Based on observation, interview, and record review, the facility failed to ensure that the pad call light (a device with sensitive touch surface ideal for patients who may have difficulty using standard call cord to signal need for assistance from a professional staff) was within reach for one (1) out of 37 sampled residents. This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay of care and services that can negatively affect resident's comfort and well-being. Findings: During a review of Resident 31's admission Record, the admission Record indicated the facility admitted the resident on 8/9/2024 with diagnoses including but not limited to dementia (a general term for a condition with loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mild protein-calorie nutrition (a type of undernutrition when a person does not consume enough protein and calories which may lead to muscle loss, fat loss, and the body not working as it usually would). During a review of Resident 31's History and Physical (H&P) dated 8/10/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 31's Minimum Data Set (MDS, a federally mandated assessment tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating, and oral hygiene, and substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 3 had impairment on both lower extremities. During a review of Resident 31's care plan (CP) on risk for falls related to but not limited to balance problem with standing, balance problem with walking, joint pains, mental status initiated 8/14/2024 with target date 11/10/2024, the CP indicated an intervention to place call light within reach. During a concurrent observation and interview on 10/1/2024 at 9:37 a.m., inside resident 31's room with the Director of Nursing (DON), observed Resident 31's call light caught in between the mattress and the right upper siderail, and not within the resident's reach. The DON stated the call light should have been placed within Resident 31's reach. During an interview on 10/4/2024 at 2:00 p.m., with the Director of Nursing (DON), the DON stated Resident 31's call light should have been within reach of the resident so the resident would be able to call for assistance and have their needs met. During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, last reviewed 4/12/2024, the P&P indicated the following: Each resident is provided with a means to call staff directly for assistance form his/her bed, from toileting/bathing facilities and from the floor. The call system remains functional at all times and within reach when the resident is in the room. Calls for assistance are answered as soon as possible, but no later than five (5) minutes. Urgent requests for assistance are addressed immediately.

Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal [the body's system for processing liquids and foods] tract) received appropriate care and services to prevent complications of enteral feeding for one out of two sampled residents (Resident 27) by failing to ensure the enteral feeding tube tip attached to a Y adapter (a three-way connector in which two ends are adjacent to the tubing) was covered with a cap when not in use. The deficient practice had the potential to contaminate the enteral feeding system. Findings: During a review of Resident 27's admission Record (AR), the AR indicated the facility admitted the resident on 1/6/2021, and readmitted the resident on 11/25/2022, with diagnoses including gastro-esophageal reflux disease (GERD, is a chronic digestive disorder that occurs when stomach contents flow back into the esophagus) and dysphagia (difficulty swallowing). During a review of Resident 27's History and Physical (H&P), dated 8/2/2023, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 27's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/3/2024, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident had a feeding tube. During a review of Resident 27's Order Summary Report, the report indicated an order for: 11/25/2022 Change Y adapter every (q) 2 weeks by night (NOC) shift (11p-7a) every night shift every 14 days. 1/23/2024 Continuous gastrostomy tube feeding formula Jevity 1.5 at 84 cubic centimeter per hour (cc/hr., a measure of volume flow rate) times (X) 20 hrs. to provide 1680 milliliters (ml, a unit of volume)/2016 calories (Cal, a unit of energy)/24 hrs. Start infusion pump (a medical device that delivers fluids, such as nutrients and medications) at 2 p.m. until 10 p.m. or until dose met. Two times a day. During a concurrent observation and interview on 10/1/2024, with Licensed Vocational Nurse 2 (LVN 2), inside Resident 27's room, observed Resident 27's feeding off and disconnected from the resident. The Y adapter tubing that was attached to the feeding system was not capped. LVN 2 stated the Y adapter tubing should be capped or placed in a clean plastic bag when not in use for infection control. During an interview on 10/3/2024, at 1:26 p.m., with the Director of Nursing (DON), the DON stated Resident 27's Y adapter should be capped when not in use to prevent gastrointestinal infection. During a review of the facility's recent policy and procedure (P&P) titled, Enteral Feedings- Safety Precautions, last reviewed on 4/12/2024, the P&P indicated to ensure the safe administration of enteral nutrition. Ensure tubing are capped when not in use.

Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice for one of two sampled residents (Resident 32) investigated under respiratory care by failing to ensure: 1. A physician's order was obtained for Resident 32's use of bilevel positive airway pressure (BIPAP, a noninvasive machine that helps people breathe). 2. The BIPAP mask and tubing were kept off the floor. These deficient practices had a potential for Resident 32 to develop respiratory complications. Findings: During a review of Resident 32's admission Record (AR), the AR indicated the facility admitted the resident on 7/25/2022, and readmitted the resident on 9/22/2024, with diagnoses including acute respiratory failure with hypercapnia (a condition where the lungs have trouble removing carbon dioxide from the blood, causing a buildup of carbon dioxide in the blood), pleural effusion (a condition where too much fluid builds up in the space between the lungs and chest wall), and dependence on supplemental oxygen (a medical treatment that provides extra oxygen to people who have trouble breathing or low blood oxygen levels). During a review of Resident 32's History and Physical (H&P), dated 9/23/2024, the H&P indicated the resident had acute hypoxemic respiratory failure (occurs when there is not enough oxygen in the blood) and to continue with budesonide (a steroid medication used to treat inflammatory diseases, such as asthma and rhinitis, and to reduce swelling in the lungs) and DuoNeb (combines ipratropium and albuterol to treat chronic obstructive pulmonary disease). The H&P indicated the resident had the capacity to make decisions. During a review of Resident 32's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/26/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on continuous oxygen therapy (a treatment that involves supplying oxygen at a higher concentration than room air to treat and prevent hypoxemia). During a review of Resident 32's Order Summary Report, the report did not indicate an order for a BIPAP machine. During a review of Resident 32's Care Plan titled Respiratory risk related to COPD, acute hypoxemic hypercapnia respiratory failure, last revised on 9/27/2024, the CP indicated an intervention of appropriate equipment at bedside for emergency use, breathing treatment as ordered, and medication as ordered: Budesonide, DuoNeb. During a concurrent observation, interview, and record review, on 10/1/2024, at 3:35 p.m., inside Resident 32's room, with the Infection Preventionist (IP), observed a BIPAP machine on the resident's side table's drawer with the BIPAP's tubing and mask on the floor. The IP stated the BIPAP tubing mask should be off the floor to prevent respiratory infection to the resident. During a review of the resident's Order Summary Report, the IP stated there is no order for the resident to use a BIPAP. The IP stated it is important to have a physician's order for the use of BIPAP to ensure the machine has the correct settings to provide the appropriate therapy to the resident. During an interview on 10/3/2024, at 1:20 p.m., with the Director of Nursing (DON), the DON stated there should be an order on the use of BIPAP for resident safety and to prevent respiratory distress to the resident. During a review of the facility's recent policy and procedure (P&P) titled, Physician Orders, last reviewed on 4/12/2024, the P&P indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. During a review of the facility's recent policy and procedure (P&P) titled, Policy and Procedure for BIPAP/CPAP Machine Usage, last reviewed on 4/12/2024, the P&P indicated a physician or qualified healthcare provider must evaluate the resident and confirm the need for BIPAP/CPAP therapy.

Based on observation, interview, and record review the facility failed to accurately and safely provide or obtain pharmaceutical services to one (1) of three (3) sampled residents (Resident 36) investigated during medication administration task. The facility failed to flush the medications in between administration via gastrostomy tube (G-tube - a medical device that is inserted through the abdomen into the stomach to provide nutrition, fluids, and medications to patients who are unable to consume food or liquids by mouth). This deficient practice had the potential to place Resident 36 at risk of health complications such as drug interaction and delay in the provision of care. Findings: During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 3/9/2024 and was readmitted into the facility on 4/17/2024 with diagnoses that included dementia (a general term for a condition with loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), gastrostomy status, and chronic pain syndrome. During a review of Resident 36's History and Physical (H&P) dated 12/17/2023, the H&P indicated the resident could make needs known but was unable to make medical decisions.During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/23/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 36 had impairment of both upper and both lower extremities and received feeding thru the tube. During a review of Resident 36's Order Summary Report, the Order Summary Report indicated the following physician orders: 4/17/2024: May crush all crushable medications given via G-tube every shift. 4/17/2024: Flush gastrostomy tube with 30 milliliters (ml - a unit of measurement) of water pre (before) and post (after) medication administration. 4/17/2024: Check G-tube residual every shift if 150 ml or greater, stop feeding and notify physician. 4/17/2024: Check G-tube placement every shift. 6/27/2024: Continuous G-tube feeding formula: Glucerna (a type of feeding formula that is calorically dense designed for patients with diabetes or elevated glucose response) 1.5 at 60 ml per hour (ml/hr - a unit of measurement) for 20 hours to provide 1200 ml per 1800 calories for 24 hours. Start infusion pump at 4:00 p.m. until 10 :00 a.m. or until dose met. During a review of Resident 36's care plan on nutritional problem related to enteral feeding (- a form of nutrition that is delivered into the digestive system as a liquid) initiated 4/25/2024 last revised 6/27/2024 indicated to administer medications as ordered and to monitor/document for side effects and effectiveness.During a medication administration observation on 10/2/2024 at 8:58 a.m. inside Resident 36's room with Licensed Vocational Nurse 2 (LVN 2), LVN 2 was observed checking the resident's G-tube placement and residual prior to administration of medications. LVN 2 administered the first medication mixed with 10 ml of water, clamped the tube and was about to administer the second medication without flushing with water prior administration. When asked, LVN 2 stated she should have flushed the G-tube with at least 10 ml of water in between each medication to ensure the medication was fully administered and there was no clog, and to ensure there was no drug interaction in between medications. During an interview on 10/3/2024 at 2:29 p.m. the Director of Nursing (DON) stated during medication administration via G-tube, the nurses should flush the G-tube with at least 10 ml of water in between each medication to ensure all the medications were all absorbed fully and to ensure there was no drug interaction in between the medications. A facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube, last reviewed 4/12/2024, indicated a purpose to provide guidelines for the safe administration of medications through an enteral tube. The P&P indicated: Administer each medication separately. If administering more than one medication, flush with 10 ml water (or prescribed amount) between medications.

