Based on record review and interview, it was determined that the facility failed to ensure that PRN (as need) psychotropic drugs were limited to 14 days and document the rationale in the resident's medical record for extending PRN psychotropic drugs beyond 14 days for 1 of 6 residents reviewed for unnecessary medications in a final sample of 16 residents (Resident Identifier is #67). Findings include: Review on 3/13/25 of Resident #67's February 2025's Physician's Orders revealed the following physician's order written on 2/23/25 with a stop date of 2/26/25: 1. Lorazepam 2 mg/ml conc [concentrate] 0.25 ml [milliliters] (0.5 mg [milligram]) SL[sublingual] every 4 hrs [hours] PRN mild anxiety/agitation . 2. Lorazepam 2 mg/ml conc 0.5 ml (1 mg) SL every 4 hrs PRN mod [moderate-severe anxiety/agitation. Review on 3/13/25 of Resident #67's February 2025's Physician's Orders revealed the following physician's order written on 2/27/25 with no stop date: 1. Lorazepam 2 mg/ml conc [concentrate] 0.25 ml [milliliters] (0.5 mg [milligram]) SL[sublingual] every 4 hrs [hours] PRN mild anxiety/agitation . 2. Lorazepam 2 mg/ml conc 0.5 ml (1 mg) SL every 4 hrs PRN mod [moderate-severe anxiety/agitation. Review on 3/13/25 of Resident #67's medical record revealed no rationale for extending the above PRN order beyond 14 days. Review on 3/13/25 of Resident #67's Medication Administration Record (MAR) for February 2025 and March 2025 revealed that Resident #67 received no doses of PRN Lorazepam medication in February 2025 and one PRN dose of Lorazepam was given on 3/11/25. Interview on 3/13/25 at approximately 10:00 a.m. with Staff B (Director of Nursing) confirmed that the above orders did not have a rationale for the PRN order to be extended beyond 14 days. Review on 3/13/25 of the facility's policy titled, Medication Administration, dated 9/5/02, revealed: 27. If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the consulting the Consultant Pharmacist as needed, shall reevaluated the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. a. If PRN medication is for an Antipsychotic or Psychotropic medication, applicable stop date for reassessment will be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that residents were offered or provided education on the risks and benefits of the pneumococcal vaccination for 4 of 5 residents reviewed for immunizations (Resident identifiers are #12, #18, #30, and #67). Findings include: Resident #12 Review on 3/12/25 of Resident #12's medical record revealed that Resident #12 was [AGE] years old and was admitted to the facility in 9/2023. Resident #12's immunization record revealed that pneumovax 23 was given on 9/25/12 and prevnar 13 was given on 9/3/15. Further review of Resident #12's medical record revealed that there was no indication that further pneumococcal vaccination was offered or that education was provided on the pneumococcal vaccination. Resident #18 Review on 3/12/25 of Resident #18's medical record revealed that Resident #18 was [AGE] years old and was admitted to the facility in 5/2024. Resident #18's immunization record revealed that the pneumovax 23 was given on 10/1/03. Further review of Resident #18's medical record revealed that there was no indication that further pneumococcal vaccination was offered or that education was provided on the pneumococcal vaccination. Resident #30 Review on 3/12/25 of Resident #30's medical record revealed that Resident #30 was [AGE] years old and was admitted to the facility in 2/2024. Resident #30's immunization record revealed that the pneumovax 23 was given on 9/1/09. Further review of Resident #30's medical record revealed that that there was no indication that further pneumococcal vaccination was offered or that education was provided on the pneumococcal vaccination. Resident #67 Review on 3/12/25 of Resident #67's medical record revealed that Resident #67 was [AGE] years old and was admitted to the facility in 2/2025. Resident #67's immunization record revealed that the Prevnar 13 was given on 10/24/16 and pneumovax 23 given on 10/15/18. Further review of Resident #67's medical record revealed that that there was no indication that further pneumococcal vaccination was offered or that education was provided on the pneumococcal vaccination. Interview on 3/12/25 at 10:53 a.m. with Staff A (Infection Preventionist) confirmed the above findings. Review on 3/12/25 of facility policy titled, Pneumococcal Vaccine: Residents, dated 9/10/2024, revealed: . 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccine status will be conducted within five (5) working days of the resident's admission if no conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. (see current vaccine information statements at http.www.cdc.gov/vaccines/hcp/vis/index/html for educational materials.) Provision of such education shall be documented in the resident's medical record . Review on 3/12/25 of the Center for Disease Control and Prevention guideline titled, Vaccines and Immunizations -Adult Immunization Schedule - Pneumococcal Vaccination, dated November 21, 2024, retrieved from https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-notes.html, revealed: .Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 or 1 dose of PCV21 at least 5 years after the last pneumococcal vaccine dose .Previously received only PPSV23: 1 dose PCV15 or 1 dose PCV20 or 1 dose PCV21 at least 1 year after the last PPSV23 dose.

