .Policy Interpretation and Implementation 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate and advance directive if he or she chooses to do so .4. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information . Record review of the Order Summary Report with active orders as of [DATE] revealed an order dated [DATE] Code Status; DNR (Do Not Resuscitate) EFF(effective) 081424. An additional order dated 8/2024 revealed DNR. Record review of a Nurse Note dated [DATE] at 6:19 PM revealed .States that she is not a DNR . Record review of the Resident/Representative Consent for Cardiopulmonary Resuscitation (CPR) form, dated [DATE], indicated the RR, rather than the resident herself, had signed the document upon admission. The form contained a statement that read, I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on this resident . Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #148 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. During an interview on [DATE] at 11:30 AM, Social Services stated that the Resident/Representative Consent for CPR was signed by the resident's representative at the time of admission and not by the resident. She admitted that she did not discuss CPR with Resident #148 upon admission. Considering Resident #148's BIMS score of 15, which demonstrates cognitive intactness, she agreed that she should have followed up with the resident directly to verify her preferences regarding CPR. In an interview with Resident #148 on [DATE] at 12:10 PM, the resident confirmed that no one had discussed CPR with her or asked for her wishes regarding resuscitation. She expressed that depending on the circumstances, she might want CPR performed. A review of the admission Record revealed that Resident #148 was admitted to the facility on [DATE] with diagnoses that included Unspecified dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide Activity of Daily Living (ADL) care related to removal of facial hair (Resident #3) and nail care (Resident #44) for two (2) of 13 sampled residents. Findings Included: Record review of the facility policy titled Activities of Daily Living (ADL)s with revision date of March 2018, revealed Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Resident #3 An observation on 08/26/24 at 12:14 PM, revealed Resident #3 sitting in her geri chair in the hall and she had scattered white facial hairs above her upper lip and two white chin hairs that were approximately one (1) inch long. An observation on 08/27/24 at 8:45 AM, revealed Resident #3 lying in her room asleep. She had scattered white facial hairs above her upper lip and two chin hairs that were approximately 1 inch long. During an interview on 08/27/24 at 10:27 AM, Certified Nursing Assistant (CNA) #1 revealed that Resident #3's scheduled shower days were Mondays, Wednesdays, and Fridays. She confirmed that Resident #3 had white facial hair on her upper lip and chin and she revealed that her facial hair should have been shaved during her bath the day before. CNA #1 confirmed that her facial hair had not been taken care of. Record review of Resident #3's admission Record revealed that she admitted to the facility on [DATE] with diagnoses that included Huntington's Disease, Dementia, and Heart Failure. Record review of Resident 3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/31/2024, Section C revealed a Brief Interview for Mental Status (BIMS) should not be conducted because the resident was rarely or never understood. Section GG - Functional Abilities and Goals revealed Resident #3 was dependent in maintaining personal hygiene. Resident #44 During an observation on 08/26/24 at 12:17 PM, revealed Resident #44 sitting up in his wheelchair in his room and his fingernails were long, jagged and had a brown substance underneath them. His fingernails were approximately one-half to three-fourths inch long. Resident #44 revealed that they had not cut his nails in a while and stated, Sometimes I scratch myself. He also confirmed that the staff did not check his nails every day. During an interview on 08/27/24 at 10:24 AM, CNA #1 revealed that they were supposed to provide for the resident's needs such as nail care and shaving facial hair during their bath or shower time. She confirmed Resident #44 had long, jagged nails with brown substance underneath and that his nails should have been addressed yesterday during his shower time. CNA #1 revealed that by not doing nail care could cause the resident to scratch himself, it could cause skin tears and possible infection. CNA #1 revealed that Resident #44 should have gotten his shower yesterday on the evening shift on 08/26/24 and stated that it did not look like his nails had been cleaned or clipped. On 08/27/24 at 10:30 AM, during an observation and interview with the Registered Nurse (RN) Supervisor, confirmed