**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 professional standard for 1 of 7 residents observed for medication administration (Resident identifier is #84). Findings include: [NAME], [NAME] A., and [NAME]. Clinical Nursing Skills & Techniques. 10th ed. St. Louis, Missouri: Elsevier, 2022, page 602, .Medication Administration: .3. Stay with the patient until the medication is taken. Provide assistance as necessary. Do not leave medication at bedside without a health care provider's order . Observation on 2/12/25 at approximately 7:50 a.m. to 8:00 a.m. on Unit 5 (Dementia Unit) revealed Staff D (Licensed Practical Nurse) preparing Resident #84's morning medications and putting them in a boost drink at the medication cart. Staff D added chocolate syrup to the drink. Further observation revealed Staff D brought Resident #84's morning medications mixed in a chocolate drink to Resident #84 in the dining room. Staff D then told Resident #84, Drink your chocolate milk, and left the chocolate drink with medications on the dining room table with Resident #84. Staff D left the dining room and Resident #84 was left unattended to take his/her medication. Interview on 2/12/25 at approximately 8:00 a.m. with Staff D confirmed the above observation. Review on 2/12/25 of Resident #84's latest BIMS (Brief Interview for Mental Status) assessment, dated 1/21/25, revealed a score of 2 indicating severe cognitive impairment. Review on 2/12/25 of Resident #84's February 2025's Medication Administration Record revealed the following morning medications that were in Resident #84's drink: Lactulose solution (laxative)15 mls (milliliters), Miralax powder (laxative)17 gm (grams), Sertraline (antidepressant) 75 mg (milligrams), and Acetaminophen (analgesic) 650 mg.

Based on observation and interview, it was determined that the facility failed to ensure that expired medications were removed from stock in 1 of 3 medications rooms observed. Findings include: Observation on 2/11/25 at approximately 9:00 a.m. of the Unit 4 medication room revealed an open bottle of Lantus Insulin with a discard date of 2/7/25 in the medication refrigerator. Interview on 2/11/25 at approximately 9:00 a.m. with Staff A (Registered Nurse) confirmed the above findings. Review on 2/12/25 of the facility policy, titled Care/Cleaning/Storage of Medication Rooms, dated 06/2023 revealed: .3. Maintain medications up until the expiration dates.4. Check for proper storage and expiration dates .

Based on interview and record review, it was determined that the facility failed to follow physician orders for timely laboratory services for 1 of 1 resident reviewed for psychotropic medication side effects in a final sample of 31 residents (Resident identifiers is #143). Findings include: Review on 2/12/25 of Resident 143's active physician's orders, dated 2/5/25, revealed the following: -LFT (Liver Function Test) and CBC (Complete Blood Count) with differential on 2/6/25. Interview on 2/12/25 at 12:30 p.m. with Staff H (Licensed Practical Nurse (LPN)) confirmed the above orders were placed on 2/5/25 for Resident #143. Interview on 2/12/25 at 1:02 p.m. with Staff O (Assistant Director of Nursing) confirmed that Resident #143's labs had not been obtained. Interview further revealed that the [Company name omitted] comes every Tuesday and Thursday and there were 2 missed opportunities for the blood work to be obtained. Review on 2/12/25 of the facility's policy, Laboratory Services, revised on 12/27/2023, revealed .Blood draws are scheduled twice weekly, every Tuesday and Thursday and as needed for stat labs .Obtain a Physician Order for appropriate Lab Studies. Order transcription into the electronic health record under orders. Notify unit clear via email of labs as ordered by physician. The Unit Clerk enters the order information into [Company name omitted] portal. Unit Clerk writes on unit calendar the date lab to be drawn .