Based on interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary drugs for one of two sampled residents (Resident 27) investigated under anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) by failing to ensure there was adequate monitoring on the use of an anticoagulant-Apixaban. The deficient practice had the potential to predispose the resident on the adverse effect (a harmful or abnormal result) of anticoagulant use such as bleeding. Findings: During a review of Resident 27's admission Record (AR), the AR indicated the facility admitted the resident on 1/6/2021, and readmitted the resident on 11/25/2022, with diagnoses including atrial fibrillation (a heart condition that causes an irregular heartbeat, often faster than normal), gastro-esophageal reflux disease (GERD, a chronic digestive disorder that occurs when stomach contents flow back into the esophagus), and long-term use of anticoagulants. During a review of Resident 27's History and Physical (H&P), dated 8/2/2023, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 27's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/3/2024, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class anticoagulant. During a review of Resident 27's Order Summary Report, dated 11/25/2022, the report indicated an order for Apixaban Tablet 2.5 milligrams (mg., a unit of weight) Give 1 tablet via gastrostomy tube (G-Tube, a small flexible tube that is surgically inserted through the abdomen and into the stomach to provide nutrition, fluids, and medicine) two times a day for cerebrovascular accident (CVA, a medical condition that occurs when blood flow to the brain is suddenly interrupted) prophylaxis (PPX, an attempt to prevent disease). During a review of Resident 27's Care Plan (CP) titled The resident is at risk for easy bruising and/or bruising due to fragile skin, intake of ASA/Anticoagulants: Apixaban, last revised on 9/3/2024, the CP indicated an intervention to monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting (N&V), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath (SOB), nose bleeds and tally by hashmarks. During a concurrent interview and record review on 10/3/2024, at 1:03 p.m., with the Director of Nursing (DON), the Order Summary Report and the Medication Administration Record (MAR) for Resident 27 was reviewed. The DON stated there was an order for Apixaban 2.5 mg tablet via G-Tube twice a day, however, there was no order for monitoring for adverse effects on the use of anticoagulant- Apixaban. The DON opened the MARs and found no monitoring done for the use of the Apixaban since it was ordered. The DON checked the CP and found an intervention on the plan to monitor for discolored urine, black tarry stools, sudden severe headache, N&V, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, SOB, nose bleeds and tally by hashmarks but it was not done because it was not populated in the MAR. The DON stated it is important to assess for adverse effects of the anticoagulant such as bleeding to report to the physician and intervene timely. During a review of the facility's recent policy and procedure (P&P) titled, Anticoagulation- Clinical Protocol, last reviewed on 4/12/2024, the P&P indicated assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications.

Based on observation, interview, and record review the facility failed to discard nine (9) boxes of BinaxNOW COVID-19 Antigen Self-Test ( a rapid antigen point-of-care test that can be used to diagnose an active COVID-19 [an infectious disease caused by the SARS-CoV-2 virus) used on staff and residents with expiration date of 1/18/2024 stored in the facility's Medication Room observed during medication storage and labeling facility task. The deficient practice increased the risk of the resident being misdiagnosed with COVID-19 that leads to delay in the care and treatment. Findings: During a concurrent observation and interview on 10/3/2024, at 9:40 a.m., with Licensed Vocational Nurse 1 (LVN 1), inside the Medication Room, 9 boxes of BinaxNOW COVID-19 Antigen Self-Test with expiration date of 1/18/2024 was observed. LVN 1 stated they used those self-test kits to test staff and residents for COVID-19. LVN 1 stated expired medications and test kits should be disposed of after its expiration date to prevent adverse effects (a harmful or abnormal result) of drugs and false diagnosis to residents and staff. During a concurrent observation and interview on 10/3/2024, at 2:22 p.m., with the Director of Nursing (DON), inside the Medication Room, 9 boxes of BinaxNOW COVID-19 Antigen Self-Test with expiration date of 1/18/2024 was observed. The DON stated there was an extension on the use of the BinaxNOW COVID-19 Antigen Self-Test and she will double check with her Infection Preventionist (IP) what the real expiration date of the test kit was. The DON stated BinaxNOW COVID-19 Antigen Self-Test with expiration date of 1/18/2024 should have been thrown away so that the staff or residents do not get false negative or false positive result when used for testing. During an interview on 10/3/2024, at 2:30 p.m., with the IP, the IP stated the BinaxNOW COVID-19 Antigen Self-Test with expiration date of 1/18/2024 should have been discarded already as it was past its expiration extension set by Centers for Disease Control and Prevention (CDC, a U.S. federal agency that protects public health) to prevent erroneous results that could delay care and treatment to residents and staff. During a review of the facility's recent policy and procedure (P&P) titled Expired Products, last reviewed on 4/12/2024, the P&P indicated staff must regularly check all products for expiration dates during routine inventory audits and before use. Expired medications, food, and supplies must be immediately segregated and marked to prevent accidental use. Expired products must be stored in a designated area until proper disposal