that Resident #44's fingernails were long, jagged and had brown substance underneath. The RN Supervisor revealed that personal hygiene included nail care, grooming, and facial hair and that the CNAs were supposed take care of these needs during their baths or showers. The RN Supervisor revealed that long, jagged, and dirty fingernails could cause skin tears, abrasions, and she agreed that it could cause infection if nails were not cared for properly. She also agreed that Resident #44's nails were not clipped nor cleaned during his shower he received the day before and stated, I will get someone on this now. During an interview on 08/27/24 at 10:40 AM, the Administrator (ADM) revealed that personal hygiene included nail care and shaving facial hair on men and ladies. She revealed that during resident showers, it was the CNAs responsibility to check the residents from head to toe and to take care of any issues that included fingernails and facial hair. Record review of Resident #44's admission Record revealed an initial admission date of 03/01/2023 with diagnoses that included Cerebral Infarction, Dysphagia, and Chronic Systolic Heart Failure. Record review of Resident #44's Physician Orders revealed an order with start date of 07/01/2024, to inspect nails daily, clean, and cut as needed. Record review of Resident #44's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/2024. Section C - Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) Score of 07 which indicated Resident #44 had severe cognitive deficits. Section GG- Functional Abilities and Goals revealed that he was dependent on staff to maintain personal hygiene.

Based on observation, staff and resident interview, record review and facility policy review the facility failed to implement an Activity of Daily Living (ADL) care plan related to removal of facial hair (Resident #3) and nail care (Resident #44) for two (2) of 13 sampled residents. Findings Included: Record review of the facility policy, Care Plans, Comprehensive Person-Centered with revision date of March 2022 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 . Resident #3 Record review of Resident #3's Care Plan with a problem onset date of 04/19/2022 revealed .requires assistance with ADLs (Activities of Daily Living) . Approaches . Total assistance x 1 staff for all ADLs (Bed Mobility, Transfers, Locomotion, Dressing, Eating, Toileting, Hygiene, Bathing) . On 08/26/24 at 12:14 PM, an observation of Resident #3 revealed her sitting in her geri chair in the hall and she had scattered white facial hairs above her lip and two white chin hairs which were approximately one (1) inch long. On 08/27/24 at 8:45 AM, an observation of Resident #3 revealed her lying in her bed asleep and she had scattered white facial hairs above her upper lip and two chin hairs which were approximately one (1) inch long. On 08/27/24 at 10:27 AM, an interview with Certified Nursing Assistant (CNA)#1 revealed that Resident #1's scheduled shower days were Monday, Wednesday, and Friday and the CNAs were supposed to take care of facial hair during that time. CNA #1 confirmed that Resident #3 had white facial hair to her upper lip and chin and that her facial hair had not been shaved during her bath the day before. Record review of Resident #3's admission Record revealed an admission date of 08/07/2008 with diagnoses that included Huntington's Disease, Dementia, and Heart Failure. Record review of Resident 3's MDS with an Assessment Reference Date (ARD) of 07/31/2024, Section C revealed a Brief Interview for Mental Status (BIMS) should not be conducted because the resident was rarely or never understood. Section GG - Functional Abilities and Goals revealed Resident #3 was dependent in maintaining personal hygiene. Resident #44 Record review of Resident #44's Care Plan with a problem onset undated, revealed .is at risk for impaired function/Daily ADL abilities and requires assistance to complete Activities of Daily Living (ADLs) .Approaches .Inspect nails daily, clean and cut as needed . An observation on 08/26/24 at 12:17 PM, revealed Resident #44 sitting up in his wheelchair in his room and his fingernails were long, jagged and had a brown substance underneath them. His fingernails were approximately one-half (1/2) to three-fourths (3/4) inch long. Resident #44 revealed that they had not cut his nails in a while and stated, Sometimes I scratch myself. He also confirmed that the staff did not check his nails every day. On 08/27/24 at 10:24 AM, an interview with CNA #1 revealed that they were supposed to provide for resident needs such as nail care and shaving facial hair during their bath or shower time. She confirmed that Resident #44 had long, jagged nails with a brown substance underneath and that his nails should have been addressed yesterday during his shower