**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete quarterly assessments, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 5 of 42 sampled residents (Resident #3, #22, #23, #28, and #76) reviewed for completion of the MDS. The findings include: Review of the MDS 3.0 RAI Manual v (version) 1.17.1 October 2019, page 2-33 revealed, .The Quarterly assessment must be completed at least every 92 days following the previous OBRA [Omnibus Budget Reconciliation Act] assessment of any type .The ARD [Assessment Reference Date] (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type .The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Hypertension, Diabetes Mellitus, Acute Respiratory Failure, and Dysphagia. Review of Resident #3's quarterly MDS with an ARD dated 9/4/2021 revealed Item Z0500B was completed 11/29/2021. The quarterly MDS should have been completed by 9/18/2021 but was not completed until 11/29/2021. Review of the medical record, revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia, Hemiparesis, Acute Kidney Failure, Depression, and Heart Failure. Review of Resident #22's quarterly MDS with an ARD date of 10/18/2021 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 11/1/2021 but had never been completed. Review of the medical record, revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Schizophrenia, Dysphagia, Dementia. Review of Resident #23's quarterly MDS with an ARD date of 10/26/2021 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 11/9/2021 but had never been completed. Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses of Dementia, Depression, Anxiety, Falls, and Pain. Review of Resident #28's quarterly MDS with an ARD date of 9/21/2021 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 10/5/2021 but had never been completed. Review of the medical record, revealed Resident #76 was admitted to the facility on [DATE] with diagnoses of Displaced Intertrochanteric fracture of Right Femur, Dysphagia, and Falls. Review of Resident #76's quarterly MDS with an ARD date of 9/10/2021 revealed Item Z0500B was not completed. The quarterly MDS should have been completed by 9/24/2021 but had never been completed. During an interview on 12/1/2021 at 8:15 PM, MDS Coordinators #1, #2, and #3 confirmed the quarterly assessments for Residents #3, #22, #23, #28, and #76 were not completed timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess residents for the use of urinary catheters and antipsychotic medications for 2 of 21 sampled residents (Resident #280 and #382) reviewed for accuracy of assessments. The findings include: Review of the medical record, revealed Resident #280 was admitted on [DATE] with diagnoses of Fracture Right Femur, Parkinson's Disease, Acute Renal Failure, Urinary Tract Infection, Acute Cystitis, Hypertension, and Retention of Urine. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #280 was not coded for indwelling catheter. Review of the Care Plan dated 1/2/2021, revealed .Resident has a urinary catheter . Observation in the resident's room on 11/29/2021 at 10:10 AM and 4:00 PM, and on 11/30/2021 at 8:23 AM and 4:27 PM, revealed Resident #280 had an indwelling urinary catheter. During an interview on 12/1/2021 at 4:12 PM, MDS Coordinator #1 confirmed the Resident #280 should have been coded for an indwelling catheter. Review of the medical record, revealed Resident #382 was admitted to the facility on [DATE] with diagnoses of Neurogenic Bladder, Hypotension, Chronic kidney Disease, Atrial Fibrillation, Anxiety, Metabolic Encephalopathy, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #382 was coded as receiving antipsychotic medications on a routine basis. Review of annual MDS dated [DATE], revealed Resident #382 was coded as receiving antipsychotic medications on a routine basis. Review of the Physician Order Reports and Medication Administration Records for 4/1/2021 through 11/30/2021, revealed Resident #382 did not receive antipsychotic medications. During an interview on 12/1/2021 at 6:20 PM, MDS Coordinator #2 confirmed Resident #382 was coded incorrectly for receiving antipsychotic medications on the MDS dated [DATE] and 10/23/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter for 2 of 2 sampled residents (Resident #52 and #280) reviewed for indwelling urinary catheters. The findings include: Review of the facility's policy titled, Physician Orders, dated 11/6/2019, revealed .Review of new orders in daily clinical meeting .Review Verify Orders page and verify orders, as needed . Review of the facility's policy titled, Catheter Care Procedure, dated 5/23/2018, revealed .Grasp catheter with two fingers to stabilize it .Provide perineal hygiene .Using a clean washcloth, clean catheter. Starting close to the urinary meatus, clean catheter .along its length for about 10 cm [centimeters], moving away from the body .reapply catheter securement device . Review of the medical record, revealed Resident #52 was admitted on [DATE] with a diagnoses of Diabetes, Hypertension, Dysphagia, Urinary Tract Infection, Gastroesophageal Reflux Disease, and Retention of Urine. Review of Physician's Orders dated 10/18/2021, revealed .FOLEY CATHETER 16 FRENCH WITH 10 CC [cubic centimeters] .URINARY RETENTION . Observation in the resident's room on 12/1/2021 at 1:28 PM, revealed Certified Nursing Assistant (CNA) #2 washed her hands, donned her gloves, gathered her supplies, removed Resident #52's brief, and cleaned down each side of the labia. CNA #2 removed her gloves, did not perform hand hygiene, donned new gloves, and rinsed and dried the catheter. CNA #2 removed her gloves, did not perform hand hygiene and donned new gloves. CNA #2 positioned the resident on her right side, removed her gloves, did not perform hand hygiene, donned new gloves, and cleaned from front to back. CNA #2 rinsed and dried the resident, removed her gloves, did not perform hand hygiene, donned new gloves, and positioned the resident back in the bed. The resident did not have a catheter securement device. Review of the medical record, revealed Resident #280 was admitted on [DATE] with a diagnoses of Fracture Right Femur, Parkinson's Disease, Acute Renal Failure, Urinary Tract Infection, Acute Cystitis, and Hypertension, Retention of Urine. Review of Care Plan dated 11/3/2021, revealed that the resident had a urinary catheter. Observation in the resident's room on 11/29/2021 at 10:10 AM and 4:00 PM, on 11/30/2021 at 8:23 AM and 4:27 PM, and on 12/1/2021 at 7:13 AM and 10:14 AM, revealed Resident #280 had an indwelling urinary catheter. Review of the medical record revealed there was no Physician's Order for Resident #280's indwelling catheter. During an interview on 12/1/2021 at 8:51 AM, the Director of Nursing and the Assistant Director of Nursing confirmed that there were no orders for the indwelling urinary catheter for Resident #280. Observation in the resident's room on 12/1/2021 at 10:18 AM, revealed Licensed Practical Nurse (LPN) #1 gathered supplies, donned her gloves, removed Resident #280's brief, cleaned the right perineal area with a soapy wash cloth using a back and forth motion, and the cloth was noted to have a moderate amount of a brown substance. LPN #1 dried the resident with a towel in the same back and forth motion, removed her gloves, and washed her hands. LPN #1 then donned new gloves, and cleaned the left perineal area with a soapy wash cloth, using a back and forth motion, and the cloth was noted to have a moderate amount of a brown substance. LPN #1 dried the left perineal area with a towel using the same back and forth motion. LPN #1 then retrieved a package of wipes from a drawer, and wiped the catheter tubing from the port upward towards the resident. LPN #1 did not clean the catheter from the meatus down and contaminated the area with the brown substance. Resident #280 did not have a catheter securement device. During an interview on 12/1/2021 at 1:56 PM, CNA #2 confirmed that she should wash her hands between glove changes and that the indwelling catheter should be secured. During an interview on 12/1/2021 at 1:58 PM, LPN #1 confirmed that she should not have wiped back and forth during catheter care and that she should have cleaned the catheter from the meatus down. LPN #1 confirmed that the brown substance on the washcloth was feces. LPN #1 stated, .should have cleaned .got all the soap off .rinsed the soap off .pat dry . During an interview on 12/1/2021 at 2:23 PM, the Unit Manager confirmed staff should wash hands between glove changes. The Unit Manager confirmed that Resident #280 should have orders for her indwelling urinary catheter and catheters should be secured. The Unit Manager confirmed staff should discard contaminated wash cloths during perineal care, and should clean the catheter tubing starting at the meatus moving towards the bed side drainage bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete discharge assessments, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 16 of 42 sampled residents (Resident #4, #5, #8, #9, #11, #14, #16, #17, #18, #19, #20, #24, #25, #27, #32, and #73) reviewed for completion of the MDS. The findings include: Review of the MDS 3.0 RAI Manual v (version) 1.17.1 October 2019, page 2-37 revealed .Discharge Assessment .Must be completed when a resident is discharged .Must be completed (item Z0500B) within 14 days after the discharge date . Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation, Depression, Hypertension, and Diabetes Mellitus. Review of Resident #4's discharge MDS with an Assessment Reference Date (ARD) date of 7/24/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/7/2021 but had never been completed. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Pyogenic Arthritis, Anxiety, Depression, and Spinal Stenosis. Review of Resident #5's discharge MDS with an ARD date of 7/23/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/6/2021 but had never been completed. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Infection of Amputation Stump Left Lower Extremity, Diabetes Mellitus, Peripheral Vascular Disease, and Hypertension. Review of Resident #8's discharge MDS with an ARD date 7/24/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/7/2021 but had never been completed. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Open Left, Lower Leg Wound, and Hypertension. Review of Resident #9's discharge MDS with an ARD date of 8/28/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 9/11/2021 but never had been completed. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Lymphoblastic Lymphoma, Diabetes Mellitus, Depression, and Hypertension. Review of Resident #11's discharge MDS with an ARD date of 8/5/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/19/2021 but never had been completed. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses of Displaced Bicondylar Fracture of Left Tibia, and Hypertension. Review of Resident #14's discharge MDS with an ARD date of 7/23/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/6/2021 but never had been completed. Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses of Spinal Stenosis, Stage 3 Sacral Pressure Ulcer, Hypertension, and Diabetes Mellitus. Review of Resident #16's discharge MDS with an ARD date of 7/22/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/5/2021 but never had been completed. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Cerebral Infarction, and Hypertension. Review of Resident #17's discharge MDS with an ARD date of 8/5/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/19/2021 but never had been completed. Review of the medical record, revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Cirrhosis of Liver, Diabetes Mellitus, Atherosclerotic Heart Disease, Hypertension, and Heart Failure. Review of Resident #18's discharge MDS with an ARD date of 7/24/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/7/2021 but never had been completed. Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Hyperglycemia, Hypertension, and Diabetes Mellitus. Review of Resident #19's discharge MDS with an ARD date of 8/8/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/22/2021 but never had been completed. Review of the medical record, revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of Muscle Wasting and Atrophy, Cachexia, Acute Kidney Failure, and Paranoid Schizophrenia. Review of Resident #20's discharge MDS with an ARD date of 11/11/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 11/25/2021 but had never been completed. Review of the medical record, revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of Lack of Coordination, Diabetes, Dementia, Heart Disease, Heart Failure, and Muscle Weakness. Review of Resident #24's discharge MDS with an ARD date of 8/7/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/21/2021 but had never been completed. Review of the medical record, revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Acute Cholecystitis, Kidney Failure, Diabetes, Dysphagia, and Depression. Review of Resident #25's discharge MDS with an ARD date of 7/23/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/6/2021 but had never been completed. Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Osteomyelitis, Hypertension, Muscle Weakness, and Dysphagia. Review of Resident #27's discharge MDS with an ARD date of 7/23/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/6/2021 but had never been completed Review of the medical record, revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Hypertension, Dementia, and Chronic Atrial Fibrillation. Review of Resident #32's discharge MDS with an ARD date of 9/22/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 10/6/2021 but had never been completed. Review of the medical record, revealed Resident #73 was admitted to the facility on [DATE] with diagnoses of Osteoarthritis, Convulsions, and Hypertension. Review of Resident #73's discharge MDS with an ARD date of 7/22/2021 revealed Item Z0500B was not completed. The discharge MDS should have been completed