Based on observation, interview and record review, the facility did not ensure prescription medications were administered by qualified staff to resident's (R) skin for 2 of 5 observations. (R24 and R26) Findings include: Surveyor reviewed facility policy titled, Medication Administration, stated in part: .-1. Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations to prepare medications . Surveyor reviewed R24's physician orders on 02/04/25 which state in part: -Ammonium Lactate External Lotion 12 % (Lactic acid), apply to both legs topically in the morning for dry skin. -Nystatin External Powder 100000 unit/GM, apply to skin infection area topically three times a day for Candida yeast infection. Surveyor reviewed R26's physician orders on 02/04/25 which state in part: -Lac-Hydrin External Cream 12 % (Lactic Acid (Ammonium Lactate), apply to Bilateral Legs topically one time a day for dry skin. On 02/04/25 at 8:13 AM, Surveyor observed Licensed Practical Nurse (LPN) D administer R24's medications. Surveyor observed R24's prescription cream and Nystatin powder sitting on R24's bedside dresser. LPN D indicated that R24 has prescription cream for R24's legs, but LPN D will need to check with Certified Nurse Assistant (CNA)s to see if CNAs applied prescription cream to R24's legs. LPN D took prescription medication bottles that were lying on bedside dresser and brought the prescriptions back to medication cart. LPN D stated, Prescription creams should be in medication cart locked. LPN D stated she has been off for a week and unsure why the creams are in R24's room. Surveyor asked LPN D what is the normal process for applying prescription creams to R24's legs. LPN D indicated that only nurses are supposed to apply prescription creams to R24's legs. On 02/04/25 at 8:15 AM, Surveyor observed LPN D approach CNA E and asked CNA E if CNA E applied prescription medication to R24's legs this morning. CNA E indicated that CNA E applied R24's special creams after R24 received a bath this morning. On 02/04/25 at 8:16 AM, Surveyor observed LPN D approach Registered Nurse (RN) C and informed RN C that CNA E had applied prescription creams to R24 and R26. Surveyor asked RN C if CNAs are allowed to apply prescription creams. RN C indicated that CNAs are not allowed to apply prescription creams ever. RN C indicated that sometimes prescription medications will be left in resident rooms if there is a self-administer order put in the chart that they can self-administer the medication. On 02/04/25 at 11:18 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for who administers and applies prescription topical medications for R24 and R26. DON B indicated that DON B already went into R26's room and took topical medications out of room. DON B indicated that CNAs are not to administer any medications under any circumstances and that education is already in effect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure a resident with an enteral tube receives the appropriate treatment and services to prevent complications. Registered Nurse (RN) administered a medication through Resident (R) 12's enteral tube without completing a water flush prior to the medication. This occurred for 1 of 2 enteral medication observations. Findings include: According to the National Library of Medicine, when administering medications via enteral tube, .After tube placement is checked, a clean 60-mL [milliliters] syringe is used to flush the tube with a minimum of 15 mL of water before administering the medication. Follow agency policy regarding flushing amount . https://www.ncbi.nlm.nih.gov/ According to facility policy and procedure, entitled, Medication Administration Enteral Tubes, last reviewed/revised 01/23 .Enteral tubes are flushed with at least 15 ml of water before administering any medications and after all medications have been administered . R12 was admitted to the facility on [DATE], with the following diagnosis, in part: dysphagia (difficulty swallowing) following nontraumatic intracerebral hemorrhage. R12 had the following physician order on the medical record: May crush and cocktail all medications and administer via G-tube every shift. Flush with 30cc [ml] of water before and after administration of medication . On 01/30/24 at 11:11 AM, Surveyor observed RN F administer a medication through R12's enteral tube. After preparing and dissolving the medication, RN F carried the medication to the bedside table and explained to R12 what they were going to do. RN F obtained a graduate and syringe from the over bed table and filled the graduate with warm water. RN F exposed the enteral tube, assessed the site, and gave the tube a gentle tug to verify placement, per facility policy. RN F drew the dissolved medication into a syringe, opened the port on the tube and instilled the medication into the tube. RN F followed the medication with 200 milliliters of water for the ordered water flush. RN F did not flush the enteral tube with water before administering the medication. On 01/31/24 at 7:32 AM, Surveyor interviewed RN F about the procedure for administering medications through an enteral tube. RN F stated once they have the medications prepared, they go in and explain to the resident what they are going to do. Then they expose the tube, observe the insertion site, and gives it a gentle tug to verify placement. Then if placement is good and no concerns observed at the site, they administer the medication with a syringe and follow it with a water flush. Surveyor asked if they do a water flush before administering medications. RN F stated they did not usually do a water flush prior to administering the medication. On 01/31/24 at 9:15 AM, Surveyor interviewed Director of Nursing (DON) B about the observation of RN F administering a medication through R12's enteral tube without doing a water flush prior to the medication. DON B stated their policy stated a water flush should be completed prior to administering the medication. DON B stated RN F was not following facility policy.

