**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to follow physician orders for 1 (Resident (R)9) of 2 residents reviewed for the provision of care and services. Findings included: A review of a facility policy titled, Incontinence Care Protocol, dated 03/2022, revealed, It is the policy of [facility] systems to outline the appropriate management for all residents with incontinence, to prevent the loss of skin integrity. A listed protocol directed staff to Apply moisture barrier cream and Assess/monitor skin with each incontinent episode. Review of an admission Record indicated the facility admitted R9 on 06/07/2023 with diagnoses that included encephalopathy and prostate cancer. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/11/2023, revealed R9 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, the resident required limited assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS noted R9 was frequently incontinent of urine and bowel. According to the MDS, the resident did not have any wounds or skin conditions. Review of Resident #9's Care Plan, initiated on 06/07/2023, revealed R9 had a potential for impairment of skin integrity. The Care Plan directed staff to apply moisture barrier after each incontinent episode. A review of the label for Calmoseptine ointment revealed, Uses: A moisture barrier that prevents and helps heal skin irritations from: urine. A review of R9's [NAME] Report, dated 06/07/2023, revealed, Skin Preventative. Moisture barrier after each incontinent episode. On 09/30/2023 at 10:25 AM, Certified Nursing Assistant (CNA)10 was observed providing incontinence care for R9. CNA10 properly explained to the resident what she needed to do and the resident provided permission for the surveyor to observe the care being provided. R9's existing incontinence brief was removed and was observed to be wet, but not soaked. R9 was cleaned using wet wipes and a clean incontinence brief was placed on the resident. R9's skin was observed to be clean, dry, and without any breakdown or redness. There was no application of a barrier cream. During an interview on 09/30/2023 at 10:30 AM, CNA10 stated the facility used Calmoseptine as a barrier cream, noting it was used whenever the aides noticed redness on a resident's buttocks or groin area. CNA10 stated if Calmoseptine was used, a nurse was notified. During an interview on 09/30/2023 at 10:35 AM, Licensed Practical Nurse (LPN)13 stated the facility used Calmoseptine as a barrier cream, noting a corresponding order would be on the treatment administration record (TAR). LPN13 noted that, if he or the aides noticed redness or breakdown, he contacted the nurse on call to obtain a treatment order. LPN13 stated there was always a nurse on call. LPN13 identified that the aides obtained barrier cream from a nurse to apply. During an interview on 09/30/2023 at 12:25 PM, R9 stated the nurses kept them clean and dry, though the resident was unable to endorse if staff applied cream during incontinence care. R9 noted there were no issues with their skin or timely incontinence brief changes. During an interview on 09/30/2023 at 12:30 PM, CNA10 stated she did not apply barrier cream to Resident #9 during the observation of incontinence care, noting their skin was not red. CNA10 opened a [NAME] (a list of care instructions in the electronic medical record,) which revealed Resident #9 was to receive barrier cream following every incontinence episode. CNA10 then stated she had not applied the barrier cream as she had ran out, and did not have anyone to get it for her, as the nurses were all agency and did not have a key to get into the storage area. On 09/30/2023 at 12:50 PM, the Director of Nursing (DON) accompanied the surveyor to the storeroom, noting that, while the storeroom was accessible by all staff, the Calmoseptine cream was not located in the storeroom. The DON stated barrier cream was stored in the treatment cart, noting all nurses had a master key and were able to obtain the cream whenever requested by an aide. During an interview on 09/30/2023 at 4:00 PM, CNA15 stated barrier cream was applied following every changing, which was noted on the [NAME]. The CNA stated barrier cream was obtained from a nurse, stating the aides generally knew who needed barrier cream, which they obtained prior to entering the resident's room. During an interview on 09/30/2023 at 4:15 PM, the DON stated CNAs were required to apply barrier cream after each incontinence episode for all incontinent residents, noting that while this was not documented in the plan of care, the nurses charted the barrier cream application on the resident's TAR once alerted by the CNA. The DON stated CNA10 should have applied a barrier cream to R9's perineal area after providing incontinence care, noting there was no reason not to. A review of CNA10's Nurse Aide Competency Evaluation, dated 11/28/2022, revealed the CNA received education and provided a return demonstration for incontinence care and review of the [NAME] as it pertained to the prevention of skin breakdown. During an interview on 09/30/2023 at 4:30 PM, the Administrator was made aware of the concern and stated he expected the aides to apply barrier cream following each incontinence episode.

Based on observation, interview and facility policy review, the facility failed to provide safe and effective medication administration by allowing expired medications to be available for resident use in two (2) of two (2) medication storage rooms. Findings include: The facility provided policy titled Medication Storage Guidance dated 2021 directed, Tuberculin Tests: Aplisol Injection: Tubersol Injection. Store in the refrigerator at 36 degrees to 46 degrees F [Fahrenheit] (two (2) degrees to eight (8) degrees C [Celsius]). Protect from light. Do not freeze. Date when opened and discard unused portion after 30 days. Observation of the Front Medication Room on 8/18/21 at 12:20 p.m. with Licensed Practical Nurse (LPN) #2 revealed one (1)multi-dose bottle of Aplisol Tuberculosis skin testing solution for resident use in a box dated 7/6/21. During interview with LPN #2 at that time, s/he stated nurses should date the bottle when opened and discard it after being open for 30 days. LPN #2 stated it appeared there was at least one (1) dose left in the bottle, and it was expired. LPN #2 stated the Unit Manager checked the expiration dates of the medications, and each nurse should check the expiration date before giving the medication/solution to a resident. Observation of the Back Medication Room on 8/18/21 at 12:45 p.m. with LPN #2 revealed two (2) multi-dose bottles of Aplisol Tuberculosis skin testing solution for resident use in one (1) box dated 7/13/21. LPN #2 stated s/he would discard both bottles of the Aplisol because the only date was 7/13/21 and was expired 30 days after the open date. LPN #2 stated there were several doses remaining in each opened bottle. During an interview on 8/18/21 at 2:16 p.m., the Director of Nursing (DON) stated his/her expectation was the open date should be written on the medication, ideally on the bottle instead of the box. The nurse should check for the date opened before giving the medication, and the bottle should be discarded after 30 days. During an interview on 8/20/21 at 8:53 a.m., the Pharmacist stated for Aplisol used after 30 days post opening, the potency of the solution may not be as effective. The Pharmacist stated a medication room audit was done monthly and any irregularities or expired medications were reported to nursing staff.