**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 medication administration instructions for and failed to handle medication according to professional standards for 1 of 5 residents observed for medication administration. (Resident identifier is #136.) Findings include: Standard: [NAME], P.A, [NAME], A.G., Stockhart, P.A., & Hall, A. (2021). Fundamentals of Nursing. Elsevier., page 640 . Skill 31.1 Administering Oral Medications, .Clean gloves (if handling an oral medication) Review on 4/2/25 of the Magnesium Lactate Extended Release manufacturer's instruction, dated 11/29/24, revealed .Warnings Follow all directions on your medicine label and package .Do not crush or chew an extended release tablet . Observation on 4/2/25 at approximately 8:10 a.m. during Resident #136's medication administration revealed that Staff A (Licensed Practical Nurse) crushed the Magnesium Lactate Extended Release (ER) 84 mg (milligrams) tablet. Further observation revealed the Magnesium Lactate ER 84 mg medication card had a pharmacy warning label that read Do not crush the medication. Observation also revealed that Staff A was putting his/her bare fingers in the medication cup to remove pills twice. Interview on 4/2/25 at approximately 8:10 a.m. with Staff A confirmed the above findings. Review on 4/2/25 of Resident #136's current physician orders revealed that Resident #136 did not have a physician's order to crush medication. Interview on 4/2/25 at approximately 9:40 a.m. with Staff B (Director of Nursing) confirmed that Resident #136 did not have a physician's order to crush his/her medications. Review on 4/2/25 of the facility policy titled, Medication Administration of P.O. (by mouth) Medications, Revision Date 1/13 revealed .2. Do not touch the oral solid medication with your bare hands .4. Some medications should not be crushed. 12. If a resident has difficulty swallowing pills whole, the practitioner will be notified, an order from the practitioner will be obtained if appropriate .

Based on observation, interview, and record review, it was determined that the facility failed to implement policies and procedures for 1 of 1 resident reviewed for Transmission Based Precaution (Resident identifier is #173). Findings include: Observation on 4/1/25 at approximately 8:30 a.m. on C4 unit revealed that Resident #173's room had a contact precaution signage outside the door. Interview on 4/1/25 at approximately 8:30 a.m. with Staff C (Registered Nurse) revealed that Resident #173 was on contact precaution for Clostridium Difficile (C-diff) infection. Observation on 4/1/25 at approximately 10:28 a.m. on C4 unit revealed that Staff D (housekeeper) was in Resident #173's room wearing a gown and gloves, wiped down Resident #173's bed rails, bedside table, and furniture with a cloth. When finished, Staff D exited the room, doffed the used gown and gloves, and used an Alcohol Based Hand Rub (ABHR). Staff D did not wash their hands with soap and water. Staff D donned new gloves, Staff D did not wear a gown, re-entered Resident #173's room, and mopped the floor. Staff D exited the room, doffed the used gloves, and used ABHR. Staff D did not wash their hands with soap and water. Interview on 4/1/25 at approximately 10:28 a.m. with Staff D confirmed the above observation. Observation on 4/2/25 at approximately 12:23 p.m. on C4 unit revealed that Staff E (Licensed Nursing Assistant) donned gown and gloves, entered Resident #173's room with a meal tray, placed the meal tray at the bedside table in front of Resident #173. Staff E exited the room, doffed the used gown and gloves, and used ABHR. Staff E did not wash their hands with soap and water. Interview on 4/2/25 at approximately 12:23 p.m. with Staff E confirmed the above observation. Review on 4/2/25 of Resident #173's provider note, dated 4/1/25, revealed reason for visit was C-diff which Resident #173 completed additional Vancomycin regimen last week for another recurrent C-diff infection and that Resident #173 reported that his/her loose stool has reoccurred. Further review of the provider note revealed a diagnostic statement of recurrent enterocolitis due to C-diff. The plan was to extend the Vancomycin regimen and follow up with infectious disease. Review on 4/2/25 of Resident #173's C-diff infection care plan, with a revision date of 3/14/25, revealed that Resident #173 was positive for C-diff on 1/6/25, 1/23/25, and 3/13/25 with an intervention that contact