Based on interview and record review, it was determined that the facility failed to ensure that the facility acted upon provider approved recommendations that were identified by the pharmacist during the monthly Pharmacy Medication Regimen Review for 1 of 5 residents reviewed for unnecessary medications in a final sample of 18 residents. (Resident Identifier is #61). Findings include: Review on 6/25/25 of Resident #61's Pharmacy Review dated 3/13/25 revealed a recommendation to the physician/prescriber to Please consider ordering a serum Vitamin D 25-OH level (25-hydroxyvitamin D). Further review revealed that Yes, order a serum Vitamin D 25-OH level was checked in the affirmative and signed/dated by Staff A (Advanced Practice Registered Nurse) on 3/19/25. Review on 6/25/25 of Resident #61's medical record revealed there was no documentation that the above test had been completed. Interview on 6/25/25 at 2:20 p.m. with Staff B (Unit Manager) confirmed the above test was not completed. Interview on 6/25/25 at 2:58 p.m. with Staff A revealed that he/she had agreed to the above pharmacy recommendation and was not aware that it had not been done. Review on 6/25/25 of the facility's policy titled Medication Regimen Review revised on 4/10/25 revealed, . 1. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication . 7 .f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to implement smoking policies for 1 of 2 residents reviewed for smoking in a final sample of 22 residents (Resident Identifier #66). Findings include: Review on 5/7/24 of the facility's list of residents who smoke revealed that Resident #66 was identified as a smoker by the facility. Review on 5/7/24 of Resident #66's medical record revealed that Resident #66 was admitted to the facility on [DATE]. Review on 5/7/24 of Resident #66's medical record revealed Resident #66 did not have a smoking assessment to assess for safety of smoking. Further review revealed there was no care plan for smoking. Review on 5/7/24 of the facility's binder titled Vape and Lighter Log revealed that Resident #66 had been signed out to smoke on the following dates: 4/26/24, 4/28/24, 5/1/24, 5/4/24, 5/6/24 and 5/7/24. Interview on 5/7/24 at approximately 11:27 a.m. with Resident #66 revealed that he/she does smoke outside and that staff keep the lighters at the nursing station. Further interview with Resident #66 revealed that cigarettes are kept in his/her room. Interview on 5/7/24 at approximately 11:30 a.m. with Staff A (Unit Manager) confirmed that Resident #66 smokes and that the lighters are kept at the nursing station. Further interview with Staff A confirmed that Resident #66 was not assessed for safety with smoking. Review on 5/8/24 of facility's policy titled Resident Smoking review and revision date 4/30/24, revealed under Policy Explanation and Compliance Guidelines . #7. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment . #8. Residents will smoke in accordance with his/her care plan.

**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 the residents' environment remained free of accident hazards for 1 of 2 residents reviewed for smoking in a final sample of 27 residents (Resident Identifier is #3). Findings include: Review on 5/12/23 of Resident #3's care plan revealed that Resident #3 smokes independently, and has the following interventions in place: 1. Educate and remind to keep smoking materials in a safe place. 3. Educate and remind of center policy and expectations. 4. Re-enforce that no smoking is allowed in the building. Review on 5/12/23 of Resident #3's smoking assessment dated [DATE] revealed that Resident #3 was assessed to smoke independently and is aware of the facility's smoking policy. Review on 5/12/23 of section C of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/14/23 revealed that Resident #3 has a Brief Interview of Mental Status (BIMS) of a 14 indicating that Resident #3 is cognitively intact. Observation on 5/12/23 at approximately 11:50 a.m. of Resident #3's room revealed an electronic cigarette on Resident #3's bedside table. Interview on 5/12/23 at approximately 11:52 a.m. with Resident #3 who stated that he/she keeps a lighter in the bedside table drawer and charges the electronic cigarette on top on the bedside table. Interview on 5/12/23 at approximately 11:55 a.m. with Staff C (Director of Nursing) revealed that residents who were assessed to smoke independently may keep cigarettes in their room but may not keep lighters or electronic cigarettes. Observation on 5/12/23 at approximately 12:00 p.m. with Staff C of Resident #3's bedside table drawer contents revealed a lighter and on top of the bedside table, an electronic cigarette. Review of the facility smoking policy titled Resident Smoking revised on 8/1/21 .Policy Explanation and Compliance Guidelines: Number 4 .Electronic cigarettes will be treated the same as any other smoking product. Interview on 5/12/23 at approximately 1:49 p.m. with Staff D (Front Desk Receptionist) confirmed that resident's smoking materials are supposed to be kept in a lock box behind the reception desk and residents stop and pick up their lighters and smoking materials prior to going outside. Staff D further confirmed that if the receptionist is away from the desk, residents do come back into the facility and go to their rooms with their smoking materials.