time. CNA #1 revealed that not doing nail care could cause the resident to scratch himself, it could cause skin tears and possible infection. CNA #1 revealed Resident #44 should have gotten his shower yesterday on the evening shift on 08/26/24 and she agreed that Resident #44 had not received nail care and stated that it did not look like his nails had been cleaned or clipped. On 08/27/24 at 10:30 AM, an observation and interview with Registered Nurse (RN) Supervisor, confirmed that Resident #44's fingernails were long and jagged. She also confirmed the brown substance under his nails. The RN Supervisor revealed that personal hygiene included nail care, grooming, and facial hair and the CNAs were supposed take care of these needs during their baths or showers. The RN Supervisor revealed that long, jagged, and dirty fingernails could cause skin tears, abrasions, and she agreed that it could cause infection if nails were not cared for properly. She also agreed that Resident #44's nails were not clipped nor cleaned during his shower he received the day before and stated, I will get someone on this now. On 08/27/24 at 10:40 AM, an interview with Administrator (ADM) revealed that personal hygiene included mouth care, nail care, and shaving facial hair on men and ladies. She revealed that during resident showers, it was the CNAs responsibility to check the fingernails and to take care of facial hair. She revealed that the CNAs were supposed to check the residents from head to toe while they had them in the shower and take care of any concerns which included fingernails and facial hair. She revealed that they were also supposed to report any other concerns to the nurse. The ADM confirmed Resident #3 and Resident #44's ADL Care Plan was not followed related to nail care and removal of facial hair. On 08/27/24 at 2:52 PM, an interview with Minimum Data Set (MDS) Coordinator revealed that the purpose of the comprehensive care plan was to ensure continuity of care for the residents. She confirmed that Resident #3's ADL care plan was not implemented related to her personal hygiene needs which included removal of facial hair. She also agreed that Resident #44's Care Plan was not followed when the staff failed to clean and clip his fingernails. Record review of Resident #44's admission Record revealed an initial admission date of 03/01/2023 with diagnoses that included Cerebral Infarction, Dysphagia and Chronic Systolic Heart Failure. Record review of Resident #44's Physician Orders revealed an order with start date of 07/01/2024, to inspect nails daily, clean, and cut as needed. Record review of Resident #44's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/2024. Section C - Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) Score of 07 which indicated Resident #44 had severe cognitive deficits. Section GG- Functional Abilities and Goals revealed that he was dependent on staff to maintain personal hygiene.

Based on observation, staff interview, record review and facility policy review the facility failed to implement the care plan for impaired respiratory function for (1) one of 16 resident care plans reviewed. Resident #10 Findings include: A review of the facility policy titled, Care plans, Comprehensive Person-Centered, revised December 2016 revealed, Policy Statement 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 . Policy Interpretation and Implementation . 8. The comprehensive, person-centered care plan will: b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . An observation of Resident #10 on 7/11/23 at 11:39 AM, revealed resident receiving oxygen (O2) via nasal canula and the O2 tubing and humidifier bottle with no date. A record review of the care plan for Resident #10 with a problem onset date of 3/22/22, revealed (Proper name of Resident #10) is at risk for impaired respiratory function r/t (related to) Chronic Pulmonary Edema .Approaches .Change O2 tubing and Aquapack Q (every) Monday . During an observation and interview with Licensed Practical Nurse (LPN)#1 on 7/12/23 at 8:30 AM, she confirmed there was not a date on the oxygen tubing or humidifier bottle and revealed it should be changed weekly. LPN #1 then confirmed she was uncertain of the last time the tubing and humidifier bottle was changed because there was no label or date of when it was last changed. An interview and record review of the comprehensive care plan with the Director of Nursing (DON) on 7/12/23 at 9:00 AM, confirmed staff were not following Resident #10's plan of care for oxygen therapy and revealed the purpose of the care plan is to direct the staff of the resident's specific care needed. Record review of the Face Sheet revealed that the facility admitted Resident #10 to the facility on 1/17/2018 with diagnoses of Persistent Vegetative State and Chronic Pulmonary Edema.

