Based on observation and interview, it was determined that the facility failed to follow professional principles for the storage of medications for 1 of 2 medication carts observed. Findings include: Observation on 2/6/25 at 12:03 p.m. of the high side medication cart in a common area was left unlocked and unattended. Further observation revealed that there were two residents in the area of the medication cart. Interview on 2/6/25 at 12:08 p.m. with Staff C (Clinical Corporate Nurse) confirmed the above findings. Staff C stated it was the facility policy to lock the medication cart when not attended by nursing staff. Review on 2/10/25 of the facility's policy titled Medication Storage, not dated, revealed the following .Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biological's will be stored in locked compartments (i.e., Medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperatures controls. b. Only authorized personnel will have access to the keys to locked compartments. c. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .

Based on observation, interview, and record review, it was determined that the facility failed to label and store food in accordance with professional standards for food safety to prevent foodborne illness, to measure the parts per million (PPM) for the low temperature dishwasher to ensure proper sanitization, and to maintain a clean environment for 1 of 1 kitchens observed. Findings include: Interview on 2/5/25 at approximately 8:25 a.m. with Staff J (Food Services Manager) revealed that the facility utitlized a low temperature chemical sanatizing dishwasher. Staff J stated they don't perform PPM testing as long as the temperatures were within range. Review on 2/5/25 of the Monthly Dish Machine Logs for January 2025 and February 2025 revealed that the PPM testing was not documented. The Machine Dish Log had spaced to record PPM testing 3 times a day. The Machine Dish Log contained the following statement: If temperatures or chemical concentration does not meet parameters, stop washing and alert a manager or designee. Review on 2/5/25 of the Product Specification Document copyright 2023 Ecolab USA Inc. revealed .Use a chlorine test kit and increase dosage, as necessary, to obtain the required level of available chlorine Set sanitizer concentrations at 50 parts per million. (Notice: Do not exceed 100 PPM's) . Interview on 2/6/25 at approximately 8:10 a.m. with Staff H (Regional Dietary Manager) confirmed the above findings. Observation on 2/5/25 at approximately 8:20 a.m. in the kitchen revealed the presence of dried cooked eggs, egg shells, pasta, and food debris on the floor in the food preparation area. Observation on 2/5/25 at approximately 8:25 a.m. in the walk-in refrigerator revealed a purple dried substance under the shelving. There were sdried onion skins and other miscellaneous unidentified debris. Interview on 2/5/25 at approximately 8:26 a.m. with Staff I (Cook) confirmed the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and policy review, it was determined that the facility failed to implement a water management program for the prevention of waterborne pathogens for a facility with a census of 24 residents. Findings include: Review on 2/6/25 of the facility's policy, Legionella Water Management, dated 2016, revealed the following: .III. Areas Where Legionella Could Grow and Spread: Everywhere the water temp is between 77 and 108. Which is between the mixing valve and the end use. Unoccupied rooms and apartments, more than 7 days, Storage tanks . .IV. Control Measures and Monitoring: Assure re-circulator pumps are working each week. Know where the unoccupied room and apartments are located. Do not use the water downstream of a plumbing repair. Take the water storage tank temperatures weekly . .V. Ways to Intervene When Control Limits Are Not Met: If re-circulation pumps fail, fix within 24 hours. Run the hot water in rooms and apartments that are unoccupied for more than 7 days. If water storage tank temps fall below 120 degrees, make adjustments . Review on 2/6/24 of the facility's list of unoccupied rooms for more than 6 days from October 1, 2024 to February 6, 2025 revealed the following: room [ROOM NUMBER] was unoccupied on 11/1/2024 until 11/10/2024; room [ROOM NUMBER] was unoccupied on 12/1/2024 until 12/12/2024; room [ROOM NUMBER] was unoccupied on 12/11/2024 until 12/27/2024; room [ROOM NUMBER] was unoccupied on 10/5/2024 until 10/19/2024; room [ROOM NUMBER] was unoccupied on 10/11/2024 until 1/6/2025. Interview on 2/6/25 at 11:39 a.m. with Staff K (Director of Maintenance) revealed the hot water was not run in room [ROOM NUMBER], 502, 508, 513, and 514 when the above rooms were unoccupied for more than 7 days. Interview further revealed that the facility was not taking weekly temperatures at the storage tank.

