Based on observation, interview, and record review it was determined that the facility failed to implement their policy and procedures for Transmission Based Precautions (TBP) for 3 of 4 residents reviewed for infection control practices for COVID-19 (Resident Identifiers #4, #36, and #38). Findings include: Review on 5/1/24 of the facility's COVID-19 Positive Tracking report revealed the following; Resident #4 tested positive for COVID-19 on 4/20/24 and had no symptoms. Resident #36 tested positive for COVID-19 on 4/25/24 and had no symptoms. Resident #38 tested positive for COVID-19 on 4/20/24 and was symptomatic. Observation on 4/30/24 at 10:10 a.m. of Staff A (Dietary Manger) was in Resident #4's room talking to Resident #4 within approximately 3 feet of the resident. There was a sign posted outside the door that read Droplet and Contact Precautions Staff Required: gown and gloves; Procedure: mask with eye protection. Staff A was not wearing an N95 mask, gown, or gloves. Staff A was then observed leaving Resident #4's room and entering another resident's room which did not have a Droplet and Contact Precaution sign up, while still wearing the same mask (KN95 mask). Observation on 4/30/24 at approximately 10:15 a.m. of Staff B (Transportation Staff) was in Resident #4's room approximately 3 feet away from the resident. Staff B was not wearing an N95 mask (had on a KN95 mask), gown, or gloves. Interview on 4/30/24 at 10:20 a.m. with Staff B confirmed that he/she had been in Resident #4's room and stated that he/she did not think they needed to wear full personal protective equipment (PPE) [N95 mask, gown, gloves, eye protection] as long as he/she did not touch anything in the room. Interview on 4/30/24 at 10:18 a.m. with Staff C (Assistant Director of Nursing) and Staff D (Director of Nursing) confirmed that all employees should be wearing gowns, gloves, N95 masks, and eye protection. Observation on 4/30/24 at approximately 10:21 a.m. revealed that Staff A was in Resident #36's and Resident #38's room (same room) speaking with both residents. Staff A was not wearing an N95 mask, gown, gloves, or eye protection. Staff A was wearing a KN95 mask and was observed approximately 3 feet away from the residents. There was a sign outside the residents' room that read Droplet and Contact Precautions Staff Required: gown and gloves; Procedure: mask with eye protection. Interview on 4/30/24 at 10:21 a.m. with Staff A confirmed the above. Staff A stated that he/she did not think they needed to wear any additional PPE other than the mask he/she was wearing since he/she did not touch anyone. Interview on 4/30/24 at 10:29 a.m. with Staff D confirmed that all staff should be wearing full PPE when in the above resident's rooms. Interview on 4/30/24 at 10:41 a.m. with Staff E (Infection Preventionist) and Staff F (Administrator) confirmed that staff should be wearing an N95 mask, gown, gloves, and eye protection while in the above residents's rooms, even if just going into speak with the resident. Review on 5/1/24 of the facility's KN95 mask box containing the KN95 masks used by the facility revealed the outside of the box read .Precautions. 1. This mask is NOT for medical use and Non Medical . Interview on 5/1/24 at 2:19 p.m. with Staff E and Staff G (Regional Nurse) revealed that the facility used the Centers for Disease Control and Prevention (CDC) guidance for infection control policies. Review on 5/1/24 of the facility's policy titled Transmission-Based (Isolation) Precautions revised on 2/9/24, revealed: .The facility will use standard approaches, as defined by the CDC, for transmission-based precautions . The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used .10. Contact Precautions - a. Intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the resident's environment . c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination . 11. Droplet Precautions - a. Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e. respiratory droplets that are generated by a resident who is coughing, sneezing, or talking . Type and Duration of Transmission-Based Precautions Recommended for Selected Infections and Conditions . Infection/Condition .SARS-CoV-2 (COVID-19) . Precaution . Droplet or Airborne (dependent if symptomatic) . Duration . As per CDC symptom-based strategies based on severity of illness . Review on 5/1/24 of the facility's policy titled Personal Protective Equipment revised 6/14/23, revealed: .1. All staff who have contact with resident and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious material is likely . Review on 5/1/24 of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated March 18, 2024 and retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed: .2. Recommended Infection Prevention and Control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .Personal Protective Equipment HCP [Health Care Personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH [National Institute for Occupational Safety and Health] approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) .

Based on interview, record, policy and manufacturer's instructions review, it was determined that the facility failed to obtain consent and inform a Durable Power of Attorney (DPOA) of the Federal Drug Administration (FDA) black box warning for 1 out of 5 residents reviewed for unnecessary medications in a final sample of 13 residents (Resident Identifier is #39). Findings include: Review on 5/23/23 of Resident #39's electronic medical record revealed that Resident #39 has a diagnosis of Alzheimer's Disease, Dementia with behavioral disturbances, and depression. Review on 5/23/23 of Resident #39's May 2023 Medication Administration Record (MAR) revealed the following order: Seroquel Oral [Quetiapine Fumarate] Tablet 50 mg [milligram] Give 50 mg by mouth one time only for agitation for 1 day dated 5/11/23. Review on 5/23/23 of Resident #39's record revealed that there was no consent signed for the 1 day use of Seroquel on 5/11/23. Interview on 5/23/23 at 1:30 p.m. with Staff A (Licensed Practical Nurse / Unit Manager) confirmed that for Resident #39 there was no consent signed for the 1 day use of Seroquel on 5/11/23. Review of 5/23/23 of the manufacturer's instructions for Seroquel, .WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS; and SUICIDAL THOUGHT AND BEHAVIORS . Review on 5/23/23 of the facility's policy titled, Use of Psychotropic Medication, revised 5/2/22, revealed . 5. Residents and/or representatives shall be educated on the risks and benefits . Review on 5/23/23 of the facility's policy titled, Unnecessary Drugs-Without Adequate Indication for Use, revised 5/2/22, revealed . 3. Documentation will be provided in the resident's medical record to show adequate indication for medication's use and the diagnosed condition for which it was prescribed .

