Inspection·November 10, 2021

F 0684 policy was to monitor and document bruising on weekly skin assessments. Level of Harm - Minimal harm or potential for actual harm Interview on 11/08/21 at 12:00 P.M. with the Director of Nursing (DON) confirmed the presence of the bruising and petechiae on the arms of Resident #26 and that the medical record was silent for any mention of bruising or petechiae for Resident #26. Residents Affected - Few Review of the facility's undated policy titled Skin Assessment revealed skin assessments should be completed on admission and weekly thereafter, noting any skin conditions such as redness, bruising, and skin tears. 2. Review of the medical record for Resident #234 revealed an admission date of 10/16/21. Resident #234's diagnoses included chronic atrial fibrillation, peripheral vascular disease, chronic obstructive pulmonary disease and muscle weakness. Review of the MDS assessment, dated 10/20/21, revealed Resident #234 was receiving an anticoagulant medication. Review of the physician orders, dated 10/18/21, revealed orders for Eliquis 2.5 mg twice daily. No physician order was present to monitor for side effect of anticoagulant therapy. Review of the plan of care for Resident #234 did not reveal any care plan related to anticoagulant therapy or monitoring for adverse effects of anticoagulant therapy. Review of the nurse progress notes from 09/30/21 to 11/07/21 for Resident #234 revealed the progress notes to be silent for nose bleeds, Interview on 11/07/21 at 9:34 A.M. with Resident #234 revealed her nose bleeds a lot since starting the anticoagulation therapy. Resident #234 shared that the nurses were aware. Resident #234 shared she last had a nose bleed the night before last but that she got it to go away without staff help. Interview on 11/09/21 at 2:02 P.M. with State Tested Nurse Aide (STNA) #342 revealed Resident #234 has had a couple of minor nose bleeds since she has been the facility. STNA shared that she did report the nose bleeds to a nurse, but could remember which nurse or when. Interview on 11/09/21 at 11:50 A.M. with the DON confirmed the medical record for Resident #234 was silent for a care plan or any interventions to monitor for side effects of anticoagulation therapy, and contained no mention of nose bleeds. The DON confirmed that facility policy was to monitor for adverse effects for those residents being treated with anticoagulation medications. Review of the facility's policy titled Medication Administration, revised 2019, revealed the nurse should report and document any adverse side effects of medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366112 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brown Memorial Home Inc 158 E Mound St Circleville, OH 43113 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide physician ordered interventions to prevent a resident's decrease in range of motion. This affected one (#4) of one resident reviewed for limited range of motion. The facility identified four residents with contractures. The facility census was 37. Findings include: Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses including primary generalized arthritis, pain, and unspecified dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/01/21, revealed Resident #4 was rarely/never understood and required extensive assistance from two staff members for bed mobility. Resident #4 was assessed to have a functional impairment on one side to an upper extremity. Review of the care plan, dated 05/30/17 and revised on 08/12/21, revealed Resident #4 needed extensive assistance with Activities of Daily Living (ADL) and had a left hand contracture. Interventions included to wash the left hand twice daily with soap and water, pat dry, and apply rolled washcloth in Resident #4's left hand. There was no mention of the resident refusing for the placement of the washcloth in Resident #4's left hand. Review of the active physicians order, dated 08/10/21, revealed Resident #4 had orders to wash the left hand twice daily with soap and water, pat dry, and apply a rolled washcloth in the left hand. Observation on 11/07/21 at 10:02 A.M. revealed Resident #4 was in her wheelchair in the dining room and did not have a rolled washcloth or other device placed in her left hand. Subsequent observations on 11/07/21 at 3:37 P.M., 11/08/21 at 9:25 A.M. revealed Resident #4 was in her wheelchair in the dining room and did not have a rolled washcloth or other device placed in her left hand. Interview with State Tested Nursing Assistant (STNA) #333 on 11/08/21 at 9:28 A.M. verified Resident #4 did not have a rolled washcloth or other device placed in her left hand. Observation on 11/09/21 at 10:15 A.M. revealed Resident #4 was in her wheelchair and did not have a rolled washcloth or other device placed in her left hand. Interview with Licensed Practical Nurse (LPN) #352 on 11/09/21 at 10:20 A.M. revealed the facility STNAs typically