can occur. Staff should be trained to recognize and manage expired products appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the order for Restorative Nursing Assistance (RNA - a type of program in long term care facilities intended to restore lost abilities or maintain potentially deteriorating functions for residents) program was entered accurately in the electronic health record (EHR) for one (1) out of 1 sampled resident (Resident 36) during an investigation under the position/mobility care area. This deficient practice had the potential for incomplete and inaccurate medical documentation and cause a delay in provision of necessary care and services Resident 36 needs. Findings: During a review of Resident 36's admission Record, the admission Record indicated the facility admitted the resident on 3/9/2024 and was readmitted on [DATE] with diagnoses that included dementia (a general term for a condition with loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), gastrostomy status, and chronic pain syndrome. During a review of Resident 36's History and Physical (H&P) dated 12/17/2023, the H&P indicated the resident can make needs known but unable to make medical decisions. During a review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/23/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 36 had impairment of both upper and both lower extremities and received feeding thru the tube. During a review of Resident 36's Order Summary Report, the Order Summary Report indicated the following physician orders: 5/9/2024: Restorative Nursing Assistance (RNA - a type of program in long term care facilities intended to restore lost abilities or maintain potentially deteriorating functions for residents) for passive range of motion (PROM) exercise program both lower extremities (BLEs) seven (7) times per week daily as tolerated every day shift. 5/9/2024 and discontinued on 9/25/2024: RNA for PROM of both upper extremities (BUEs) followed by application of elbow splint daily six (6) per week. Check every two (2) hours for signs and symptoms of skin breakdown, off Saturdays every day shift Monday, Tuesday, Wednesday, Thursday, Friday, Sunday. 9/25 /2024: RNA for PROM of BUEs followed by application of elbow splint and RUE wrist/hand splint daily for 6 weeks. Check every 2 hours for skin integrity or redness, off on Saturdays one time a day Monday, Tuesday, Wednesday, Thursday, Friday, Sunday for 6 weeks. On for up to 4 to 6 hours. During a review of Resident 36's Restorative Record flowsheet for 9/2024 and 10/2024, the Restorative Record flowsheet indicated Resident 36 was last provided the RNA for PROM of BUEs and splint application on BUE on 9/25/2024. The Restorative Record flowsheet for 10/2024 indicated Resident 36's RNA program only included PROM exercises of BLEs. During an observation on 10/1/2024 at 9:20 a.m., 10/3/2024 at 9:30 a.m., and 10/3/2024 at 11:27 a.m., inside Resident 31's room, observed resident up on the wheelchair with protective sleeves on both arms without a splint applied. During a concurrent interview and record review on 10/3/2024 at 12:04 p.m., Resident 36's physician's order, and Restorative Record flowsheets for 9/2024 and 10/2024, with Restorative Nursing Assistant 1 (RNA 1), present was reviewed. RNA 1 verified Resident 36 had a physician's order for application of BUE elbow splint and RUE wrist/hand splint after PROM exercises 6 times per week dated 9/25/2024 but was not in the flowsheet. RNA 1 stated the application of splint had been on hold for almost one month as the resident had pain during exercises and was placed on occupational therapy (a type of treatment that assists patients how to function in their respective roles and how to perform their daily tasks or activities) treatments. RNA 1 stated she was not aware that the order for application of splint was resumed as she was not working when it was resumed. RNA 1 stated new RNA orders are communicated to them by the charge nurse or Director of Rehabilitation (DOR). RNA 1 stated if the application of splint was not provided to Resident 36 as ordered, it placed the resident for worsening of the contracture. During a concurrent interview and record review on 10/3/2024 at 12:20 p.m., Resident 36's physician's order and Restorative Record flowsheet for 9/2024 and 10/2024 was reviewed with the Director of Nursing (DON). The DON verified Resident 36 had a previous order for application of splint on BUE elbow 6 times per week discontinued 9/25/2024 and was reentered on 9/25/2024 to include application of splint on the RUE wrist/hand. The DON verified the Restorative Record flowsheet from 9/26/2024 to 9/30/2024 and 10/2024 did not indicate the new order. The DON stated the charge nurse who entered the order did not indicate the order type in the electronic health record (EHR), hence the new order did not populate in the Restorative Record flowsheet. The DON stated the charge nurse should have entered the new order for application of splints correctly to ensure the RNAs assigned to Resident 36 were aware of the new order to prevent delay in the provision of care and prevent further contracture. The DON stated it was an order entry error. During a review of the facility's policy and procedure (P&P) titled, Physician Orders, last reviewed 4/12/2024, the P&P indicated orders for medications ad treatments will be consistent with principles of safe and effective order writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted the resident on 4/2/2024, with diagnoses including neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness) and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 15's History and Physical (H&P), dated 4/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 7/7/2024, the MDS indicated the resident had the ability to makes self-understood and understand others and the resident mostly required substantial