precautions was reinstated on 3/13/25. Review on 4/2/25 of the facility policy titled, Contact Precautions, with no date, revealed .Contact Precautions should be implemented for the following: .C. difficile .Gloves And Handwashing: .remove gloves before leaving resident's room and wash hands immediately .remove gown and observe hand hygiene before leaving the resident's room .References: Centers for disease control and prevention. Guideline for Isolation Precautions: Preventing Transmissions of Infectious Agents in Healthcare Settings .2007 . Interview on 4/2/25 at approximately 3:15 p.m. with Staff G (Infection Preventionist) stated that for contact precautions, staff can use ABHR when staff are in a resident room not providing care and gloves are not visibly soiled. Staff G confirmed the above policy and that the policy stated to wash hands. Review on 4/2/25 of the CDC guidelines titled, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007), dated 11/27/23, revealed .perform hand hygiene ~ in the following clinical situations: .After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .After removing gloves .Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorohexidine, iodophors, and other antiseptic agents have poor activity against spores .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that residents were assessed for the ability to self-administer medication for 1 out of 4 residents reviewed for choices in a final sample of 35 residents (Resident Identifier #116). Findings include: Observation on 4/29/24 at approximately 8:30 a.m. of Resident #116 revealed he/she was in bed administering medications to his/herself off of a napkin. The napkin contained approximately 5 pills. There was no staff present in the room. Interview on 4/29/24 at approximately 8:30 a.m. with Staff B (Licensed Practical Nurse) confirmed the above findings. Staff B revealed that this is his/her regular practice with Resident #116. Review on 4/30/24 of Resident #116's medical record, under physician orders, revealed that there was no order for Resident #116 to self-administer medications. Further review of Resident #116's medical record revealed that there was no assessment done with Resident #116 to self-administer medications. Review on 4/30/24 of the facility's policy titled Medication-Administration of Medications revision date 10/18 revealed: .7. Medications shall not be left at bedside .

Based on interview, observation, and record review, it was determined that the facility failed to ensure that residents with pressure ulcers had documentation of weekly assessments that contained measurements and descriptions of the pressure ulcer for 1 out of 3 residents reviewed for pressure ulcers in a final sample of 35 residents (Resident Identifier #114). Findings include: Review on 5/1/24 of Resident #114's medical record revealed that Resident #114 had a pressure ulcer on his/her coccyx. Review on 5/1/24 of Resident #114's weekly wound assessments revealed: 3/21/24 wound measurements 0.73 centimeters (cm) by (x) 0.99 cm (iimproving) 3/28/24 no documented wound assessment 4/4/24 wound measurements 1.29 cm x 0.4 cm (deteriorating) Interview on 5/1/24 at approximately 11:15 a.m. with Staff G (Wound Nurse) confirmed the above findings.

Based on record review, interview, and observation, it was determined that the facility failed to ensure licensed nurses had the competencies and skill sets in accordance with the facility assessment for 1 of 2 nurses reviewed for competencies. Finding include: Review on 4/30/24 of the facility assessment, dated 1/2024, revealed under the education section: .All nurses, MNAs [Medication Nursing Assistants], and LNAs [Licensed Nursing Assistant] will .have an annual Knowledge and Competency Testing form completed . The assessment further revealed Medication Management: Medication Administration RN [Registered Nurse]/LPN [Licensed Practical Nurse] were indicated. Review of Staff A's (RN) last Knowledge and Competency Documentation revealed a completion date of 2021. Interview on 5/1/24 at approximately 9:45 a.m. with Staff G (Staff Development Coordinator) revealed competencies are completed on hire. The interview further revealed that specifically for medication administration, competencies would not be done again unless there are identified medication errors or questionable medication pass techniques and observations of these would be by unit managers or staff development.

