**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications for one of one resident (Resident #8) reviewed for enteral feeding tubes. The facility failed to ensure staff followed physician ordered water flushes before and after medication administration given via the G-Tube for Resident #8. This failure could place residents at risk of tube obstruction and a decrease in hydration. Findings include: Record review of Resident #8's admission Record revealed an [AGE] year-old male originally admitted on [DATE] and most recently admitted on [DATE]. His diagnoses included G tube status (tube inserted into the stomach for feeding, medication administration, and/or hydration), dysphagia (difficulty swallowing), and cerebral infarction due to thrombosis (stroke due to blood clot in the brain). Record review of Resident #8's quarterly MDS dated [DATE] revealed a BIMS score of 12 which indicated mild cognitive impairment. Record review of Resident #8's care plan on 9/4/24 revealed in part: Focus: Resident #8 has G-tube placement for medication administration r/t dysphagia. Goal: Resident #8 will be free of aspiration through the review date. Interventions: Flush g-tube with 60cc water before and after medication administration, and flush g-tube with 5cc water between medications every shift. Record review of Resident #8's Order Summary Report dated 9/4/24 revealed in part: Check placement of G tube prior to use every shift for placement. Flush G tube with 5ml of water between each medication administration every shift. Flush G tube with 60ml of water before and after medication administration every shift. Colace Capsule 100mg. Give 1 tablet via G tube two times a day related to constipation. Cymbalta Oral Capsule Delayed Release Particles 20mg. Give 1 capsule via G tube one time a day related to major depressive disorder. DO NOT CRUSH. GlycoLax Powder. Give 17gm via G Tube one time a day for constipation. Mix with 4oz-8oz of water. Keppra Solution 100mg/ml. Give 5ml via G tube two times a day for seizures. Losartan Potassium Tablet 100mg. Give 1 tablet via G tube one time a day related to hypertension. Hold if SBP less than 120 or DBP less than 60. Mucinex Fast-Max DM Max Oral Liquid 20mg-400mg/20ml. Give 20ml via G tube two times a day for congestion for 1 month. Order start date 8/29/24. Namenda Tablet 10mg. Give 1 tablet via G tube two times a day related to dementia. Phenytoin Suspension 125mg/5ml. Give 4ml via G tube two times a day related to convulsions. Observation of medication administration on 9/4/24 at 10:02am for Resident #8 revealed after LVN C appropriately checked Resident #8's blood pressure (124/68) then sanitized her hands, she retrieved each of Resident #8's medications from the medication cart. Each tablet or capsule was taken out of its pill pack or bottle and placed in separate medication cups. Each tablet was crushed individually in separate pouches and placed in separate medication cups. The Cymbalta capsule was opened, and its contents emptied into a medication cup. Each of the liquid medications were measured out into separate medication cups. LVN C filled 5 plastic 8 ounce cups with water and placed the medications and the cups of water on the resident's rolling table and took them inside the room with her. LVN C washed her hands appropriately and put on a gown and gloves. LVN C attached a 60ml syringe to Resident #8's G tube and aspirated (drew back the piston) to check for residual. LVN C then used her stethoscope to insure proper placement of the G tube. LVN C flushed Resident #8's G tube with 60ml of water, added approximately 5-10ml of water to each medication cup and added approximately 8 ounces of water to the GlycoLax powder. LVN C gave each medication through the G tube with 5ml water flushes between each medication. LVN C gave Resident #8 the GlycoLax. After LVN C gave Resident #8 all his medications, she flushed his G tube with 10ml of water. When asked how much water she flushed the G tube with when she was done, LVN C stated, 10mls. In an interview 9/4/24 at 10:38am, LVN C was asked to read Resident #8's orders regarding medication administration through his G tube. LVN C stated the orders read to flush with 5ml of water between each medication and flush with 60ml before and after medication administration. When asked how much water she flushed Resident #8's G tube with when she was finished with his medications, she stated she flushed it with 10ml of water. LVN C stated it was important to flush the G tube with 60ml of water to ensure that all of the medication was flushed through the G tube. LVN C stated if the resident did not receive all his medications, his medication levels could be off and he could have a seizure or complications. LVN C stated if the g-tube was not flushed properly, it could clog. LVN C stated they were in-serviced on G tubes and medication administration about every three months and the last was a few months ago. In an interview on 9/4/24 at 3:34pm, the DON stated it was important to