to maximal assistance on mobility and activities of daily living (ADLs, are essential and routine tasks that most young, healthy individuals can perform without assistance). During an observation on 10/1/2024, at 9:18 a.m., observed Resident 15 lying in bed with both upper bed rails (a rail or board along the side of a bed that connects the headboard with the footboard) up and the right side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024, at 9:17 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 15's room, observed Resident 15 lying in the bed with both upper bed rails up and the right side of the bed placed against the wall. CNA 1 stated placing the bed against the wall can be a considered a restraint because it restricts the resident's movement by preventing the resident from getting out from the right side of the bed. During an interview on 10/3/2024, at 1:10 p.m., with the Director of Nursing (DON), the DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall to ensure resident safety and to honor the resident's right to accept or refuse the treatment. During A review of the facility's recent policy and procedure (P&P) titled, Use of Restraints, last reviewed on 4/12/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. e. During a review of Resident 32's admission Record (AR), the AR indicated the facility admitted the resident on 7/25/2022, and readmitted the resident on 9/22/2024, with diagnoses including wedge compression fracture (a common fracture [break in bone] of the spine) of first lumbar vertebra (the topmost vertebra in the lumbar spine), lack of coordination, and radiculopathy (a condition that occurs when a nerve root in the spines is compressed or irritated, resulting in a range of symptoms). During a review of Resident 32's H&P, dated 9/23/2024, the H&P indicated had the capacity to make decisions. During a review of Resident 32's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and the resident required substantial to maximal assistance on mobility and activities of daily living (ADLs). During an observation on 10/1/2024, at 3:35 p.m., observed Resident 32 lying in bed with both upper bed rails up and the right side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024, at 9:21 a.m., with CNA 1, inside Resident 32's room, observed Resident 32 lying on the bed with the right side of the bed placed against the wall. CNA 1 stated placing the bed against the wall is considered a restraint because it restricts the resident's movement by preventing the resident from getting out from the right side of the bed. During an interview on 10/3/2024, at 1:10 p.m., with the Director of Nursing (DON), the DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall to ensure resident safety and to honor the resident's right to accept or refuse the treatment. During A review of the facility's recent policy and procedure (P&P) titled, Use of Restraints, last reviewed on 4/12/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. f. During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted the resident on 9/8/2022, with diagnoses of vascular dementia (a chronic condition that occurs when blood flow to the brain is disrupted, damaging brain tissue and affecting memory, thinking, and behavior), psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), and depression (a mental health condition that involves a persistent low mood or loss of interest in activities). During a review of Resident 25's H&P, dated 9/2/2023, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 25's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident required substantial to maximal assistance on mobility and activities of daily living (ADLs). During an observation on 10/1/2024, at 9:18 a.m., observed Resident 25 lying in bed with both upper grab bars raised, and the left side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024, at 9:28 a.m., with CNA 1, inside Resident 25's room, observed Resident 15 lying on the bed with the left side of the bed placed against the wall. CNA 1 stated placing the bed against the wall is considered a restraint because it restricts the resident's movement by preventing the resident from getting out from the left side of the bed. During an interview on 10/3/2024, at 1:10 p.m., with the Director of Nursing (DON), the DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall to ensure resident safety and to honor the resident's right to accept or refuse the treatment. During A review of the facility's recent policy and procedure (P&P) titled, Use of Restraints, last reviewed on 4/12/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. Based on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for six (6) out (9) sampled residents (Residents 10, 31, 6, 15, 32, and 25) investigated during review of physical restraints care area by failing to obtain a physician's order, perform an assessment, develop a care plan, and obtain an informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment) for placement of bed against the wall. These deficient practices had the potential to result in the restriction of residents' freedom of movement and violate the resident's rights to be free from any restraints that are imposed for reasons other than the treatment of the resident's medical symptoms. Findings: a. During a review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 7/10/2023 and readmitted the resident on 8/7/2023 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), low back pain, and psychosis (a condition that happens when a person has trouble telling the difference between what's real and what's not). During a review of Resident 10's History and Physical (H&P) dated 9/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required setup/clean-up assistance with eating, partial/moderate assistance with oral hygiene, upper body dressing, rolling left and right, lying to sitting, lying