Based on observation, interview, and record review, it was determined that the facility failed to implement the facility's infection control policies contact precautions for 2 residents reviewed for transmission based precautions in a final sample of 31 residents (Resident identifiers are #13 and #113). Findings include: Resident #113 Observation on 2/11/25 at approximately 8:35 a.m. revealed Staff E (Unit Aide) entering Resident #113's room with a face mask and gloves on. Further observation revealed Staff E left the resident's room with a face mask and gloves on. Interview on 2/11/25 at approximately 8:35 a.m. with Staff E revealed that he/she did not know that Resident #113 was on contact precautions. Interview on 2/11/25 at approximately 8:55 a.m. with Staff A (Registered Nurse) revealed that Resident #113 was on contact precautions for norovirus. Staff A confirmed that Staff E should wear a gown along with gloves and mask prior to entering a room with contact precautions. Observation on 2/11/25 at approximately 12:15 p.m. revealed Staff K (Licensed Nursing Assistant (LNA)) delivered Resident #113's lunch tray to his/her room wearing a mask and gloves. Staff K was not wearing a gown. Observation on 2/12/25 at approximately 8:00 a.m. of Resident #113's room revealed Staff L (LNA) putting blankets on Resident #113's bed and hanging up clothing with a mask and gloves. Staff L was not wearing a gown. Observation on 2/12/25 at approximately 8:30 a.m. revealed Staff M (LNA) entering Resident #113's room with his/her breakfast tray wearing only a mask. Staff M was not wearing gloves or a gown. Interview on 2/12/25 at approximately 2:15 p.m. with Staff I (Infection Preventionist) confirmed that Resident #113 was on contact precautionsObservation on 2/11/25 at approximately 12:00 p.m. in the hallway on Unit 4 revealed a face mask placed on a railing. Interview on 2/11/25 at approximately 12:00 p.m. with Staff A revealed that he/she was unsure if the face masked was used or not.Resident #13 Observation on 2/11/25 at 12:24 p.m. of Resident #13's room revealed signage on the door of the room stating Contact Precaution .Gowns, [NAME] gown upon entry into the room or cubicle . Further observation revealed Staff B (LNA) entering Resident #13's room wearing gloves, a surgical mask, and no gown. Interview on 2/11/25 at approximately 12:26 p.m. with Staff B revealed that he/she was not aware that he/she needed to don gown prior to entering the resident's room with contact precautions to deliver food. Interview on 2/12/25 at 1:00 p.m. with Staff I revealed that he/she reports that the facility is in outbreak for suspected Norovirus or gastrointestinal illness. Interview further revealed that the facility followed the CDC guidelines for infection control and precautions and that the facility had modified the CDC guidance for their facility. Review on 2/12/25 of the Facility Policy/Procedure Titled: Procedures for Airborne, Contact, and Droplet Isolation. (Modified from CDC Guidelines) Contact Precautions .Wear a gown when entering resident area if you anticipate that you will have substantial contact with the resident, resident items, or environmental surfaces or if the resident is incontinent. Review on 2/12/25 of Key Infection Control Recommendations for the Control of Norovirus Outbreaks in Healthcare Settings retrieved from https://www.cdc.gov/healthcare-associated-infections/media/pdfs/Norovirus-ControlRecomm-508.pdf revealed the following: Personal Protective Equipment (PPE) If norovirus infection is suspected, adherence to PPE use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry).

**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 ensure resident medications had accurate labeling to facilitate the safe administration of medications in 1 of 4 medication carts and medications not discarded after expiration in 1 of 3 medication rooms observed (Unit 2: left medication cart; Unit 4: medication room) (Resident Identifiers are #27 and #32). Findings include: Unit 2: left medication cart Observation on 1/9/24 at 9:45 a.m. of Unit 2: left medication cart revealed 2 plastic medication cups with prepoured medications stacked together without resident and medication identifiers. Interview on 1/9/24 at 9:45 a.m. with Staff A (Licensed Practical Nurse (LPN)) confirmed the above findings and revealed the medications were for Resident #27 and Resident #32. Staff A revealed they routinely prepour medications. Review of [NAME], [NAME] A., and [NAME] Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Chapter 35 Page 719, revealed .7.d. Prepare medication for one client at a time . Unit 4: Medication Room Observation on 1/9/24 at 10:03 a.m. of the medication room revealed a Tuberculin Purified Protein Derivative vial labeled with an open date of 11/21 in the refrigerator. Interview on 1/9/24 at approximately 10:03 a.m. with Staff C (Registered Nurse) and Staff B (LPN) confirmed the above findings. Review on 1/9/24 of the manufacturer's instructions for Tuberculin Purified Protein Derivative revealed .Vials in use for more than 30 days should be discarded .

**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 for 1 out of 1 resident observed for tube feeding during medication administration. (Resident identifier is #125) 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 . Review on 12/15/22 at 10:40 a.m. of Resident #125 medication administration record revealed the following order One 8 ounce container of Jevity 1.5 [ feeding formula] with 200 ml [milliliter] of H2O [water] flush before and after each bolus feed via PEG [Percutaneous Endoscopic Gastrostomy] tube at 0500 [5:00 a.m.], 1100 [11:00 a.m.], 1600 [4:00 p.m.], and 2200 [10:00 p.m.] . Observation on 12/15/22 at 10:40 a.m. of Resident #125's gastrostomy tube feeding administration with Staff A (Registered Nurse) revealed that Staff A administered the Jevity 1.5 formula via the Resident #125's gastrostomy tube without administering the 200 ml water flush. Interview on 12/15/22 at 10:40 a.m. with Staff A confirmed the above findings. Review on 12/15/22 at 12:30 p.m. of the facility policy titled General Care and Maintenance of Gastrostomy Tubes dated 06/19/2018. Care during feedings: .4. Flush tube with ordered amount of water before and after each feeding and medication administration and/or every 4 hours during a continuous feeding.