Based on observation, interview, and record review, it was determined that the facility failed to properly label medication in 1 of 4 medication carts observed (second floor 2F unit medication cart). Findings include: Observation on 2/21/24 at approximately 10:30 a.m. of the second floor 2F unit medication cart revealed an open Lispro insulin flex pen without an open date and/or an open expiration/discard date that was in use for Resident #119. Interview on 2/21/24 with Staff E (Medication Nurse Assistant) confirmed the above finding. Review on 2/22/24 of the facility's policy titled Storage and Destruction of Medications dated 2/8/18, revealed: .3.medications shall include all necessary information, such as .Date opened Review on 2/22/24 of Humalog Insulin Lispro Injection manufacturer specifications, dated 3/2013, revealed: .16.2 Storage and Handling .In-use HUMALOG vials, cartridges, pens, and HUMALOG KwikPen .must be used within 28 days or be discarded, even if they still contain HUMALOG .

Based on record review, observation, interview, and policy review, it was determined that the facility failed to follow policies for managing healthcare personnel with symptoms of SARS-CoV-2 (COVID-19) working in the facility (Staff identifiers are F, G, H, I, J, K, L, and M) and to sanitize a dining utility cart between uses on 1 of 2 units observed (second floor dining room). Findings include: Observation on 2/21/24 at 8:00 a.m. of the facility's staff entrance revealed COVID-19 screening for staff to attest every time a staff member enters the facility. Observation further revealed a form that each staff member has to record the date, time, name, temp, and yes or no to Have you experienced any new symptoms of COVID-19 in the past 48 hours? and In the past 10 days, have you tested positive for COVID-19 or had contact with anyone confirmed to have COVID-19? Interview on 2/21/24 at 8:10 a.m. with Staff N (Administrator) revealed that the facility was currently in an outbreak with COVID-19, 9 residents were on isolation precautions and 21 staff had tested positive on 2/19/24. Review on 2/22/24 of the facility's policy titled Infection Control Program - COVID -19 Residents/Staff/Visitor dated 1/19/24, revealed .Staff that present with high risk exposure and/or clinical manifestations of Covid -19 will be managed on a case by case basis in accordance with this policy, Staff Illness policy and current CDC [Centers for Disease Control and Prevention] guidelines .It is the responsibility of the Employee to .Avoid reporting for work with a possible infectious illness . Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff F's (Housekeeping) symptom (cold symptoms) on set began on 2/16/24, tested positive on 2/19/24, and their last day of work was 2/19/24. Review on 2/22/24 of the facility's payroll log revealed Staff F worked on 2/16/24 for 10.62 hours and on 2/19/24 began work at 4:26 a.m. until he/she left the facility after testing positive for COVID-19. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff G's (Dining Services) symptom (runny nose) on set began on 2/17/24, tested positive on 2/19/24 and their last day of work was 2/19/24. Review on 2/22/24 of the facility's payroll log revealed Staff G began work at 7:57 a.m. on 2/19/24 until he/she left the facility after testing positive for COVID-19. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff H's (Dining Services) symptoms (runny nose and cough) on set began on 2/16/24, tested positive on 2/19/24, and their last day of work was 2/19/24. Review on 2/22/24 of the facility's payroll log revealed Staff H worked on 2/16/24 for 7.33 hours, on 2/17/24 for 7.3 hours, on 2/18/24 for 7.27 hours, and on 2/19/24 began work at 5:56 a.m. until he/she left the facility after testing positive for COVID-19. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff I's (Dining Services) symptom (cold symptoms) on set began on 2/17/24, tested positive on 2/19/24, and their last day of work was 2/19/24. Review on 2/22/24 of the facility's payroll log revealed Staff I worked on 2/19/24 for 3.72 hours until he/she left the facility after testing positive for COVID-19. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff J's (Dining Services) symptoms (cough and congestion) on set began on 2/16/24, tested positive on 2/19/24, and their last day of work was 2/18/24. Review on 2/22/24 of the facility's payroll log revealed Staff J worked on 2/16/24 for 6.52 hours, on 2/17/24 for 7.22 hours, and on 2/18/24 for 7.33 hours. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff K's (Dining Services) symptom (runny nose) on set began on 2/17/24, tested positive on 2/19/24, and their last day of work was 2/18/24. Review on 2/22/24 of the facility's payroll log revealed Staff K worked on 2/17/24 for 7.28 hours and on 2/18 for 7.1 hours. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff L's (Dining Services) symptom (cold symptoms) on set began on 2/18/24, tested positive on 2/19/24, and their last day of work was 2/19/24. Review on 2/22/24 of the facility's payroll log revealed Staff L worked on 2/18/24 for 7.9 hours and on 2/19/24 for 5.52 hours until he/she left the facility after testing positive for COVID-19. Review on 2/22/24 of the facility's contact tracing list and investigation revealed that Staff M's (Housekeeping) symptom (cough) on set began 2/17/24, tested positive on 2/19/24, and last day of worked was 2/18/24. Review on 2/22/24 of the facility's payroll log revealed Staff M worked on 2/17/24 for 7.78 hours and on 2/18/24 for 8.1 hours. Interview on 2/22/24 at 8:45 a.m. with Staff N and Staff O (Director of Nursing) confirmed that Staff F, G, H, I, J, K, L, and M worked while symptomatic. Interview further revealed that the above staff were attesting upon entrance no to being symptomatic but once staff tested positive, they started their investigation and asked the positive staff when their symptoms started. Interview on 2/22/24 at 10:30 p.m. with Staff P (Infection Prevention) revealed that education about staying home when feeling sick was an ongoing effort but Staff P provided education in October during a flu clinic and in December during National Influenza Vaccine Week. Review on 2/22/24 of the facility's policy titled Staff Illness dated 1/19/24, revealed .Requirements: Prior to shift, all staff will self-screen for illness . Staff with a potential communicable disease or infected skin lesions, are prohibited from having contact with resident and/or their food until they have cleared per nationally recognized standards and regulations .It is the responsibility of the staff to: Not report to work if ill . Review on 2/22/24 of the CDC Interim Guidance for Managing Healthcare Personnel [HCP] with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html, updated September 23, 2022, revealed, .Evaluating Healthcare Personnel with Symptoms of SARS-CoV-2 Infection HCP with even mild symptoms of COVID-19 should be prioritized for viral testing with nucleic acid or antigen detection assays .If using NAAT [Nucleic Acid Amplification Test] (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining work restrictions and confirming with a second negative NAAT. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or a second negative antigen test taken 48 hours after the first negative test. For HCPs who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses.Observation on 2/21/24 at approximately 12:20 p.m. in the second floor dining room revealed a utility cart containing 4 used breakfast trays. The lunch cart arrived at the dining room and Staff A (Licensed Nursing Assistant (LNA)) removed the 4 used breakfast trays (been distributed to residents and then returned after meal) from the utility cart and placed them on the countertop. Staff A then proceeded to take a lunch tray from the lunch cart and place it on the utility cart where the used breakfast trays had been without sanitizing the cart. Interview on 2/21/24 at approximately 12:20 p.m. with Staff B (LNA) revealed that the kitchen staff that delivered the lunch trays usually took the used breakfast trays downstairs on the utility cart. Staff B stated that the utility cart should have been sanitized before placing the lunch tray on the utility cart. Review on 2/21/24 of the facility policy titled Health Services Center Dining Program dated 1/20/23 revealed: .4 At the conclusion of the meal nursing personnel will return the trays to the cart. Dining personnel will retrieve the cart from the HSC (Health Service Center) and return them to the kitchen so all items can be cleaned and sanitized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow physician's orders and standards of practice during medication administration observation for 1 out of 3 residents observed (Resident identifier is #3). Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th Edition, St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders, The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 2/1/23 of Resident #3's February 2023 Medication Administration Record (MAR) revealed the following physician's order: Miralax powder, Give 17 grams of powder in 8 ounces (oz) of fluid of choice daily at 8:00 a.m. Observation on 2/1/23 at approximately 7:20 a.m. during medication administration with Staff A (Licensed Practical Nurse) revealed that he/she was about to enter Resident #3's room without the resident's ordered Miralax. Interview on 2/1/23 at approximately 7:20 a.m. with Staff A confirmed the above findings and they were done preparing medications and were not going to administer Resident #3's ordered Miralax. Review on 2/1/23 of the facility policy titled, Medication Administration, Dated 10/7/22 revealed: .3. Medications must be administered in accordance with the orders, including any required time frame Reference for the professional standard of practice for the administration of medication is the 10th Edition of Clinical Nursing Skills and Techniques, [NAME]-[NAME] page 602 which revealed the following: Preadministration Activities, . 7. Avoid touching tablets and capsules. Observation on 2/1/23 at approximately 7:20 a.m. with Staff A (Licensed Practical Nurse) revealed that he/she dropped 3 pills on the medication cart (2 pills landing on the medication cart and 1 pill landing on the keyboard) and picked the 3 pills up with his/her bare fingers and placed the medication in a medication cup. Further observation revealed Staff A open a capsule with his/her bare fingers and emptied the capsule into a medication cup. Staff A administered the 3 medications that fell to the resident. Interview on 2/1/23 at approximately 7:20 a.m. with Staff A confirmed the above findings. Staff A stated that he/she does not wear gloves when opening capsules. Interview on 2/2/23 at approximately 11:30 a.m. with Staff B (Director of Nurses/Infection Preventionist) confirmed that medications in capsule should not be opened without gloves and medications that land on the medication cart should not be administered.