Based on observation, interview, record review, facility policy and staff training review, and review of the Centers for Medicare and Medicaid (CMS) Quality, Safety, and Oversight (QSO) Memo 24-08-NH, the facility failed to use a gown for required enhanced barrier precautions (EBP) while administering medications through a gastric tube for Resident #44, failed to clean a wrist blood pressure monitor between use on Resident's #44 and #52, and failed to maintain a clean wall-mounted fan while in use and directed toward clean linen in the laundry area. This affected two residents (#44 and #52) of 60 residents reviewed for infection control and had the potential to affect all 60 residents residing in the facility. The facility reported 13 residents (#17, #22, #25, #30, #32, #44, #48, #113, #120, #121, #125, #126 and #162) on EBP precautions. Findings include: 1. Observation on 05/13/25 at 8:06 A.M. with Licensed Practical Nurse (LPN) #615 of medication administration for Resident #44 revealed LPN #615 prepared three medications for administration into a gastric tube while at the medication cart then entered Resident #44's room which had a sign posted on the door to observe EBP with gowns and gloves stored in a door rack for staff use. LPN #615 donned gloves but did not put on the required gown before engaging Resident #44 and administering the medications through the gastric tube. Once completed, LPN #615 removed the soiled gloves, performed hand hygiene and then left the resident's room. Interview at the time of the observation with LPN #615 confirmed not wearing the required gown for EBP. Review of the medical record for Resident #44 revealed an admission date of 02/27/25 with diagnoses including encephalopathy, diabetes mellitus type two, hypertensive heart disease with heart failure and gastrostomy status. The admission Minimum Data Set (MDS) assessment completed on 03/06/25 indicated Resident #44 had moderate cognitive impairment, and the plan of care dated 02/28/25 specified a need for enteral feeding through a gastric tube. Review of CMS QSO Memo 24-08-NH, entitled Enhanced Barrier Precautions in Nursing Homes, dated 03/20/24, revealed EBP are indicated for residents with indwelling medical devices even if the resident is not known to be infected or colonized with a multidrug resistant organism (MDRO). The effective date for implementation of EBP under the guidelines was 04/01/24. Review of the facility policy, Enhanced Barrier Precautions, revised 09/14/23, revealed EBP required the use of gloves and a gown with residents who had an indwelling medical device during high-contact resident care. Review of the facility staff training completed on 05/13/25 revealed the use of a gown and gloves for high-contact resident care activities was indicated for residents with indwelling medical devices. 2. Observation on 05/13/25 at 8:06 A.M. with LPN #615 of medication administration for Resident #44 revealed LPN #615 obtained a blood pressure reading using a wrist monitor prior to medication preparation then placed the monitor on top of the medication cart without cleaning it after use. LPN #615 then prepared Resident #44's medications, administered them as ordered and then moved the medication cart to where Resident #52 was located. LPN #615 picked up the soiled blood pressure monitor and used it to obtain Resident #52's blood pressure prior to preparing the resident's medications. Once completed, LPN #615 returned to the medication cart and set the soiled blood pressure monitor on top of the medication cart without cleaning it after use. Interview at the time of the observation with LPN #615 verified the wrist blood pressure monitor was not cleaned after use between Resident's #44 and #52. Review of the medical record for Resident #44 revealed an admission date of 02/27/25 with diagnoses including encephalopathy, diabetes mellitus type two, hypertensive heart disease with heart failure and gastrostomy status. Review of the medical record for Resident #52 revealed an admission date of 02/24/25 with diagnoses including chronic kidney disease, palliative care, dementia, atrial fibrillation and congestive heart failure. Review of facility staff training completed on 05/13/25, entitled Infection Control Review - Shared Medical Devices, revealed cleaning and disinfecting shared medical devices between residents are crucial for preventing the spread of infections, reducing healthcare-associated infections, and protecting residents' safety. 3. Observation on 05/14/25 at 11:19 A.M. with Housekeeping Supervisor (HS) #610 of the laundry room revealed in the clean laundry area there were two unknown laundry workers actively folding linen out of a large mostly filled clean linen cart. In proximity was a large wall mounted fan blowing air toward the two laundry workers and the clean linen. The fan had visible dirt buildup with accumulated dirt seen flapping from the air flow out of the fan toward the clean linen. Interview at the time of the observation with HS #610 confirmed the wall mounted fan being used in the clean laundry area was visibly dirty and blowing toward the clean linen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure as needed medication orders for psychotropic drugs were limited to 14 days. This affected three (Residents #3, #23, and #34) of six residents reviewed for unnecessary medication. The census at the time of the survey was 90 residents. Findings include: 1.Record review for Resident #34 revealed the resident was readmitted to the facility on [DATE]. Pertinent diagnoses for the resident included unspecified dementia, other dissociative and conversion disorders, cognitive communication deficit, chronic pain, anxiety disorder, and major depressive disorder. The brief interview for mental status (BIMS) from MDS dated [DATE] revealed the resident had a score of five indicating severe cognitive impairment. Review of physician orders for Resident #34 revealed on 03/09/22 the physician had ordered