Based on observation, interview and record review, the facility staff did not ensure proper hand hygiene when distributing food. The facility did not have a freezer internal temperature monitoring system for stored foods. Staff did not check the dishwasher internal temperature for proper dish sanitization. This has the potential for foodborne illness to all 28 residents (R) reviewed in the facility. Findings include: Facility policy entitled Hand Washing-Food and Nutrition Services, stated in part, . Hands and exposed portions of arms should be washed immediately before engaging in food preparation. 1. b. After touching bare human body parts other than clean hands and clean, exposed portions of arms, i. Before donning disposable gloves for working with food and after gloves are removed, j. After engaging in other activities that contaminate the hands . Example 1 On 01/30/24 at 7:46 AM, Surveyor observed [NAME] D serve breakfast in the main dining room. Surveyor observed [NAME] D take his right gloved hand and scratch under his left gloved wrist below the band-aid located on his forearm/wrist. [NAME] D then reached for toast with the contaminated right gloved hand and buttered the toast. Then [NAME] D took a pair of tongs, picked the bread up, placed the piece of toast onto the plate, and readjusted the toast with the contaminated gloved right hand. Surveyor did not observe hand hygiene performed before, during, or after serving breakfast to all residents. On 01/30/24 at 11:44 AM, Surveyor observed [NAME] D prepping/serving room trays and the main dining room. [NAME] D applied a pair of gloves and picked up [NAME] D's eyeglasses off the kitchen counter and applied them on his face. Then [NAME] started serving lunch. Surveyor witnessed 4 cold chicken sandwiches on a plate off to the side of the steam table. [NAME] D picked up a cold chicken sandwich with contaminated gloved hands and placed the sandwich on R15's plate. [NAME] D picked up another cold chicken sandwich with contaminated gloved hands and placed the sandwich on R13's plate. Surveyor observed [NAME] D readjust eyeglasses with gloved fingertips and palms and then touch [NAME] D's face with gloved hands and scratched cheek. [NAME] D continued with contaminated gloved hands to pick up cold chicken sandwiches and serve them to residents. Surveyor did not observe any hand hygiene before, during, or after prepping/serving food to residents. On 01/30/24 at 12:00 PM, Surveyor interviewed Dietary Manager (DM) C and asked about hand hygiene in the kitchen when prepping/serving food. DM C indicated that the expectation for all staff in the kitchen is to wash their hands before and after prepping/serving meals. DM C indicated that [NAME] D should have taken gloves off and washed his hands after scratching his arm with gloved hands. DM C indicated that [NAME] D should have taken his gloves off and washed his hands after touching eyeglasses and placing them on his face. Example 2 On 01/29/24 at 12:20 PM, Surveyor observed freezer #3 to not have an internal thermostat. On 01/29/24 at 12:25 PM, Surveyor interviewed DM C and asked how the staff keeps food stored properly in the freezer if there is no internal temperature gauge in case the outside gauge thermometer breaks. DM C indicated that staff read the thermometer off the outside and there is no internal thermometer. DM C then indicated that she ran out of an internal thermometer and is ordering one for freezer #3. Example 3 On 01/29/24 at 12:30 PM, Surveyor observed Dietary Aide (DA) E washing dishes in the kitchen. Surveyor did not observe DA E check the internal temperature when washing dishes. On 01/29/24 at 12:35 PM, Surveyor interviewed DA E and asked if internal dishwasher temperatures are checked. DA E indicated that staff check the temperature gauges on the bottom gauge and the top gauge. DA E indicated they do not check an internal temperature. On 01/31/24 at 7:32 AM, Surveyor interviewed DM C and asked about checking dishwasher temperatures when washing dishes. DM C indicated that the kitchen uses a hot wash cycle and checks temperature gauges on the bottom and top gauge for correct temperature. Surveyor asked DM C if the staff checks internal temperature to make sure the correct sanitizing system is in place. DM C indicated that the kitchen does not check internal temperatures. DM C can order some internal temperature stickers to place for the first cycle of dishes being washed going forward.