flush the G tube with 60ml of water after medication administration to ensure that no medications stayed in the tube and potentially caused a blockage. The DON stated a blockage could lead to resident not getting their medications and having an adverse reaction. The DON stated a blockage could also lead to a rupture of the G tube or having to replace it. The DON stated the facility did skills checkoffs upon hire and annually for all nursing staff. In an interview on 9/5/24 at 09:26am, the Admin stated it was important to follow the provider's orders when any medications were given to any resident. The Admin stated it was important to flush the G tube with 60ml of water to ensure that all of the medications were given and water could flow easily through it. Record review revealed the facility had an in-service on medications administered via G tube and by mouth on 3/25/24 and LVN C signed it. Record review revealed LVN C completed a competency assessment for administering medications through an enteral tube on 4/25/24. The assessment was signed by the DON. Record review of the facility's policy on Administering Medications through an Enteral Tube dated November 2018 reflected in part: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. General Guidelines: 14. When the last of the medication begins to drain from the tubing, flush the tubing with 15m of warm purified water (or the prescribed amount).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5% or greater. The medication error rate was 33.33% based on 10 errors out of 30 opportunities for 2 (Resident # 26 and Resident #6) of 3 residents observed for medication administration in that: 1. The facility failed to ensure that MA B did not mix eight crushed medications in one pill cup for Resident #26. 2. The facility failed to ensure that MA B did not incorrectly hold medications based on administration parameters for Resident #6. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: 1. Resident #26 Record review of Resident #26's admission Record revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: dysphagia (difficulty swallowing), Alzheimer's disease (brain disorder that causes memory loss and other cognitive impairment), dementia (decline in cognitive abilities), gastritis (inflammation of the stomach lining), and epigastric pain (upper abdominal pain). Record review of Resident #26's Quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #26's Order Summary Report on 9/4/24 revealed in part: May alter medications by crushing or opening caps and administer in food and/or liquid every shift. buPROPion HCL Oral Tablet 100mg. Give 3 tablets by mouth one time a day for depression. 3 tabs to = 300mg. Carvedilol Oral Tablet 25mg. Give 1 tablet by mouth two times a day for HTN. Hold if BP less than 110/60. Docusate Sodium Oral Tablet 100mg. Give 1 tablet by mouth one time a day for constipation. Lasix Oral Tablet 20mg. Give 1 tablet by mouth one time a day for HTN/edema. Lisinopril Oral Tablet 20mg. Give 1 tablet by mouth one time a day for HTN. Hold if BP less than 110/60 and notify charge nurse. Multivitamin-Minerals Oral Tablet. Give 1 tablet by mouth one time a day for supplement. Namenda Oral Tablet 5mg. Give 1 tablet by mouth two times a day r/t Alzheimer's disease. Nutren 2.0 Oral Liquid. Give 120ml by mouth four times a day for maintain weight. Reglan Oral Tablet 10mg. Give 1 tablet by mouth before meals related to GERD. There was no order stating that medications could be cocktailed (mixed together) after crushing them. Observation of medication administration on 9/4/24 at 9:38am for Resident #26 revealed after MA B appropriately checked Resident #26's blood pressure (131/86) and pulse (71), then sanitized her hands, she retrieved each of Resident #26's medications from the medication cart. Each tablet was taken out of its pill pack or bottle and placed in separate medication cups. The liquid supplement was measured out into an 8 ounce plastic cup. Each tablet was crushed individually in separate pouches. The crushed tablets were then all combined in one medication cup. Pudding was added to the cup and the crushed tablets were mixed into the pudding. The resident was given the tablets mixed with the pudding by MA B in 3 spoonfuls. Afterward, MA B handed Resident #26 the liquid supplement cup and encouraged her to drink it. 2. Resident #6 Record review of Resident #6's admission Record revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included essential (primary) hypertension (high blood pressure), atherosclerotic heart disease (plaque build-up in the arteries in the heart), combined systolic and diastolic congestive heart failure (the heart muscles do not work properly allowing excess fluid buildup in the lungs and other tissues), peripheral vascular disease (reduced blood flow to organs and limbs), chronic kidney disease, and traumatic subdural hemorrhage (brain bleed caused by hitting the head). Record review of Resident #6's Quarterly MDS dated [DATE] revealed a BIMS score of 8 which indicated moderate cognitive impairment. Record review of Resident #6's Order Summary Report on 9/4/24 revealed orders that read in part: Allopurinol Tablet 100mg. Give 1 tablet by mouth three times a day for gout. Cholecalciferol Oral Tablet 125mcg. Give 1 tablet by mouth one time a day for supplement. Cyanocobalamin Tablet 500mcg. Give 1 tablet by mouth one time a day for vitamin. Ferrous Sulfate Oral Solution 220mg/5ml. Give 7.5ml by mouth two times a day for anemia. 