Based on interview and record review, it was determined that the facility failed to implement policies and procedures for providing COVID-19 vaccines for 2 of 5 residents reviewed for COVID-19 immunizations (Resident identifiers are #1 and #10). Findings include: Resident #1 Review on 3/12/24 of Resident #1's COVID-19 vaccine consent form, dated 2/1/24, revealed that Resident #1 had given consent to be vaccinated with the COVID-19 vaccine. Review on 3/12/24 of Resident #1's medical record revealed no documentation that Resident #1 received the COVID-19 vaccine after giving consent on 2/1/24. Resident #10 Review on 3/12/24 of Resident #10's COVID-19 vaccine consent form, dated 11/12/23, revealed that Resident #10 had given consent to be vaccinated with the COVID-19 vaccine. Review on 3/12/24 of Resident #10's immunization record revealed no documentation that Resident #10 received the COVID-19 vaccine giving consent on 11/12/23. Interview on 3/13/24 at approximately 10:15 a.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A stated that the pharmacy had available single doses of COVID-19 vaccines since October 2023. Review on 3/13/24 of the facility policy titled, COVID-19 Vaccination, revision date of 2/7/24, revealed .Centers will provide the opportunity to received COVID-19 vaccinations following Centers for Disease Control and Prevention (CDC) recommendations subject to availability, to patient/residents .1. Obtain COVID-19 vaccination history .3 Based on the patient's COVID-19 vaccination history, offer the vaccination following the manufacturer's recommended schedule .5. Obtain consent .8. Obtain physician order for COVID-19 vaccination. 8.1 Use the Medical Director Authorization. 9. Administer the vaccine . Review on 3/13/24 of the facility's Updated (2023-2024 Formula) COVID-19 vaccine information from CDC, dated 9/22/23, revealed .Interim 2023-2024 COVID-19 Immunizations Schedule for Persons 6 months of Age and Older .Table 1a. For people who are NOT moderately or severely immunocompromised .2023-24 Moderna COVID-19 Vaccine .Age 12 years and older .unvaccinated (0 doses) Give 1 dose now .Any number of previous doses COVID-19 vaccines, NOT including at least 1 dose of 203-24 COVID-19 vaccine Give 1 dose at least 8 weeks (2 months) after the previous dose .Table 1b. For people who are NOT moderately or severely immunocompromised .2023-24 Pfizer-BioNTech COVID-19 Vaccine .Age 12 years and older .unvaccinated (0 doses) Give 1 dose now .Any number of previous doses COVID-19 vaccines, NOT including at least 1 dose of 203-24 COVID-19 vaccine Give 1 dose at least 8 weeks (2 months) after the previous dose .Table 2a. For people who ARE moderately or severely immunocompromised .2023-24 Moderna COVID-19 Vaccine .Age 12 years and older .unvaccinated (0 doses) Give a 3-dose initial series. Administer: Dose 1 now, Dose 2 at least 4 weeks after Dose 1 Dose 3 at least 4 weeks after Dose 2 .3 or more doses of Moderna COVID-19 Vaccine, NOT including at least 1 dose of 2023-24 COVID-19 vaccine Give 1 dose at least 8 weeks (2 months) after the previous dose .Table 2b. For people who ARE moderately or severely immunocompromised .2023-24 Pfizer-BIoNTech COVID-19 Vaccine .Age 12 years and older .unvaccinated give a 3-dose initial series. Administer: Dose 1 now, Dose 2 at least 3 weeks after Dose 1 Dose 3 at least 4 weeks after Dose 2 .3 or more doses of Pfizer-BioNTech COVID-19 Vaccine, NOT including at least 1 dose of 2023-24 COVID-19 vaccine .Give 1 dose at least 8 weeks (2 months) after the previous dose .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #70 Observation on 1/12/23 at approximately 8:27 a.m. with Staff D (Registered Nurse (RN)) revealed that Staff D popped 1 tablet of Resident #70's Calcium 500 Plus D3 [Vitamin D] (500-5 mg) medication from Resident #70's Calcium 500 plus D3 (500-5 mg) bingo card into a medication cup. Review on 1/12/23 with Staff D during Resident #70's medication administration revealed that Resident #70's Calcium 500 plus D3 (500-5 mg) bingo card and electronic medication administration record stated to give 2 tablets of Calcium 500 plus D3 (500-5 mg). Observation on 1/12/23 at approximately 8:30 a.m. with Staff D revealed that Staff D gave Resident #70's 1 tablet of the Calcium 500 plus D3 (500 mg-5 mg) medication. Interview on 1/12/23 at approximately 9:00 a.m. with Staff D stated that he/she completed his/her administration of medications with Resident #70. Staff D confirmed above findings. Resident #71 Observation on 1/12/23 