to sitting on side of bed, and substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 10's care plan (CP), there was no CP addressing the placement of the resident's bed against the wall. During a review of Resident 10's Order Summary Report, the Order Summary Report did not indicate a physician's order to place the resident's bed against the wall. During an observation on 10/1/2024 at 10:16 a.m. inside Resident 10's room, observed resident lying in bed, with the left side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024 at 9:40 a.m. inside Resident 10's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 10's bed is placed against the wall and both upper half siderails are up. CNA 1 stated Resident 10 tries to get out of bed unassisted at times and placing the bed against the wall can be considered a restraint as it restricts the resident's movement by preventing the resident from getting out of from the left side of the bed. During an interview on 10/3/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated placing the bed against the wall is considered a restraint as it restricts the resident's movement by preventing the resident from getting out of bed on one side. The DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall. The DON stated the purpose of the informed consent is for the resident and/or resident representative to be aware of the risks and benefits of placing the bed against the wall and honor their right to consent to or decline the use of a restraint. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last reviewed 4/12/2024, indicated the following: Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same way the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom). b. How the restraint will be used to benefit the resident's medical symptom. c. The type of restraint, and period of time for the use of the restraint. b. During a review of Resident 31's admission Record, the admission Record indicated the facility admitted the resident on 8/9/2024 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mild protein-calorie nutrition (a type of undernutrition when a person does not consume enough protein and calories which may lead to muscle loss, fat loss, and the body not working as it usually would). During a review of Resident 31's History and Physical (H&P) dated 8/10/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 31's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating, and oral hygiene, and substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 31 had impairment on both lower extremities. During a review of Resident 31's care plan (CP), there was no CP addressing the placement of the resident's bed against the wall. During a review of Resident 31's Order Summary Report, the Order Summary Report did not indicate a physician's order to place the bed against the wall. During an observation on 10/1/2024 at 9:36 a.m. inside Resident 31's room, observed resident lying in bed, with the left side of the bed placed against the wall. During a concurrent observation and interview on 10/3/2024 at 9:30 a.m. inside Resident 31's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 31's bed is placed against the wall and both upper half siderails are up. CNA 1 stated placing the bed against the wall can be considered a restraint as it as it restricts the resident's movement by preventing the resident from getting out from the left side of the bed. During an interview on 10/3/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated placing the bed against the wall is considered a restraint as it restricts the resident's movement by preventing the resident from getting out of bed on one side. The DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall. The DON stated the purpose of the informed consent is for the resident and/or resident representative to be aware of the risks and benefits of placing the bed against the wall and honor their right to consent to or decline the use of a restraint. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last reviewed 4/12/2024, indicated the following: Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same way the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom). b. How the restraint will be used to benefit the resident's medical symptom. c. The type of restraint, and period of time for the use of the restraint. c. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 11/29/2011 and readmitted the resident on 6/7/2022 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), blindness left eye, and schizophrenia (a mental disorder characterized by delusions [a fixed false belief that conflicts with reality], hallucinations [sensory experiences that only exist in the mind], disorganized thoughts, speech and behavior). During a review of Resident 6's History and Physical (H&P) dated 5/13/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/27/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/touching assistance with eating; partial/moderate assistance with oral hygiene and toileting hygiene, roll left to right, sit to lying, and lying to sitting onside of bed; substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 6 had impairment on both lower extremities. During a review of Resident 6's care plan (CP), there was no CP addressing the placement of the resident's bed against the wall. During a review of Resident 6's Order Summary Report, the Order Summary Report did not indicate a physician's order to place the bed against the wall. During an observation on 10/1/2024 at 9:46 a.m. inside Resident 6's room with Licensed Vocational Nurse 2 (LVN 2), observed resident lying in bed. The resident's left side of the bed is placed against the wall. LVN 2 stated the bed was placed against the wall because it is the resident's preference. During a concurrent observation and interview on 10/3/2024 at 9:45 a.m. inside Resident 