Based on observation, staff interview, and record review the facility failed to sign out controlled medications prior to administration to a resident for (1) one of (6) six residents reviewed during medication pass. Resident #29. Findings include: An observation, on 7/12/23 at 9:20 AM revealed Licensed Practical Nurse (LPN) #1 set up medications for Resident #29. The medications included Lacosamide, Xanax, and Norco. LPN #1 did not sign out the controlled medications prior to administering them. An interview on 7/12/23 at 9:25 AM, with LPN #1 revealed that she really did not know when she was supposed to sign them (controlled medications) out. She stated that she does it after she gives them in case the resident does not take it. An interview on 07/13/23 at 08:30 AM, with the Director of Nursing (DON) revealed that all controlled medications should be signed out when the nurse punches it out. If the nurse waits to sign out controlled medications, she could forget to do it and the count would be wrong or could lead to drug diversion. Record review of the July 2023 Physician Orders for Resident #29 dated revealed orders for Xanax 0.5 mg tablet 1 (one) PO (by mouth) BID (two (2) times a day) for anxiety, Lacosamide 150 mg tablet 1 PO BID for convulsions, and Norco 7.5-325 tablet 1 PO BID for pain. Record review of the facility Face Sheet for Resident #29 revealed an admission date of 6/15/23 with diagnosis that included Chronic Obstructive Pulmonary Disease, Heart Failure, generalized Anxiety Disorder, and Unspecified Convulsions.

Based on observation, staff interview, record review, and facility policy review the facility failed to label and date oxygen tubing and a humidifier bottle (Aquapack) for (1) one of (7) seven residents receiving oxygen therapy. Resident #10. Findings include: A review of the facility policy titled, Oxygen Administration, with a revised date of October 2022, revealed Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration .Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure .6. Label oxygen supplies (tubing, mask. Etc.) with date and initial. Supplies should be changed at least weekly while in use . On 7/11/23 at 11:39 AM, an observation of Resident #10 revealed the resident was receiving oxygen (O2) per nasal canula and the oxygen tubing and humidifier bottle were not dated. An observation of Resident #10's O2 tubing and humidifier bottle with Licensed Practical Nurse (LPN) #1 on 7/12/23 at 8:30 AM, confirmed there was not a date on the oxygen tubing or humidifier bottle. State Agency asked how often should the O2 tubing, and humidifier bottle should be changed, and LPN #1 revealed weekly on Mondays. LPN #1 stated she was uncertain of the last time the tubing and humidifier bottle was changed because there was label or date of when it was last changed. LPN #1 confirmed when the tubing is changed it should be dated and revealed concerns from not changing the tubing and humidifier bottle as ordered is dust build up on tubing, increased risk for infection, and giving the resident non humidified oxygen causing sores or dry nostrils. An interview with the Director of Nursing (DON) on 7/12/23 at 9:00 AM, revealed that oxygen tubing and humidifier bottle should be changed weekly and initialed and dated. The DON confirmed if the tubing and humidifier bottle was not dated there was no way to be certain of when it was last changed and confirmed concerns of not changing the tubing as ordered is increased risk of infections. A record review of Resident #10's Physician Orders for July 2023, revealed an order dated 1/24/19 for O2 at 3 L/MIN (liters per minute) continuously Chronic Pulmonary Edema and an order dated 4/24/23, Change O2 tubing and AquaPack Q (every) Monday. Record review of the Face Sheet revealed the facility admitted Resident #10 to the facility on 1/17/2018 with diagnoses including Persistent Vegetative State and Chronic Pulmonary Edema.