at approximately 8:27 a.m. with Staff D revealed that 1 tablet of an over the counter medication of ferrous sulfate 325 mg was put into a medication cup by Staff D. Review on 1/12/23 with Staff D during Resident #71's medication administration revealed that Resident #71's electronic medication administration record stated to give 1 tablet of ferrous sulfate 324 mg. Observation on 1/12/23 at approximately 8:30 a.m. with Staff D revealed that Staff D gave Resident #71's 1 tablet of the ferrous sulfate 325 mg. Interview on 1/12/23 at approximately 9:00 a.m. with Staff D stated that he/she completed his/her medication pass with Resident #71. Staff D confirmed above findings with Resident #71. Staff D stated that there were no other supply of ferrous sulfate besides the 325 mg dose. Based on observation, record review, and interview it was determined that the facility failed to follow professional standards for following physician's orders for residents 1 of 2 narcotic books reviewed (Resident Identifier #11) and 2 out of 25 medication administration observed ( Resident Identifiers are #11, #70 and #71). Findings include: Standard: [NAME], [NAME] A. and [NAME]. Fundamentals of Nursing . 7th ed. 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 . Resident #11 Review on 1/12/23 at 8:45 a.m. of the medication storage and disposition of controlled drugs log on the Transitional Care Unit with Staff A (Licensed Practical Nurse (LPN)) revealed that Resident #11 has an order for morphine sulfate 10 milligrams [mg] in 5 milliliters [ml] solution (medication for pain management) give 2.5 ml by mouth every 3 hours as needed for moderate to severe pain. On 12/10/22 at 22:56 [10:56 p.m.] Resident #11 was administered 0.5 mg instead of the ordered 2.5 mg. Interview 1/12/23 at approximately 9:30 a.m. with Staff B (Interim Director of Nursing Services) confirmed the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, it was determined that the facility failed to establish a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records are in order and that an account of all controlled drugs is maintained for 2 of 2 narcotic books reviewed. Findings include: Review on 1/11/23 at 8:45 a.m. of the Transitional Care Unit low end medication cart with Staff A (Licensed Practical Nurse (LPN)) revealed that the controlled drug receipt and removal index/inventory page (inventory page used for receipt and tracking of the narcotics that are in the medication cart) in a binder did not have the two nurse receipt signatures required that log into the index/inventory page verifying that the narcotic was received and accounted for, nor did it have indication of removal from the count on the inventory page. Further investigation revealed that the controlled medication utilization record (record from pharmacy) in the alphabetical section of the narcotic count binder did not have the date received or the two nurse signatures. Interview on 1/11/23 at 8:50 a.m. with Staff A revealed that he/she usually does count with another nurse by using the binder that has the Controlled Medication Utilization record by alphabetical last name and has not used the index for logging or doing narcotic count. Staff A confirmed that he/she would not be able to confirm if a narcotic drug and controlled medication utilization record was removed from the count or from the alphabetical list of resident narcotics. Interview on 1/11/23 at 10:30 a.m. with Staff B (Interim Director of Nursing) revealed that their facility policy was for two nurses to log in narcotics and to be utilizing the index page for count. Staff B confirmed the above findings. Review on 1/12/23 at 12:20 p.m. of the facilities policy titled NSG300 Controlled Substances: Management of Revision date 04/01/22 .Policy Storage: Two Licensed nurses and/or authorized nursing personnel, per state regulations are required to document placement of controlled substances into inventory. Review on 1/20/23 at 9:00 a.m. of the facilities Omnicare 5.1 policy titled Delivery and Receipt of Routine deliveries. revised date 01/01/22 section 2.4 Immediately log accepted controlled substances into facility's controlled medication inventory system per facility policy. Standard [NAME] A. [NAME] and [NAME] Fundamentals of Nursing 7th edition page 688 .Medication Regulation and Nursing Practice .The nurse is responsible for following legal provisions when administering controlled substances or narcotics which are carefully controlled through federal and state guidelines