6's room with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 31's bed is placed against the wall and both upper half siderails are up. CNA 1 stated Resident 6 required assistance in getting out of bed and tries to get out of bed unassisted at times. CNA 1 stated placing the bed against the wall can be considered a restraint as it restricts the resident's movement by preventing the resident from getting out from the left side of the bed. During an interview on 10/3/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated placing the bed against the wall is considered a restraint as it restricts the resident's movement by preventing the resident from getting out of bed on one side. The DON stated there should have been a physical restraint assessment, a physician's order, a care plan, and an informed consent from the resident of the resident representative prior to placing the resident's bed against the wall. The DON stated the purpose of the informed consent is for the resident and/or resident representative to be aware of the risks and benefits of placing the bed against the wall and honor their right to consent to or decline the use of a restraint. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last reviewed 4/12/2024, indicated the following: Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones' body. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same way the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered as a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom). b. How the restraint will be used to benefit the resident's medical symptom. c. The type of restraint, and period of time for the use of the restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards for four of four sampled residents (Residents 11, 144, 33, and 28) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area by failing to ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F760 Findings: a. During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted the resident on 8/12/2024, with diagnoses including type 2 diabetes mellitus (DM2, a chronic disease characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), and long-term use of insulin. During a review of Resident 11's History and Physical (H&P), the H&P indicated the resident had the ability to make his needs known but cannot make medical decisions. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident receiving hypoglycemic (a class of drugs that help lower blood sugar levels) medications. During a review of Resident 11's Order Summary Report, dated 8/12/2024, the report indicated an order for Humalog Injection Solution 100 units per milliliters (unit/ml, a milliliter is a unit of fluid volume equal to one-thousandth of a liter) (Insulin Lispro). Inject as per sliding scale (progressive increase in premeal or nighttime insulin doses): if 150-200= 2 units (the standard amount required for a precise measured activity); 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units call MD if blood sugar (BS) greater than (>) 400 or less than (<) 60, subcutaneously before meals and at bedtime for DM2. During a review of Resident 11's Location of Administration Report for Insulin for 8/2024 to 10/2024, the report indicated Humalog injection solution 100 unit/ml was administered on the following dates and sites: 8/13/2024 at 8:20 p.m. on the Abdomen - Right Upper Quadrant (RUQ) 8/14/2024 at 11:18 a.m. on the Abdomen - RUQ 8/15/2024 at 11:21 a.m. on the Abdomen - Right Lower Quadrant (RLQ) 8/15/2024 at 9:09 p.m. on the Abdomen - RLQ 8/16/2024 at 11:31 a.m. on the Abdomen - RUQ 8/17/2024 at 12:35 p.m. on the Abdomen - RUQ 8/18/2024 at 5:52 p.m. on the Abdomen - RLQ 8/18/2024 at 8:33 p.m. on the Abdomen - RLQ 8/19/2024 at 4:34 p.m. on the Abdomen - RLQ 8/21/2024 at 12:28 p.m. on the Abdomen - RLQ 8/22/2024 at 11:30 a.m. on the Abdomen - RLQ 8/23/2024 at 10 p.m. on the Abdomen - RLQ 8/25/2024 at 8:15 p.m. on the Abdomen - RLQ 9/10/2024 at 8:12 p.m. on the Abdomen-RLQ 9/16/2024 at 9:28 p.m. on the Abdomen-RLQ 9/29/2024 at 12:41 p.m. on the Abdomen-RLQ 9/29/2024 at 8:22 p.m. on the Abdomen-RLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the Director of Nursing (DON), reviewed Resident 11's Order Summary Report and Location of Administration Record of insulin dated 8/2024 to 10/2024. The DON stated there were multiple instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). b. During a review of Resident 144's admission Record (AR), the AR indicated the facility admitted the resident on 9/25/2024, with diagnoses including type 2 diabetes mellitus, chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood properly), and long-term use of insulin. During a review of Resident 144's H&P, dated 9/27/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 144's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was receiving hypoglycemic medications. During a review of Resident 144's Order Summary Report, dated 9/25/2024, the report indicated an order for Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 151-200= 2 units contact MD for blood sugar less than 70; 201-249= 4 units; 250-300= 6 units; contact MD for blood sugar above 400, subcutaneously two times a day for DM. During a review of Resident 144's Location of Administration Report for insulin for 9/2024 to 10/2024, the report indicated Insulin Lispro Injection Solution 100 unit/ml was administered on the following dates and sites: 9/29/2024 at 8:22 p.m. on the Abdomen - Left Lower Quadrant (LLQ) 9/30/2024 at 9:24 p.m. on the Abdomen - LLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the DON, reviewed Resident 144's Order Summary Report and Location of Administration Record of insulin dated 9/2024 to 10/2024. The DON stated there were instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). c. During a review of Resident 33's admission Record, the admission Record indicated the facility