Based on observation, interview, and policy review it was determined that the facility failed to maintain a clean environment for proper washing and sanitizing of dishes and utensils in the main kitchen and failed to ensure food was kept at the proper temperature in 6 of 6 kitchettes observed. Findings include: Main Kitchen Observation on 4/29/24 at approximately 8:00 a.m. in the kitchen dishwashing area with Staff H (Food Services Director) revealed two wall fans, with accumulated gray dust and grease debris, blowing air towards the clean dishes. Interview on 4/29/24 at approximately 8:00 a.m. with Staff H confirmed the above finding. Observation on 4/29/24 at approximately 8:05 a.m. with Staff H revealed a food mixer with built-up food debris and grease. Interview on 4/29/24 at approximately 8:05 a.m. with Staff H confirmed the above finding and revealed it had not been used since the day prior. Review on 4/29/24 of facility's policy titled Surface: Cleaning and Sanitization revealed: .Non-Food Contact Surfaces. Must be cleaned and rinsed .Examples: walls, floors, storage shelves, equipment exteriors .Food Contact Surfaces. Must be cleaned, rinsed, and sanitized .Examples: knives, cutting boards, pots and pans, prep tables, and other equipment that touches food . Unit Kitchenettes Review on 4/29/24 of the 6 kitchenette refrigerator temperature logs revealed no recorded temperatures on the following dates and locations: March 2024: Unit A-1: 3/21/24, 3/22/24, and 3/23/24 Unit A-2: 3/22/24 and 3/23/24 Unit B-2: 3/21/24, 3/22/24, and 3/23/24 Unit B-3: 3/21/24, 3/22/24, and 3/23/24 Unit C-3: 3/22/24 Unit C-4: 3/23/24 April 2024: Unit A-1: 4/21/24 and 4/30/24 Unit A-2: 4/30/24 Unit B-2: 4/21/24 and 4/30 Unit C-3: 4/20/24, 4/21/24, and 4/30/24 Unit C-4: 4/20/24, 4/21/24, and 4/30/24 Interview on 4/29/24 at approximately 8:30 a.m. with Staff H confirmed the above finding. Review on 4/29/24 of facility policy titled, Storing: Food and Equipment revealed: .Refrigerator and Freezer .An assigned team member will check the temperature of all refrigerators and freezers two times per day .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to monitor a resident who was experiencing significant weight loss for 1 of 5 residents reviewed for nutrition in a final sample of 35 residents (Resident identifier is #224). Findings include: Review on 4/4/23 of Resident #224's medical record revealed that Resident #224 admitted to the facility on [DATE]. Review on 4/4/23 of Resident #224's Weights and Vitals Summary revealed the following weights; - 2/22/23 194.2 pounds - 2/23/23 195 pounds - 2/24/23 189 pounds. - 3/10/23 182.3 pounds. There were no additional weights recorded for Resident #224. Resident #224 had a 6.7 pound weight loss between 2/23/23 amd 2/24/23. Resident #224 experienced a 6.13 percent (%) weight loss in two weeks and five days. Review on 4/4/23 of Resident #224's Weight Change Note dated 3/14/23 revealed Weight Warning: Value: 182.3 . Date [3/10/23] . -5.0% change [6.1% .] Reweight pending, will monitor as available. This note was authored by Staff D (Registered Dietician). Interview on 4/6/23 at 12:34 p.m. with Staff C (Registered Nurse) stated that he/she will have residents reweighed if there is a 3 pound variance in weights. Staff C confirmed that a reweight had not been completed for Resident #224. Interview on 4/6/23 at 12:46 p.m. with Staff D revealed that he/she expected Resident #224 to have a reweight done based on the 3/14/23 above note. Staff D confirmed a reweight had not yet been done. Interview on 4/6/23 at 1:15 p.m. with Staff D revealed he/she would expect a reweight to be done within a week. Review on 4/6/23 of the facility's policy Vital Signs & Weights with a revision date of April 2021 revealed, .10. Weights will be taken at least monthly on each resident unless directed otherwise by the Head Nurse/designee, MD [Medical Doctor], or Dietician .