Based on observation, interview, and record review, it was determined that the facility failed to assess a resident's ability to self-administer medications for 1 of 3 residents reviewed for choices in a final sample of 13 residents (Resident Identifier is #23) Findings include: Observation on 5/22/23 at approximately 10:09 a.m. of Resident #23's bedside table revealed the following medications: one bottle of Fexofenadine 24 hour allergy with expiration date of May 2022, one bottle of Flonase nasal spray, and one bottle of Systane eye drops. Resident #23 was not in the room. Interview on 5/22/23 at approximately 10:58 a.m. with Staff B (Registered Nurse) confirmed the above finding. Interview further revealed that Resident #23 is alert and oriented and that Resident #23 did not have an order to self-administor medications. Review on 5/22/23 of Resident #23's medical record revealed that there were no physician's order for Fexofenadine 24 hour allergy, Flonase, or Systane, and that Resident #23 had not been assessed to self-administer medications. Review on 5/23/23 of the facility's policy titled Resident Self-Administration of Medication, with revision date of 5/4/22, revealed the following: .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered .7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into other resident's rooms or to confused roommates of the resident who self-administers medications .8. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage.

**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 that physician orders were obtained to address skin conditions that required an intervention for 1 out of 2 residents reviewed for skin conditions in a final sample of 13 residents (Resident Identifier is #196). Findings include: The [NAME]-[NAME], 2009, Fundamentals of Nursing 7th Edition, St. Louis, Missouri: Mosby, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, 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 . Observation on 5/22/23 at approximately 9:13 a.m. revealed a dressing at Resident #196's right upper arm dated 5/16/23. Review on 5/22/23 of Resident #196's medical record confirmed that Resident #196 was admitted to the facility on [DATE] from an inpatient hospitalization and that Resident #196 had a PICC [peripherally inserted central catheter] intravenous access removed and dressed prior to discharge from the hospital. Record review further revealed that Resident #196 did not have a physician's order for assessment or removal of his/her right upper arm dressing. Interview on 5/22/23 at approximately 10:55 a.m. with Staff B (Registered Nurse) confirmed the above observation and record review information. Interview further revealed that there was not a current physician's order for assessment or removal of Resident #196's right upper arm dressing. Review on 5/23/23 of Resident #196's admission nursing assessment dated [DATE] revealed documentation of a dressing at his/her right upper arm. Review on 5/23/23 of Resident #196's weekly skin assessment dated [DATE] revealed the following: .intact dress RUA [right upper arm] where PICC line was removed. Review on 5/23/23 of the facility's policy titled PICC/Midline/CVAD Dressing Change, with revision date 11/28/22, revealed the following: .Physician's orders will specify type of dressing and frequency of changes.

Based on interview and record review, it was determined that the facility failed to monitor and maintain a resident's ordered fluid restriction for 1 of 1 resident reviewed for hydration in a final sample of 13 residents (Resident Identifier is #197). Findings include: Review on 5/22/23 of Resident #197's medical record revealed that Resident #197 was admitted to the facility from an inpatient hospitalization on 5/19/23 and that Resident #197 had a diet order that stated the following: 1500 fluid restriction/ [every] 24 hours . 360 cc [cubic centimeter] with all meals 420 cc nursing and snacks with a start date of 5/19/23. Review on 5/23/23 of Resident #197's hospitalization discharge summary revealed that Resident #197 was diagnosed while inpatient with hyponatremia [low blood sodium], with a treatment plan of sodium chloride tablets and fluid restriction. Review on 5/23/23 of Resident #197's Licensed Nursing Assistant (LNA) task documentation revealed the following fluid intake amounts in milliliters (mL) documented by LNA's from 5/19/23 through 5/22/23: 5/22/23 1620 mL total Interview on 5/23/23 at approximately 12:00 p.m. with Staff B (Registered Nurse) confirmed the above finding that Resident #197's fluid intake on 5/22/23 from LNA documentation exceeded the ordered fluid restriction. Review on 5/23/23 of Resident #197's medication and treatment administration record and nursing notes revealed no information on Resident #197's fluid intake from nursing. Interview on 5/23/23 at approximately 12:00 p.m. with Staff B confirmed that Resident #197 has an ordered daily fluid restriction, but that Resident #197 did not have documented fluid intake amounts from nursing notes or documented fluid intake totals from LNAs and nursing notes, and the physician was not notified on 5/22/23 of Resident #197's fluid intake exceeding the fluid restriction amount. Review on 5/23/23 of the facility's policy titled Fluid Restriction, with a revision date of 4/7/22, revealed the following: .It is the policy of the facility to ensure that fluid restrictions will be followed in accordance to physician's orders .and will be recorded on the medication record or other format as per facility protocol.

Based on observation, interview, and review of manufacturer's instructions, it was determined that the facility failed to label opened glucometer control solution bottles with expiration dates to ensure glucometers were in safe operating condition for 2 of 2 glucometers reviewed. Findings include: Observation on 5/22/23 at approximately 8:45 a.m. of opened high and low control solution bottles revealed no opened dates or open expiration dates labeled on them, or on the open box they were stored in. Interview on 5/22/23 at approximately 8:45 a.m. with Staff A (Licensed Practical Nurse / Unit Manager) confirmed the above finding. Review of control solution manufacturer's instructions, dated 2/2022, revealed: Storage and Handling .The control solution can be used for three months after opening the vial.