by 8/5/2021 but had never been completed. During an interview on 12/1/2021 at 8:15 PM, MDS Coordinators #1, #2, and #3 confirmed the discharge assessments for Resident #4, #5, #8, #9, #11, #14, #16, #17, #18, #19, #20, #24, #25, #27, #32, and #73 were not completed timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, 2 of 5 (Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1) nurses failed to follow the facility policy for administration of medications through an enteral tube and administration of eye drops. The findings included: 1. The facility's Medication Administration Enteral Tubes policy documented, .The powder from each medication is mixed with water before administration. The souffle cup is rinsed with water to get all of the medication contained within the cup to facilitate the ordered dose .Enteral tubes are flushed with at least 15 ml [milliliters] of water before administering any medications and after all medications have been administered .PROCEDURES .Crush each immediate-release tablets, one at a time, into a fine powder, and dissolve in water .Dilute each liquid medication with water .Administer liquid medications first .Clean feeding syringe and return to bedside stand . Medical record review revealed Resident #18 was admitted to the facillity on 7/31/18 with diagnoses of Gastrostomy, Cerebral Infarction, Type 2 Diabetes, Dysphagia, and Hypertension. The physician's orders dated 12/5/18 documented, ASPRIN 81 MG [milligrams] .Give 1 Tablet .1 time Daily .AMLODIPINE BESYLATE 10 MG . GIVE 1 TABLET .ONCE DAILY .LITHIUM .150 MG .TWICE DAILY .METOCLOPRAMIDE [Reglan] 5MG/ML .5 ML .EVERY 12 HOURS .FLUSH TUBE WITH 30ML H2O [water] BEFORE AND AFTER MEDICATION . Observations in Resident #18's room on 12/18/18 at 9:10 AM, revealed LPN #1 administered an unmeasured amount of water, then poured in dry crushed amlodipine, poured in an unmeasured amount of water, added dry crushed aspirin, added an unmeasured amount of water, added lithium solution without diluting, added an unmeasured amount of water, then added Reglan liquid without diluting and followed with an unmeasured amount of water. LPN #1 did not measure the water and only poured a small amount of water following each medication. LPN #1 did not mix these medications with water prior to administering them through the enteral tube. Interview with the Director of Nursing (DON) on 12/19/18 at 12:00 PM, outside the Chapel, the DON was asked should enteral medications be diluted prior to administering in the enteral tube. The DON stated, Yes, they should . 2. The facility's Medication Administration Eye Drops policy documented, .With a gloved finger, gently pull down lower eyelid to form a pouch, while instructing resident to look up .Hold inverted medication bottle between the thumb and index finger, and press gently to instill prescribed number of drops into pouch near outer corner of eye . Medical record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes, Dysphagia, Hypertension, and Obstructive Sleep Apnea. The physician's orders dated 11/21/18 documented, .REFRESH TEARS 0.5% [percent] EYE DROPS .Give 1 Each in both eyes. As Needed .DRY EYES . Observations in Resident #73's room on 12/18/18 at 9:40 AM, revealed RN #1 administered eye drops without forming a pouch and held the bottle of medications above the eye and administered one drop over the center of the eye. Interview with the DON on 12/19/18 at 11:07 AM, at the East Nurses' Station, the DON was asked how should eye drops be administered. The DON stated, .form a pouch .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to follow physician orders for treatment of pressure ulcers for 1 of 2 (Resident #47) sampled residents reviewed with pressure ulcers. The findings included: Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses of Contracture Left Hip, Contracture of Right Hip, Left Heel Stage ll, Right Heel Suspected Deep Tissue Injury, Left Hip Stage lll, Dementia, Osteoporosis, and Hypothyroidism. The significant change Minimum Data Set (MDS) dated [DATE] revealed a stage 2 pressure ulcer, stage 3 pressure ulcer and 1 suspected deep tissue injury (sDTI). The physician's orders dated 12/5/18 documented, .Order Date .9/11/2018 .BILATERAL HEEL BOOTS [Prevalon heel boots for prevention and treatment of heel ulcers] TO BE WORN AT ALL TIMES . The Pressure Ulcer Record dated 12/6/18 documented, .Date of Origin 09/10/2018 .Left heel stage 2 ruptured blister .Facility acquired .Length .0.3 .Width .0.3 .Depth .0.0 . SPECIALTY INTERVENTIONS .bilateral heel boots . The Pressure Ulcer Record dated 12/6/18 documented, .Date of Origin 09/10/2018 .Right heel sDTI .Facility acquired .Length .0.0 .Width .0.0 .Depth .0.0 . SPECIALTY INTERVENTIONS .bilateral heel boots .Sdtl .right heel has resolved .Prevalon boot remains in place for protection . Observations at the [NAME] Nurses' Station on 12/17/18 at 4:10 PM, revealed Resident #47 was sitting in a wheelchair only wearing one heel boot on her left foot. Wound care observations in Resident #47's room on 12/18/18 at 10:20 AM, revealed Resident #47 was in the bed lying on a special air mattress. Licensed Practical Nurse (LPN) #2 removed a non-skid sock from Resident #47's left foot. The wound area had a small scab with no drainage. A heel boot was on the resident's right foot, the wound area was dry and intact. Observations on 12/19/18 at 8:33 AM, revealed Resident #47 was dressed, sitting in her wheelchair by the bed, only wearing non-skid socks on both feet. Resident #47 was not wearing bilateral heel boots. Interview with LPN #4 on 12/19/18 at 9:38 AM, in Resident #47's room, LPN #4 was asked what Resident #47 was wearing on her feet. LPN #4 stated, Non-skid socks . LPN #4 was shown Resident #47's physician order for bilateral heel boots at all times. LPN #4 confirmed Resident #47 was not wearing bilateral heel boots. LPN #4 then placed the heel boot on the resident's left foot and was unable to find the heel boot for Resident #47's right foot. Interview with the Director of Nursing (DON) on 12/19/18 at 9:00 AM, in the DON office, the DON was asked if staff should follow physician orders for bilateral heel boots to be worn at all times. The DON stated, Absolutely .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of significant medication errors when 1 of 5 (Licensed Practical Nurse (LPN) #3) nurses did not administer significant medications at the correct dosage. The findings include: 1. The facility's Medication Administration General Guidelines policy dated 5/2016 documented .Medications are administered as prescribed .Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record [MAR]. Compare the medication and dosage schedule on the resident's MAR with the medication label .Medications are administered in accordance with written orders of the prescriber .Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart b. When dose is prepared c. Before dose is administered . 2. Medical record review revealed Resident #197 was admitted to the facility on [DATE] with diagnoses of Hypoxemia, Syncope and Collapse, Hypertension, and Chronic Ischemic Heart Disease, and Chronic Diastolic Heart Failure. The physician's order dated 12/10/18 documented .[symbol for decrease] Losartan [a blood pressure medication] 25 mg [milligrams] po [by mouth] day [daily] . The Medication Administration Record (MAR) dated 12/1/18 to 12/31/18 documented, .LOSARTAN POTASSIUM 25 MG .Give 1 Tablet by mouth 1 time (s) Daily . Observations in Resident #197's room on 12/19/18 at 8:05 AM, revealed LPN #3 administered losartan potassium 100 mg to Resident #197. The failure of the nurse to administer the correct dose of losartan potassium resulted in a significant medication error. Interview with LPN #3 on 12/19/18 at 9:45 AM, at the East Nurses' Station, LPN #3 confirmed the medication card contained Losartan Potassium 100 MG and 7 of the 30 tablets were missing from the card. LPN #3 stated, It was discontinued on 12/11/18 and I gave too much. Interview with the Director of Nursing (DON) on 12/19/18 at 11:12 AM, at the East Nurses' Station, the DON was asked how should nurses administer the correct drug and amount. The DON stated, .check Medication Administration Record, read the order and compare it to the drug .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 5 (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #3) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 26 opportunities, resulting in an error rate of 11.538%. The findings included: 1. The facility's Medication Administration General Guidelines policy dated 05/2016 documented .Medications are administered as prescribed .Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record [MAR]. Compare the medication and dosage schedule on the resident's MAR with the medication label .Medications are administered in accordance with written orders of the prescriber .Verify medication is correct three (3) times before administering the medication. a. When pulling medication package from med cart b. When dose is prepared c. Before dose is administered . 2. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses of Diabetes, Hypertension, Gastroesophegeal Reflux Disease, Cellulitis, Chronic Kidney Disease, Hypercholesteremia, Depression, and Iron Deficiency Anemia. The physician's orders dated 11/21/18 documented, .ASPIRIN 81 MG [milligrams] .Give 1 Tablet by mouth 1 time[s] Daily .LEXAPRO 10 MG TABLET [escitalopram oxalate] Give 1 Tablet by mouth 1 times[s] Daily .CLARITIN 10 MG TABLET [loratadine] Give 0.5 Tablet by mouth 1 time[s] Daily .VESICARE 5 MG TABLET .Give 1 Tablet by mouth 1 time[s] Daily .DEMADEX 20 MG TABLET [toresemide] GIVE 2 TABLETS [40 MG] BY MOUTH EVERY OTHER DAY .DOCUSATE SOD [Sodium] 100 MG SOFTGEL [docusate sodium] Give 1 Caplet by mouth 2 time[s] Daily .AMLODIPINE BESYLATE 5 MG TAB [Tablet] [amlodipine besylate] Give 1 Tablet by mouth 2 time[s] Daily . Observations on 12/18/18 beginning at 9:30 AM, at the medication cart at the East Nurses' Station, RN #1 prepared the following medications for Resident #73: Docusate Sodium 100 MG 1 tablet Vesicare 5 MG 1 tablet Aspirin 81 MG 1 tablet Toresemide 20 MG 1 tablet Loratadine 10 MG 1/2 tablet Amlodipine Besylate 5 MG 1 tablet Escitalopram 10 MG 1 tablet Interview with RN #1 on 12/18/18 at 9:35 AM, at the medication cart at the East Nurses' Station, RN #1 confirmed there were 6 and a half pills in the souffle cup to administer to this resident. There should have been 7 1/2 pills, there was only one toresemide 20 MG tablet in the souffle cup instead of 2. Observations in Resident #73's room on 12/18/18 at 9:45 AM, revealed RN #1 administered these 6 1/2 pills to this resident by mouth. The administration of the toresemide 20 MG instead of 40 MG resulted in medication error #1. 3. Medical record review revealed Resident #197 was admitted to the facility on [DATE] with diagnoses of Hypoxemia, Syncope and Collapse, Hypertension, Chronic Ischemic Heart Disease, and Chronic Diastolic Heart Failure. The physician's telephone orders dated 12/10/18 documented .[symbol for decrease] Losartan 25 mg po [by mouth] day [daily] . The physician's telephone orders dated 12/16/18 documented, .flonase 2 squirts each nostril Q [every] Day . The Medication Administration Record (MAR) dated 12/1/18 to 12/31/18 documented, .LOSARTAN POTASSIUM 25 MG .Give 1 Tablet by mouth 1 time(s) Daily . Observations in Resident #197's room on 12/19/18 at 8:05 AM, revealed LPN #3 administered losartan potassium 100 mg to Resident #197 and 1 spray of Flonase to each nostril. Failure of the nurse to administer the correct dose of losartan potassium and Flonase resulted in medication error #2 and 3. Interview with LPN #3 on 12/19/18 at 9:45 AM, at the East Nurses' Station, LPN #3 confirmed the medication card contained Losartan Potassium 100 mg and 7 of the 30 tablets were missing from the card. LPN #3 stated, It was discontinued on 12/11/18 and I gave too much. Interview with LPN #3 on 12/19/18 at 10:35 AM, at the East Nurses' Station, LPN #3 confirmed she only gave this resident 1 spray of Flonase to each nostril. Interview with the Director of Nursing (DON) on 12/19/18 at 11:12 AM, at the East Nurses' Station, the DON was asked how should nurses administer the correct drug and amount. The DON stated, . check Medication Administration Record, read the order and compare it to the drug .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observations, and interview, the facility failed to ensure medications were properly and securely stored when medications were unattended in 1 of 62 (room [ROOM NUMBER]B) resident rooms, 1 of 5 (Licensed Practical Nurse (LPN) #2) nurses left medications unattended and out of their sight, and medications were not dated when opened in 2 of 8 (West 2 Medication Cart and [NAME] 1 Medication Cart) medication storage areas. The findings included: The facility's BEDSIDE MEDICATION STORAGE policy dated 5/2016 policy documented, .PROCEDURES .4. Bedside medication .Lockable drawers or cabinets are required . The facility's STORAGE OF MEDICATION policy dated 11/2017 documented, .POLICY Medications and biologicals are stored properly .to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .PROCEDURES .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications .are allowed to access medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended any persons with authorized access .12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used . The MEDICATIONS WITH SHORTENED EXPIRATION DATES provided by the American Society of Consultant Pharmacists documented, .Symbicort .Discard when the counter reaches zero or three months after removal from the protective foil package .Lantus .Vials/Cartridges/SoloStar expire 28 days after or removing from the refrigerator, whichever comes first .Novolin R [Regular] .Vial: Expires 42 days after opening or removing from refrigerator, whichever comes first . Observations in room [ROOM NUMBER]B on 12/17/18 at 9:30 AM, 12:10 PM, 5:05 PM, and on 12/18/18 at 8:10 AM, revealed a bottle of