7.5ml to=330mg. Folic Acid Tablet 1mg. Give 1 tablet my mouth one time a day for supplement. Isosorbide Mononitrate Oral Tablet 10mg. Give 1.5 tablet by mouth one time a day for 1.5 tabs=15mg related to hypertension. Notify MD if pulse below 60 for further orders. Lactulose Oral Solution 20gm/30ml. Give 30ml by mouth one time a day related to constipation and cirrhosis of liver. Lasix Oral Tablet 20mg. Give 1 tablet by mouth one time a day related to combined congestive heart failure. Metoprolol Tartrate Oral Tablet 25mg. Give 1 tablet by mouth one time a day related to hypertension. Hold if pulse below 60 and notify MD. Namenda Oral Tablet 5mg. Give 1 tablet by mouth two times a day for dementia. Nutren 2.0 Oral Liquid. Give 90ml by mouth four times a day for maintain weight. Vericiguat Oral Tablet 2.5mg. Give 1 tablet by mouth one time a day for heart failure. Administer with food. Hold if systolic less than 90 and notify MD. Observation of medication administration on 9/4/24 at 9:51am for Resident #6 revealed after MA B appropriately checked Resident #6's blood pressure (99/65) and pulse (64), then sanitized her hands, she retrieved each of Resident #6's medications, except the Isosorbide and the Metoprolol, from the medication cart. Each tablet was taken out of its pill pack or bottle and placed in separate medication cups. The liquid supplement was measured out into an 8 ounce plastic cup. Resident #6 was given a cup of water and was able to take her medications. Afterward, MA B handed Resident #6 the liquid supplement cup and encouraged her to drink it. In an interview on 9/4/24 at 2:49pm, MA B stated the doctor said that it was OK to mix the medications together. When asked if there was an order to mix the medications, MA B stated there was not and that she is not supposed to mix them without an order. MA B stated mixing the medications without an order could lead to medication interactions that could be harmful to the resident. When asked about holding the medications for Resident #6, MA B stated the orders for both Isosorbide and Metoprolol had a hold if the resident's systolic blood pressure (the top number) was below 110 or the resident's diastolic blood pressure (the bottom number) was below 60. MA B stated the Metoprolol also had a hold order if the resident's pulse was below 60. When asked what the orders read for Resident #6's Isosorbide, MA B stated the Isosorbide had an order to notify the provider if the pulse was below 60 for further orders. MA B stated the order for Resident #6's Metoprolol stated to hold if pulse was below 60 and notify the provider. MA B stated neither medication had an order to hold depending on blood pressure parameters. MA B stated that those were the hold parameters for most blood pressure medications and she thought that Resident #6's blood pressure medications had the same parameters. MA B stated if blood pressure medications were held when not indicated, it could lead to the resident's blood pressure going up which could lead the resident to have a bad outcome. MA B stated it was important that physician's orders were followed to ensure that the resident got the right medication, right dose, etc. MA B stated she had been at the facility as a medication aide for about 2 years. MA B stated the facility did an in-service annually on medication administration. MA B stated she did not remember if they did a skills check off upon hire. MA B stated she did continuing education every year for her medication aide certification. In an interview on 9/4/24 at 3:34pm, the DON stated that they had gotten a verbal ok from the provider to cocktail medications, but there had not been a written order for it. The DON stated she called the NP earlier to clarify that it was ok to cocktail Resident #26's medications and that she put the order in after she talked to him. When asked about Resident #6's blood pressure medications, the DON stated anytime a blood pressure medication was held, the MA notified the charge nurse. The charge nurse then notified the provider to find out if there were any new orders. If the provider was not notified that medications were held, he would not know if the medications were effective or not or if the dosage/frequency needed to be changed. The DON stated that most blood pressure medication orders should include hold parameters. The DON stated the facility did skills checkoffs upon hire and annually for all nursing staff. In an interview on 9/5/24 at 9:26am, the Admin stated on 9/4/24, she had a discussion with