placed the rolled washcloth in the left hand of Resident #4 and was unsure if they had attempted to do so during the shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366112 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brown Memorial Home Inc 158 E Mound St Circleville, OH 43113 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to timely implement dietary recommendations for a resident who had minimal food intake. This affected one (#9) of two residents reviewed for nutrition. The facility identified there were no residents with significant weight loss in the last month. The facility census was 37. Residents Affected - Few Findings include: Record review for Resident #9 revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertension, hyperlipidemia, type two diabetes mellitus, dementia without behavioral disturbances, and cognitive communication deficit. Review of the admission Minimum Data Set (MDS) assessment, dated 08/18/21, revealed Resident #9 had moderately impaired cognition and required extensive assistance from one staff member for eating. Review of the care plan, dated 08/19/21 and revised on 08/23/21, revealed Resident #9 had a nutritional problem or potential nutritional problem. Interventions included to provide and serve a supplement shake as ordered, provide and serve regular diet as ordered, provide and serve magic cup three times a day, obtain and monitor laboratory/diagnostic work, weigh at same time of day and record as ordered, and provide tray set up and assistance and monitor intake and record every meal. Review of the Nutritional Status Note, written by Registered Dietician (RD) #525 on 08/19/21, revealed Resident #9 was assessed to have low meal acceptance and an appetite stimulant was recommended. Review of the Registered Dietician (RD) report with dietary recommendations, dated 08/19/21, revealed RD #525 recommended an appetite stimulant for Resident #9. Review of the physicians order, dated 09/09/21, revealed Resident #9 was ordered the appetite stimulant Remeron one 7.5 milligram tablet once a day by mouth. This was three weeks after the RD made the recommendation to start the appetite stimulant. There was no evidence in the medical record the physician addressed the appetite stimulant until 09/09/21. Interview with the Director of Nursing (DON) on 11/09/21 at 9:00 A.M. verified RD #525 had made recommendations for an appetite stimulant for Resident #9 on 08/19/21 and the facility did not obtain an order for the recommended appetite stimulant until 09/09/21. The DON stated the facility did not have a policy for a timeline to implement dietary recommendations but the goal was within one to two weeks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366112 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brown Memorial Home Inc 158 E Mound St Circleville, OH 43113 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to accurately assess a resident's pain. This affected one (#4) of one resident reviewed for pain management. The facility identified 20 residents on a pain management program. The facility census was 37. Residents Affected - Few Findings include: Record review for Resident #4 revealed the resident was admitted to the facility on [DATE] with diagnoses including primary generalized arthritis, pain, and dementia with behavioral disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/01/21, revealed Resident #4 was rarely/never understood. Resident #4 was on a pain management schedule, did not receive as needed pain medications and was not treated for non-medication interventions for pain. Review of the care plan, dated 07/21/15 and revised on 11/27/19, revealed Resident #4 had the potential for unmanaged pain. Interventions included to administer routine and as needed pain medications as ordered, anticipate the need for pain relief and respond immediately to any complaint of pain, and assess pain level on a scale of one to 10 (with one being the least and ten being the severest pain), face scale, or non-verbal indicators. Review of the active physicians order, dated 10/10/17, revealed an order to monitor the residents pain level on a scale of zero to 10 every shift. Review of the Medication Administration Records (MAR) for 09/2021, 10/2021, and 11/2021 revealed staff were monitoring the pain level of Resident #4 using a verbal pain scale. Observation on 11/08/21 at 9:25 A.M. revealed the left hand of Resident #4 was observed to be contracted. State Tested Nursing Assistant (STNA) #333 raised up the left, contracted hand of Resident #4 to observe it and the resident was observed to retreat back into her chair and grimaced when the left hand was handled. STNA #333 lowered the resident's hand immediately and the resident was observed to relax and show no signs of pain. Interview with STNA #333 on 11/08/21 at 9:28 A.M. verified Resident #4 was observed to exhibit signs of pain when the resident's left hand was