the antipsychotic medication Seroquel one 50 milligram (mg) tablet by mouth every six hours as needed (PRN) for unspecified dementia with behavioral disturbance with no end date. The medication administration record (MAR) for Resident #34 was reviewed for the month of June 2022 and had documented administrations of the PRN antipsychotic medication Seroquel as followed: one administration on 06/04/22, one administration on 06/05/22, one administration on 06/10/22, one administration on 06/20/22, one administration on 06/24/22, and one administration on 06/28/22. The facility failed to provide evidence the physician had reviewed the continued and frequent use of the PRN psychotic medication for Resident #34. No evidence was presented to confirm the 14 day re-assessment and reorder interval was completed. These findings were verified during interview with the Director of Nursing on 06/29/22 at 10:21 A.M. Review of the facility policy titled, Psychotropic Medications, with a revised date of 03/01/21, revealed PRN orders for psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days then he or she will document their rationale in the resident's medical record and indicate the duration for the PRN order. 2. Review of the medical chart for Resident #3 revealed an admission date of 03/15/22. Diagnoses include but not limited to vascular dementia without behavioral disturbance, torticollis, and brachial plexus disorders. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/22/22, revealed Resident #3 had severely impaired cognition and required extensive assistance with two staff for activities of daily living except eating required supervision with set up only. Review of the physician's orders for June 2022 revealed Resident #3 was ordered 1.0 milligrams (mg) of lorazepam on 03/16/22 for muscle spasm as needed (PRN) with a maximum dose of three tablets with no stop date. Interview on 06/30/22 at 8:07 A.M. with Registered Nurse (RN) #538 verified that there was no stop date for lorazepam PRN. Review of the facility policy titled, Psychotropic Medications, with a revised date of 03/01/21, revealed PRN orders for psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days then he or she will document their rationale in the resident's medical record and indicate the duration for the PRN order. #3: Record review of Resident #23 revealed she was admitted to the facility on [DATE] and had diagnoses including Alzheimer's Disease, cognitive communication deficit, restlessness and agitation, and acute psychosis. She had an active order for 25 milligrams of Seroquel (an antipsychotic) to be given twice per day as needed (PRN) for behaviors including hitting, scratching, and screaming. The order was dated 12/02/21. A psychiatric service visit dated 05/26/22 noted her PRN seroquel order was to be continued. The surveyor could not find evidence the PRN seroquel was specifically reviewed and renewed every 14 days. Record review of Resident #23's medication administration record revealed she received the PRN seroquel twice in April 2022 on 04/11/22 and 04/15/22, and no times in May or June 2022 as of the time of the record review. Review of a pharmacy record review for Resident #23 dated 01/28/22 revealed the pharmacy recommendation that the PRN Seroquel order be made to only last 14 days, and to be renewed every 14 days. The provider checked 'disagree' on the response list at the bottom and wrote to continue the medication as-ordered. Review of the facility's psychotropic medication policy dated 03/01/21 revealed antipsychotic medications were limited to 14 days and could not be renewed unless the physician evaluated the resident for appropriateness for another 14 days. The surveyor confirmed the above findings with the Director of Nursing on 06/29/22 at 10:25 A.M.

Based on observation, interview, and record review, the facility failed to ensure facial hair was covered and utensils and gloves were used when plating and serving foods. This had the potential to affect 45 residents who received meals served in the second floor dining room, as well as Residents #52 and #91. The facility census was 93 residents. Findings include: 1. Observation on 06/24/19 at 12:30 P.M. of lunch service in the second floor dining room revealed Dietary Aide (DA) #150 setting up the food on the steam table. DA #150 had a full beard without a hair restraint. On 06/24/19 at 12:30 P.M. with the Director of Dining Services (DDS) #160 confirmed DA #150 had a long beard and wasn't wearing a hair restraint to cover it. Observation on 06/24/19 at 12:30 P.M. of the start of meal service revealed DA #150 used gloved hands to plate quiche. DA #150 held the serving utensil in one hand and with the other hand directly touched the quiche to help slide it from the serving utensil and then position it on the plate. Using the same gloves with visible particles of quiche on them, DA #150 also handled lettuce and tomato, and assembled and plated sandwiches. On 06/24/19 at 12:57 P.M. DA #150 confirmed he used his gloved hands to directly handle and serve quiche, lettuce and tomatoes and sandwiches. DA #150 verified he should have used serving utensils. Review of the facility policy titled Employee Sanitary Practices dated 2013 revealed all employees shall wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food and use utensils to handle food. 2. Observation of the Courtyard dining room during the lunch meal on 06/24/19 at 11:45 A.M. revealed State Tested Nursing Aide (STNA) #201 used her bare hands to place lettuce and tomato on Resident #52's sandwich, and then held the sandwich in place to cut it in half. STNA #201 then repeated these actions for Resident #91's food. Interview with STNA #201 on 06/24/19 at 11:51 A.M. confirmed the above observations. Review of the facility's bare hand contact with food policy dated 2013 revealed single-use gloves were to be worn by staff when handling food directly, and bare handed contact with food was prohibited to staff.