nursing staff about not cocktailing medications without an order. The Admin stated if medications were mixed without the provider's knowledge or an order, it could lead to medication interactions which could lead to bad outcomes for residents. She stated the pharmacist routinely checked medications to make sure that there were no adverse drug interactions and if a potential adverse interaction was found, the pharmacist would notify the provider. The provider would then decide on what to do. The Admin stated that the provider was aware of medications being cocktailed but had not put any orders in for it. The Admin stated the DON contacted the provider on 9/4/24 and got orders to be able to mix medications for some residents. When asked about holding medications, the Admin stated if medications were held, the charge nurse was to be notified. The charge nurse would notify the provider for further orders. The Admin stated if blood pressure medications were held without contacting the provider, it could lead to worsening of symptoms for the resident such as blood pressure rising later in the day which could cause headaches, dizziness, nausea, or worse. The Admin stated staff has skills check offs done upon hire and annually. Record review revealed MA B had completed 7 hours of medication aide continuing education on 5/7/24. Record review of the facility's Administering Medications Policy dated April 2019 revealed in part: Policy Heading: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one resident (Resident #4) of two residents observed for infection control practices during wound care in that: 1.) The facility failed to ensure LVN A performed hand hygiene for at least 20 seconds during and after wound care for Resident #4. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. The findings included: Record review of Resident #4's Face Sheet dated 9/4/24 reflected a [AGE] year-old male with an original admission date of 12/10/22. His diagnoses included dementia (decline in cognitive abilities that affects a person's ability to perform everyday activities), chronic obstructive pulmonary disease (ongoing lung condition caused by lung damage), and Parkinson's disease (brain disorder that affects movement and causes tremor, and stiffness). Record review of Resident #4's care plan dated 5/3/24 reflected: · Resident #4 had a Stage 4 (sores extend below the subcutaneous fat into deep tissue) to right heel. Interventions included: · Reposition every 2 hours as needed to prevent any further pressure injuries. · Skilled nurse to off load heel with pillows while in bed and wear heel protectors. · Skilled nurse to perform daily wound treatment as ordered. · Skilled nurse to perform weekly skin assessments. · Skilled nurse to report any changes in skin condition to doctor and responsible party. Record review of physician orders dated 9/4/24 reflected: Cleanse with wound cleanser, pat dry with 4x4 (absorbent medical pad), apply moistened collagen pad cut to size, cover with gauze, wrap with kerlix (woven gauze used for wound care) and secure with tape every day shift every Monday, Wednesday, and Friday for wound treatment and as needed for as needed for soiled or damaged dressing. During an observation of wound care for Resident #8 on 09/04/24 at 12:51 PM LVN A washed her hands for 17 seconds prior to beginning wound care and 16 seconds after wound care was completed. In an interview on 09/04/24 at 1:27 PM 09/04/24 01:27 PM LVN A stated handwashing should be done for at least 20 seconds to prevent the spread of germs and infections. LVN A stated by not washing hands for 20 seconds or greater, it could lead to Resident #4's wound becoming infected or not healing properly. LVN A stated staff were in-serviced frequently on hand hygiene and infection control but could not remember when the last in-service was. In an interview on 09/04/24 at 3:27 PM the DON stated handwashing should be at least 20 seconds or greater when lathering hands. The DON stated by not washing hands for 20 seconds are greater could increase the chances of spreading germs. The DON stated she could not remember when the last in-service on handwashing was but a handwashing in-service and return demonstration was conducted on 9/4/24 with all nursing staff with no concerns identified. Record review of facility's Handwashing/Hand Hygiene policy revised on October 2023 reflected: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Procedure Washing Hands 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Record review of www.cdc.gov webpage titled About Handwashing dated 2/16/24 reflected: Washing your hands is easy, and it's one of the most effective ways to prevent the spread of germs. Follow these five steps every time. 1. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. 2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 3. Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice. 4. Rinse your hands well under clean, running water. 5. Dry your hands using a clean towel or an air dryer.