Based on observation, interview, and record review it was determined that the facility failed to ensure treatments were secured on 1 out of 6 units observed for 2 out of 20 B-2 Unit residents observed, and the facility failed to ensure proper storage of expired medications for 1 out of 3 medication rooms observed (Resident identifiers are #27, #61, #62 and #84). Findings include: Resident #61 (Unit B-2) Observations on 4/4/23 at 1:00 p.m. and 4/5/23 at 9:20 a.m. of Resident #61's shelf in the resident's room revealed one Preparation H 1 percent (%) ointment tube. Interview on 4/5/23 at 9:35 a.m. with Staff E (Licensed Practical Nurse) revealed that Staff E found the Preparation H tube was routinely stored in the resident's room. Interview on 4/5/23 at 3:00 p.m. with Staff F (Registered Nurse) revealed that the Preparation H tube should be secured in the treatment cart/medication room, as Resident #61 does not self-administer medications. Resident #27 (Unit B-2) Observations on 4/4/23 at 1:15 p.m. and 4/5/23 at 9:30 a.m. of Resident #27's shelf in the resident's room revealed one Antifungal Power with Miconazole Nitrate 2% bottle. Interview on 4/5/23 at 9:35 a.m. with Staff E revealed that the Antifungal Powder bottle was routinely stored in the resident's room. Interview on 4/5/23 at 3:00 p.m. with Staff F revealed that the Antifungal Powder bottle should be secured in the treatment cart/medication room, as Resident #27 does not self-administer medications, and confirmed the finding. Review on 4/6/23 of the facility's policy Storage and Safety of Medications with an origination date of 1/2015 revealed, .Oral medications, topical medications, treatments, eye drops and ear drops will be stored .on the medication room shelves. 3C Medication Storage Room Resident #62 Observation on 4/4/23 at approximately 8:45 a.m. of the 3C medication storage room with Staff A (Registered Nurse) revealed Resident #62's Combivent Respimat Inhalation Aerosol Solution 20-100 micrograms/actuation (mcg/act) inhaler that had been used, with a pharmacy dispensed date of 12/14/22 and no open date, stored with stock medications. Further observation of the Combivent Respimat 20-100 mcg/act revealed manufacturer's instructions to discard at least 3 months after first use or when locking mechanism is engaged. Interview on 4/4/23 at approximately 8:45 a.m. of the 3C medication room with Staff A confirmed the above findings. Staff C stated that the Combivent Respimat inhaler should have been labeled with an open date to determine the discard date. Review on 4/5/23 of Resident #62's March and April 2023 Medication Administration Records (MAR) revealed an active PRN [as needed] order for Combivent Respimat 20-100 mcg/act inhaler, 1 puff every 4 hours for short [sic] of breath. Further review of Resident #62's March and April 2023 MAR's revealed that Resident #62 had not received Combivent Respimat 20-100 mcg/act inhaler. Resident # 84 Observation on 4/4/23 at approximately 9:00 a.m. with Staff A (Registered Nurse) revealed Resident #84's used Combivent Respimat Inhalation Aerosol Solution 20-100 (mcg/act) inhaler with an open date of 9/13/22. Further observation of the Combivent Respimat 20-100 mcg/act revealed manufacturer's instructions to discard at least 3 months after first use or when locking mechanism is engaged, and a pharmacy instruction label stating after opening do not use after 90 days. Interview on 4/4/23 at approximately 8:45 a.m. with Staff A confirmed the above findings. Staff C stated that the Combivent Respimat 20-100 mcg/act inhaler should have been discarded 90 days after being opened on 9/13/22. Interview on 4/5/23 at 9:30 a.m. with Staff B (Registered Nurse) confirmed that Resident #84 did not have a current order for Combivent Respimat 20-100 mcg/act inhaler. Resident #84's order for Combivent Respimat 20-100 mcg/act inhaler had been discontinued after returning from the hospital on 9/30/22. Review on 4/6/23 of the facility's policy Storage and Safety of Medications with an origination date of 1/2015 revealed, 7. Medications which are expired will be removed from the medication shelves and placed in the return to bag for pharmacy pickup.