Dakins solution (1/2 strength sodium hypochlorite 25 percent, a medicated wound irrigation) sitting on top of the nightstand beside the resident's bed. Interview with the Director of Nursing (DON) on 12/18/18 at 8:50 AM, at the [NAME] Nurses' Station, the DON was asked if a wound treatment medication should be left at the bedside. The DON stated, No. Observations in Resident #197's room on 12/18/18 at 5:06 PM, revealed LPN #2 placed the resident's medication cups with medications on the over-bed table and went to the bathroom to wash her hands, leaving the medications out of her view. She then left the room to get a syringe, leaving the medications on the over-bed table and out of her view. Interview with the DON on 12/19/18 at 11:10 AM, at the East Nurses' Station, the DON was asked, should medications be left unattended. The DON stated, No. Observations in the [NAME] 2 Medication Cart on 12/19/18 at 10:45 AM, revealed 1 open vial of Novolin R with no open date, 1 open Lantus Solostar Pen with no open date, and 2 open Symbicort inhalers with no open date. Interview with LPN #1 on 12/19/18 at 10:47 AM, at the [NAME] 2 Medication Cart, LPN #1 confirmed these medications were not dated when they were opened. Observations in the [NAME] 1 Medication Cart on 12/19/18 at 10:55 AM, revealed 1 Levemir Flexpen with no open date. Interview with the Director of Nursing (DON) on 12/19/18 at 11:35 AM, in the DON Office, the DON was asked if medications with shortened expiration dates should be dated when opened. The DON stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 2 of 5 (Licensed Practical Nurse (LPN) #1 and 3) nurses failed to perform hand hygiene appropriately, use barriers, and clean reusable equipment during medication administration. The findings included: The facility's Handwashing/Hand Hygiene policy documented, Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. Discard towels into trash . The facility's Cleaning and Disinfecting Non-Critical Resident-Care Items policy documented, Reusable items are cleaned and disinfected or sterilized between residents ( .stethoscopes, durable medical equipment) . The facility's Clean Glucometer/PT [Protime] -INR [International Normalized Ratio] Competency policy documented, .If no visible organic material is present disinfect the exterior surfaces after each use using .facility approved disinfectant with either an EPA [Evironmental Protection Agency] registered detergent/germicide with a turberculocidal or HBV [Hepatis B Virus]/ HIV [Human Immunodeficiency Virus] label claim, or a dilute bleach solution of 1:10 to1:100 concentration . Observations in Resident #18's room on 12/18/18 at 9:05 AM, revealed LPN #1 went to the bathroom and placed the medication cups on the sink without a barrier. LPN #1 washed her hands, took the paper towels and dried her hands, then placed the towels on the sink behind the faucet. LPN #1 placed the syringe on the table without a barrier and without cleaning the table. LPN #1 placed the stethoscope on the resident's abdomen, and then put the stethoscope around her neck. LPN #1 did not clean the stethoscope prior to touching the resident's abdomen. After administering the medications, LPN #1 carried the trash and insulin syringe to the bathroom, washed her hands, and then proceeded gather up the trash and took it back to the room, put the syringe in a sharps box and trash in the wastebasket. LPN #1 did not perform hand hygiene after this. Interview with the Director of Nursing (DON) on 12/19/18 at 11:20 AM, at the East Nurses' Station, the DON was asked should the stethoscope be cleaned between residents. The DON stated, Yes, stethoscopes should be wiped down. The DON was asked should a barrier be used. The DON stated, Yes . Observations in Resident #18's room on 12/18/18 at 9:10 AM, revealed LPN #1 did not clean the over bed table before placing items on the table without a barrier. Observations in Resident #445's room on 12/19/18 at 7:30 AM, revealed LPN #3 carried glucometer, a bottle of test strips, lancets, and alcohol pads to the room, placed all the items in her pocket, washed her hands, then took out the items from her pocket. LPN #3 cleaned the glucometer with an alcohol pad. Observations at the East Nurses' Station on 12/19/18 at 8:05 AM, revealed LPN #3 left Resident 197's room after completing his accucheck. LPN #3 then proceeded to clean the glucometer with an alcohol pad and placed the glucometer on the top of the cart without a barrier. Interview with the DON on 12/19/18 at 11:12 AM, at the East Nurses' Station, the DON was asked how should glucometers to be disinfected. The DON stated, .We don't use alcohol wipes, we use germicidal wipes .