Based on observation, interview, and policy review, it was determined that the facility failed to ensure eye medications were labeled with open expiration dates and that expired medications were removed from use on 1 of 3 medication carts and 1 of 2 medication rooms observed (Resident Identifier is #44). Findings include: Observation on 5/10/23 at 8:45 a.m. of the Bay Unit medication room with Staff E (Licensed Practical Nurse) revealed 6 packets of Hydrocortisone 1 percent (%) cream with an expiration date of 11/2022 available for use on Bay Unit. Interview on 5/10/23 at 8:45 a.m. with Staff E confirmed the above finding. Observation on 5/10/23 at approximately 9:27 a.m. of the Strawberry Cove Medication Cart revealed the following opened eye medications for Resident #44 without an open date or an open expiration date: Latanoprost Ophthalmic Solution 0.005% Interview on 5/10/23 at approximately 9:27 a.m with Staff A (Registered Nurse) and Staff B (Licened Practical Nurse) confirmed the above findings. Record review on 5/11/23 of Resident #44's physican orders revealed the following: Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in right eye at bedtime for eye. Start date 1/30/2023. Review on 5/11/23 of Resident #44's Medication Administration Record for May 2023 revealed the resident had recieved Latanoprost Ophthalmic Solution 0.005% daily. Review on 5/11/23 of the manufactuer's instruction on the Latanoprost Ophthalmic Solution 0.005% label revealed the following: Discard after six weeks. Review on 5/11/23 of the facility policy titled, Labeling of Medication and Biologicals last revised 5/3/2022 states: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate precautions and safe administration of medications .4. Labels for each floor/unit's stock medications must include: c. The expiration date when applicable. 8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed .

Based on observation, interview, and policy review it was determined that the facility failed to clean and disinfect a glucometer after use for 1 out of 2 medication carts observed. Findings include: Observation on 5/10/23 at 9:45 a.m. of the Strawberry Cove medication cart revealed a glucometer in the top right draw with brown dried blood like substance on and around the test strip insertion site. Interview on 5/10/23 at 9:45 a.m. with Staff B (Unit Manger) revealed that the glucometer is to be cleaned after each resident use and confirmed the substance on the meter was a blood-like substance. Review on 5/12/23 of the facilities policy titled Glucometer Disinfection, revised date 08/15/2022, revealed the following: Definition: Disinfection is the process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects .Policy Explanation and Compliance Guidelines: 1. The facility will ensure blood glucometer will be cleaned and disinfected after each use and according to manufacturer's instructions and for multi-resident use . 4. Glucometer's will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. Review on 5/12/23 at 2:00 p.m. of the manufacturer's recommendations for the blood glucose meters revealed the following: Cleaning and Disinfecting Guidelines: Healthcare professionals should wear gloves and when cleaning the Assure Platinum meter. Wash Hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Further review revealed that cleaning and disinfection can be done using an EPA-registered disinfectant, germicidal wipe, or bleach solution. Standard: Review on 5/12/23 of the Center for Disease Control and Prevention guidance, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#:~:text=CDC%20is%20alerting%20all%20persons%20who%20assist%20others,never%20be%20used%20for%20more%20than%20one%20person revealed the following: Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.