handled. There was no evidence in Resident #4's medical record there was a timely follow up assessment after Resident #4 exhibited signs of pain on 11/08/21. Observation on 11/09/21 at 10:15 A.M. revealed when Licensed Practical Nurse (LPN) #352 began cleaning the left, contracted hand of Resident #4 with a warm, wet washcloth, the resident was observed to retreat back into her wheelchair and exhibit facial grimacing. LPN #352 immediately ceased cleaning the left hand of Resident #4 when indicators of pain were exhibited. Interview with Resident #4 on 11/09/21 at 10:18 A.M. revealed the resident was unable to verbalize the level of pain experienced when her left hand was cleansed using a verbal descriptor scale due to impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366112 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brown Memorial Home Inc 158 E Mound St Circleville, OH 43113 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Interview with LPN #352 on 11/09/21 at 10:20 A.M. verified Resident #4 exhibited signs of pain when her left hand was being handled and cleansed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366112 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brown Memorial Home Inc 158 E Mound St Circleville, OH 43113 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Potential for minimal harm Based on employee record reviews and staff interviews, the facility failed to provide a continuing education program and twelve hours of training annually for state tested nursing assistants employed by the facility. This had the potential to affect all 37 residents residing in the facility. Residents Affected - Many Findings include: Review of the personnel file for State Tested Nursing Assistant (STNA) #319 revealed STNA #319 was hired on 02/07/19 and there was no evidence of twelve hours of continuing education in the last year. Review of the personnel file for STNA #350 revealed STNA #350 was hired on 09/28/20 and there was no evidence of twelve hours of continuing education in the last year. Review of the personnel file for STNA #348 revealed STNA #348 was hired on 06/23/16 and there was no evidence of twelve hours of continuing education in the last year. Interview with Human Resources Manager #334 on 11/08/21 at 1:00 P.M. verified she has no evidence of a continuing education program or evidence of 12 hours of training completed annually for any of the STNAs employed by the facility. Interview with the Director of Nursing on 11/08/21 at 1:10 P.M. verified no records could be found to ensure twelve hours of training was completed by STNA #319, #350 and #348. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366112 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brown Memorial Home Inc 158 E Mound St Circleville, OH 43113 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Potential for minimal harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, review of the facility's policy, and record reviews, the facility failed to maintain a clean, sanitary kitchen equipment and failed to label and date open food items. This had the potential to affect the 37 residents residing in the facility who all received meals from the kitchen. Findings include: Observation on 11/07/21 at 8:25 A.M. revealed the bottom shelf on the reach in freezer contained a large, thick layer of sticky substance and multiple pieces of unpackaged broccoli. An opened brown paper bag containing tater tots was observed to not be labeled with the date it was opened and was lying on top of the thick layer of sticky substance. Interview with Dietary Personnel (DP) #316 on 11/07/21 at 8:26 A.M. verified there was a large,thick layer of sticky substance and multiple pieces of unpackaged broccoli located on the bottom shelf of the reach in freezer. DP #316 also verified there was an opened brown paper bag containing frozen tater tots which was not labeled with the date it was opened. Observation on 11/09/21 at 10:45 A.M. revealed the large, thick layer of sticky substance and multiple pieces of broccoli continued to remain on the bottom shelf of the reach in freezer. The opened brown bag containing tater tots and a zip-lock freezer bag containing cinnamon rolls were observed to be lying on top of the sticky substance on the bottom shelf of the reach in freezer and were not labeled with the date they were opened. Interview with Dietary Manager (DM) #304 on 11/09/21 at 10:46 A.M. verified the sticky substance and broccoli remained on the bottom shelf of the reach in freezer and verified the opened bag of tater tots and zip-lock bag of cinnamon rolls had not been labeled with the date they were opened. Review of the facility's undated policy titled Date Marking for Food Safety, revealed the individual opening or preparing a food should be responsible for date marking the food at the time the food was opened or prepared. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366112 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brown Memorial Home Inc 158 E Mound St Circleville, OH 43113 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of the facility's policy, review of the Centers for Disease Control and Prevention (CDC) guidance, and record reviews, the facility failed to appropriately wear Personal Protective Equipment (PPE) during the COVID-19 pandemic, and failed to perform appropriate hand hygiene during wound care for Resident #12 and medication administration for Resident #11. This had the potential to affect all 37 residents who resided in the facility. Residents Affected - Many Findings include: 1. Review of Resident #12's medical record revealed an original admission date of 08/24/21. Diagnoses included congestive heart failure, peripheral vascular disease, depression, chronic obstructive pulmonary disease, atherosclerotic heart disease, pneumonia, E. coli infection of gastrointestinal tract, chronic kidney disease, and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/13/21, revealed Resident #12 had clear speech, always understood others, always made himself understood and had no cognitive deficits. Review of the physician orders revealed the abdominal wound to be cleansed with normal saline and pat dry, and to apply skin prep to peri-wound area. Apply Hydrogel to wound bed, and cover with ABD pad. Secure with tape to borders. Observation of Licensed Practical Nurse (LPN) #331 and #352 providing wound care to Resident #12's abdominal wound on 11/10/21 at 10:30 A.M. revealed supplies were gathered and Resident #12 was pre-medicated for pain and assessed for pain prior to beginning the treatment. LPN #331 removed the old, dirty bandage which had a scant/trace amount of purulent drainage observed on it. The old bandage was not dated or initialed. Resident #12 stated the bandage was changed yesterday. There were two circular wounds located on the residents abdomen. Both wound beds were covered 95% in slough and 5% granulation tissue. The slough was observed to be thick and yellow/gray in color. After the old bandage was removed, LPN #331 proceeded to change gloves and perform hand hygiene, she then cleansed the wound with gauze and normal saline. She did not change gloves or perform hand hygiene, and proceeded to apply hydrogel using a cotton tipped applicator, then covered the wound with an abdominal pad and secured it with tape. LPN #331 then proceeded to remove gloves, and perform hand hygiene. The old bandage and supplies were disposed of in the trash receptacle. Interview with LPN #331 and LPN #352 on 11/10/21 at 10:40 AM verified gloves were not changed and hand hygiene was not performed between cleansing the wound with normal saline and gauze and applying the new, clean dressing. 2. Observation upon entry to the facility on [DATE] at 8:05 A.M., State Tested Nursing Assistant #341 was observed exiting room [ROOM NUMBER], which was on isolation precautions, without a mask or face shield in place. The mask was below the staff members chin during this observation. State Tested Nursing Assistant #341 verified she did not have the appropriate PPE in place during this observation. Licensed Practical Nurse #330 also was observed in the main nursing hall and was not wearing her mask appropriately as it was also under her chin and not on her face. Licensed Practical Nurse #330 verified she was not wearing her mask appropriately. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366112 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brown Memorial Home Inc 158 E Mound St Circleville, OH 43113 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the COVID-19 Pandemic, dated 09/10/21, revealed source control and physical distancing are recommended for everyone in a healthcare setting. Source control refers to use of respirators and well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent the spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. 3. Observation of medication administration on 11/08/21 at 7:20 A.M. revealed Licensed Practical Nurse (LPN) #303 preparing to administer oral medications to Resident #11. LPN #303 was observed to spill the medications from the medication cup on the floor of Resident #11's room, by mistake. LPN #303 picked up the medications with her bare hands, threw them away, and went to the medication cart and pulled new medications for Resident #11, without washing her hands. LPN #303 then returned to Resident #11 and administered the medications without washing her hands. Interview on 11/08/21 at 7:25 A.M. with LPN #303 confirmed she did not wash her hands following picking the medication cup from the floor and administering new medications to Resident #11. Review of the facility's policy titled Medication Administration, revised 2019, revealed nurses should wash hands prior to administering medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366112 If continuation sheet Page 10 of 10