Based on observations, staff interviews, and facility policy review the facility failed to perform hand hygiene upon removing gloves, failed to dispose of a pill after it fell on the medication cart, and failed to use a barrier when administering eye drops for (2) two of (6) six residents reviewed during medication pass. Resident #15 and #29. Findings include: Review of the facility policy titled, Handwashing/Hand Hygiene, revised 2015, revealed, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: .m. After removing gloves . Review of the facility policy titled, Installation of Eye Drops, undated, revealed, Purpose The purpose of this procedure is to provide guidelines for installation of eye drops to treat medical conditions, eye infections and dry eyes. After the eye drops are administered, the steps in the procedure include remove gloves and discard into designated container. Wash and dry your hands thoroughly. Clean your equipment and return it to its designated area. An observation during medication pass on 7/12/23 at 8:30 AM, with Licensed Practical Nurse (LPN) #1, revealed during the administration of the Artificial Tears eye drops LPN #1 placed the eye drop box and the eye drop bottle top on the overbed table without a barrier and without disinfecting the table. LPN #1 donned gloves to administer the eye drops. She removed her gloves after administering the eye drops and did not wash her hands before administering the remainder of the residents' medications. LPN #1 exited the resident room and placed the contaminated eye drops in the medication cart drawer. An observation on 7/12/23 at 8:40 AM, with LPN #1 revealed LPN #1 dropped a Folic Acid 1 milligram tablet on the top of the medication cart and picked it up and administered it to Resident #29. An interview on 7/12/23 at 1:30 PM, with LPN #1 confirmed that she did drop a pill on the top of the medication cart during medication pass. She stated that she should have discarded it and got another one because of contamination. She stated that she thought about it but went ahead and put it in the cup. LPN #1 confirmed she should have used a barrier for the eye drops to prevent contamination and placing them in the medication cart drawer contaminated the drawer. She stated that she realized she should have washed her hands after taking her gloves off and before giving the resident the rest of her medication. She stated that she should wash her hands anytime she removes her gloves. An interview on 07/13/23 at 08:30 AM, with the Director of Nursing (DON) revealed staff should wash their hands anytime gloves are removed to prevent contamination and spread of infection. Barriers should be used to prevent the spread of infection or wipe the table with a purple top (disinfectant) wipe because you don't know what is on the tables in resident's rooms. The DON stated that if a medication is dropped on the top of the cart, it should be disposed of and if it was picked up without the nurse having on gloves and put into the medication cup, the whole cup of medications was contaminated.

Based on observation, staff interview, record review and facility policy review the facility failed to discard out of date Influenza vaccines and failed to secure injectable Lorazepam in a locked secured box in the refrigerator for (1) one of (1) one medication storage room. Findings include: Review of the facility policy titled, Storage of Medications with a revised date of April 2007, revealed, Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Policy Interpretation and Implementation .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location . An observation on 07/12/23 at 03:50 PM, with Licensed Practical Nurse (LPN) #2 revealed 10 Fluzone single dose vaccines with an expiration date of 5/20/23, 11 single dose flu vaccines with an expiration date of 5/11/22, one (1) multidose five (5) milliliter (ml) vial out of date on 1/27/22, and four (4) five (5) ml vials of Flu vaccine out of date on 6/30/23. The observation also revealed nine (9) vials of Lorazepam 2mg(milligram)/ml (millimeter) in a locked drawer in the medication room in plastic box sealed with a zip tie. The Lorazepam vial label revealed to refrigerate. The vials were not refrigerated. The refrigerator did not have a secured lock box inside for the storage of control medications requiring refrigeration. LPN #2 confirmed these findings. An interview, concerning the out-of-date flu vaccines, on 7/12/23 at 3:53 PM with LPN #2 revealed if out of date medications are used, they may not be giving the most effective dose to the resident. LPN #2 confirmed the Lorazepam vials indicated to refrigerate. She stated they have always kept them in this locked drawer. An interview on 7/12/23 at 4:10 PM, with the Administrator (ADM) revealed Ativan (Lorazepam)should be in the refrigerator to maintain its potency. She confirmed the vials are labeled to refrigerate. The ADM confirmed the vials were in a plastic container with other medications sealed with a zip tie and in a locked drawer in the medication room that could easily be taken. She stated the Lorazepam should be in a locked box secured inside the refrigerator. She confirmed the refrigerator did not have a secured box, but they would get one. An interview on 07/13/23 at 10:20 AM, with the Director of Nursing (DON) confirmed the flu vaccines were out of date and should have been removed from the refrigerator. She stated that the Lorazepam should be in the refrigerator in a secured locked box. An interview on 07/13/23 at 10:29 AM, with Licensed Practical Nurse (LPN) #3 concerning flu vaccines revealed that she was responsible for them and should have discarded them. She stated that none of the out-of-date vaccines had been given to a resident. A telephone interview on 7/13/23 at 12:58 PM, with the facility Consultant Pharmacist revealed he was in the facility during the survey. He confirmed they probably should have caught the out-of-date flu vaccine in the refrigerator. He stated the resident could be at risk for not receiving an effective dose if an out-of-date vaccine was given. The Consultant Pharmacist stated that ideally Lorazepam should be stored in the refrigerator and the facility should have a secured lock box in the refrigerator. Review of the inpatient influenza vaccination record revealed the last influenza vaccine given was on 2/3/23 from a vial with an expiration date of 6/30/23.

Based on record review, staff interview and facility policy review the facility failed to ensure kitchen sanitation was maintained in a manner that meets professional standards for 44 of 49 residents whose meals are prepared in the kitchen. Findings include: Review of the facility policy titled Machine Warewashing, with a revision date of 6/14, revealed, .Procedure .3. The dishmachine operator documents the machine temperature and concentration of the sanitizing solution for warewashing after each meal on the Dishmachine Temperature/Chemical Log . Review of the facility policy titled, Manual Warewashing, with a revision date of 10/17, revealed, .Procedure . 6. The concentration of the sanitizing solution is checked with an appropriate test kit when the sink is filled .9. The employee using the three compartment sink documents temperature and concentration. A record review of the July Dish Machine and Pot/Pan Sink form revealed that there was no documentation of temperatures or chemical sanitation levels for the low temperature dish machine or the pot/pan sink from 7/1/23 through 7/10/23. During an interview with the Dietary Manager on 7/11/23 at 9:15 AM, she confirmed there were no documented temperatures or chemical sanitation levels for the low temperature dish machine or pot/pan sink from 7/1/23 through 7/10/23. She stated that she was off during that time and did not realize it was not done. The Dietary Manager stated that the tray aids and cooks were responsible for checking and documenting the temperatures and chemical sanitation levels; and that the cooks were responsible for making sure that it was completed when she was out. She verified that the temperatures and chemical sanitation levels should have been checked and documented. During an interview with Tray Aide #1 and Tray Aide #2 on 7/11/23 at 1:20 PM, they both confirmed that they did not check temperature or chemical sanitation levels for the dish machine or pot/pan sink while the Dietary Manager was out. During an interview with the cook on 7/11/23 at 1:22 PM, revealed he had checked some of the temperatures and chemical sanitation levels for the dish machine and pot/pan sink, but he did not document them. He stated that he should have documented the temperatures and chemical sanitation levels. The cook stated that if the temperatures and chemical sanitation levels for the dish machine and pot/pan sink are not checked then you cannot be sure the dishes are clean, and this can lead to foodborne illness for the residents. During an interview with the Administrator on 7/11/23 at 3:30 PM, she confirmed that the kitchen staff should have documented temperature and chemical sanitation levels for the dish machine and pot/pan sink. The Administrator stated that failure to ensure temperatures and chemical sanitation levels are adequately maintained could lead to resident illness.

Based on observation, staff interview, facility policy review, and record review, the facility failed to perform medication administration in a manner to prevent the likelihood of the spread of infection, as evidenced by failure to disinfect a plastic tray barrier and stethoscope, and to perform hand hygiene appropriately between residents during medication administration observations for three (3) of six (6) residents observed during medication administration. Findings include: Record review of the facility policy titled Administering Medications revised December 2012 revealed Medications shall be administered in a safe .manner . 22. Staff shall follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Record review of the facility policy titled Administering Medications through an Enteral Tube revised March 2015 revealed .Steps in the Procedure 1. Wash your hands .34. Wash your hands . Record review of the facilities Infection Control Guidelines for All Nursing Procedures revised May 2021 revealed . General Guidelines 3. Employees must wash their hands using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents d. After removing gloves 4. 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 containing 60-95% ethanol or isopropanol for all the following situations: a. Before and after direct contact with residents; . d. Before preparing or handling medications; . g. After contact with a resident's intact skin; . i. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident j. After removing gloves. On 09/20/21 at 4:30 PM, an observation of Licensed Practical Nurse (LPN) #1 administering medications to the Unsampled Resident A revealed LPN #1 did not wash her hands or use hand sanitizer before preparing medications. LPN #1 removed a plastic tray from the drawer of the medication cart and placed it on top of the medication cart. LPN #1 prepared the medications, placed the medications on the plastic tray and entered the resident's room. LPN #1 placed the plastic tray on the counter by the sink and then placed it on the bedside table without prior sanitation to either area. LPN #1 brought in a box containing a stethoscope. LPN #1 placed the box on the bed of the resident, she opened the box and removed the stethoscope. The Percutaneous Endoscopic Gastrostomy (PEG) tube placement was checked with the stethoscope by placing the stethoscope on the resident's abdomen. The stethoscope was replaced in the box and was not cleaned prior to checking placement or after returning the stethoscope to the box. The plastic tray that contained the medications and the stethoscope box were returned to the medication cart and placed on top of the medication cart. The stethoscope box and plastic tray were then placed in the medication cart drawer without being cleaned and sanitized. LPN #1 did not wash her hands or use hand sanitizer prior to entering the resident's room, after administering the medications, before exiting room or returning to the medication cart. On 09/20/21 at 4:50 PM an observation of LPN #1 administering medications to Unsampled Resident B revealed LPN #1 did not wash her hands or use hand sanitizer before preparing the medications. LPN #1 then entered the resident's room and administered the medications to the resident. LPN #1 did not wash her hands or use hand sanitizer after the medications were administered, before exiting room or returning to the medication cart. On 09/20/21 at 4:55 PM an observation of LPN #1 administering a medication to a resident while she was in the dining room revealed LPN #1 did not wash her hands or use hand sanitizer before preparing the medications. LPN #1 entered the dining room and administered the medication to the resident. LPN #1 did not wash her hands or use hand sanitizer after the medication was administered, before exiting the dining room or returning to the medication cart. 09/20/21 at 5:00 PM an interview with LPN #1 confirmed she did not clean the plastic tray or stethoscope after administering PEG medications to Unsampled Resident A. The interview also confirmed that she did not wash her hands or use hand sanitizer after administering the PEG medications for Unsampled Resident A, before or after administering by mouth (PO) medications to Unsampled Resident B and before or after administering PO meds to the resident in the dining room. LPN #1 confirmed that she should have cleaned the plastic tray and stethoscope box prior to using it and she should have sanitized the plastic tray and stethoscope box after the medication administration prior to placing it back in the medication cart. LPN #1 confirmed that she should have washed her hands or used hand sanitizer prior to entering and exiting the resident rooms and that her failure to do this could spread infection and germs and LPN #1 confirmed that she has had in-services related to infection control and stated, I was just nervous. 09/20/21 at 5:25 PM, an interview with the Director of Nursing (DON) confirmed that plastic barrier trays used during medication administration should be cleaned and disinfected before and after use, stethoscopes should be cleaned and disinfected before and after use and hand hygiene should be done by staff before and after direct contact with residents. Record review of LPN #1's COVID-19 Orientation/Infection Control dated 9/14/21 and signed and checked off by LPN #1 and the DON revealed guidance 1. Oriented to infection control procedure. 2. Proper hand hygiene performed. 3. Standard precautions orientation. 4. Location of PPE (Personal Protective Equipment) .