admitted the resident on 3/7/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 -a disorder characterized by difficulty on blood sugar control and poor wound healing) and heart failure (a condition that develops when the heart does not pump enough blood to the body's needs). During a review of Resident 33's History and Physical (H&P) dated 3/8/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 33's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/10/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, and oral hygiene; supervision or touching assistance with rolling left and right; substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 33 received insulin. During a review of Resident 33's Order Summary Report, the Order Summary Report indicated the following physician's order dated 3/7/2024: Humalog injection solution (insulin lispro) [a hormone that works by lowering levels of sugar in the blood; a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours] inject as per sliding scale: if 150 - 200 = 2 units ( a unit of measurement); 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. Call physician for blood sugar less than (<) 60 or more than (>) 400, subcutaneously (SQ) before meals and at bedtime for DM 2. During a review of Resident 33's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Humalog injection solution was administered as follows: 07/03/24 9:00 p.m. 07/03/24 8:12 p.m. SQ Abdomen - left lower quadrant (LLQ) 07/04/24 7:00 a.m. 07/04/24 6:13 a.m. SQ Abdomen - LLQ 07/14/24 5:00 p.m. 07/14/24 4:34 p.m. SQ Abdomen - right upper quadrant (RUQ) 07/14/24 9:00 p.m. 07/14/24 9:02 p.m. SQ Abdomen - RUQ 07/23/24 9:00 p.m. 07/23/24 8:14 p.m. SQ Abdomen - LLQ 07/25/24 5:00 p.m. 07/25/24 4:14 p.m. SQ Abdomen - LLQ 08/16/24 9:00 p.m. 08/16/24 8:32 p.m. SQ Abdomen - LUQ 08/17/24 7:00 a.m. 08/17/24 6:42 a.m. SQ Abdomen - LUQ 08/21/24 9:00 p.m. 08/21/24 9:35 p.m. s SQ Abdomen - LUQ 08/22/24 7:00 a.m. 08/22/24 6:22 a.m. SQ Abdomen - LUQ 08/29/24 7:00 a.m. 08/29/24 6:38 a.m. SQ Abdomen - LLQ 08/31/24 7:00 a.m. 08/31/24 7:19 a.m. SQ Abdomen - LLQ During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 33's physician's orders, MAR, and location of administration sites for Humalog injection solution from 8/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline for Humalog injection solution, last revised on 8/2024, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin. d. During a review of Resident 28's admission Record, the admission Record, the admission Record indicated the facility admitted the resident on 3/4/2021 and readmitted the resident on 7/28/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 - a disorder characterized by difficulty on blood sugar control and poor wound healing), long term use of insulin, and lack of coordination. During a review of Resident 28's History and Physical (H&P) dated 7/29/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/3/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating, and oral hygiene; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 28 received insulin. During a review of Resident 28's Order Summary Report, the Order Summary Report indicated the following physician's order dated 7/28/2024: Lantus subcutaneous (SQ) solution 100 unit per milliliters (unit/ml - a unit of measurement) [insulin glargine - a long-acting type of insulin that works slowly over about 24 hours used to lower blood sugar in adults and children with diabetes] inject 18 units subcutaneously (SQ) one time a day for DM 2. During a review of Resident 28's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Lantus SQ solution was administered as follows: 07/16/24 9:00 a.m. 07/16/24 9:04 a.m. SQ Abdomen - right upper quadrant (RUQ) 07/17/24 9:00 a.m. 07/17/24 9:21 a.m. SQ Abdomen - RUQ 07/20/24 9:00 a.m. 07/20/24 8:20 a.m. SQ Arm - Upper arm (rear) (left) 07/21/24 9:00 a.m. 07/21/24 8:42 a.m. SQ Arm - Upper arm (rear) (left) 08/18/24 9:00 a.m. 08/18/24 8:59 a.m. SQ Arm - Upper arm (rear) (right) 08/23/24 9:00 a.m. 08/23/24 9:40 a.m. SQ Arm - Upper arm (rear) (right) 09/06/24 9:00 a.m. 09/06/24 9:42 a.m. SQ Arm - Upper arm (rear) (left) 09/07/24 9:00 a.m. 09/07/24 8:43 a.m. SQ Arm - Upper arm (rear) (right) 09/27/24 9:00 a.m. 09/27/24 8:51 a.m. SQ Abdomen - left upper quadrant (LUQ) 09/28/24 9:00 a.m. 09/28/24 9:07 a.m. SQ Abdomen - LUQ 09/29/24 9:00 a.m. 09/29/24 8:37 a.m. SQ Arm - Upper arm (rear) (right) 09/30/24 9:00 a.m. 09/30/24 8:45 a.m. SQ Arm - Upper arm (rear) (right) During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 28's physician's orders, MAR, and location of administration sites for Lantus SQ solution from 7/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline for insulin glargine - injection, undated, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for two of six sampled residents (Residents 15, 44, 31, 6, and 12) investigated under accidents by failing to ensure 1. Resident 15, 44, 31, and 36's fall mat (a floor mat designed to reduce the risk of injury from fall by providing a soft-landing surface) did not have medical equipment or furniture on top of the mat. This deficient practice lessened the effectiveness of the fall mat to prevent falls with injury by placing a heavy equipment and furniture on top of the fall mat, decreasing its effectiveness to lessen the impact of a fall due to permanent dented mat surface and placed the residents at risk for injury if they were to hit the equipment or furniture during a fall. 2. Failing to ensure the portable air conditioning (AC) appliance exhaust panel or sleeve inside Resident 12's window was secured properly and did not fall on top the resident's bed. This deficient practice had the potential for the panel or sleeve to fall onto the resident while in bed, resulting in injury. Findings: 1. a. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted the resident on 4/2/2024, with diagnoses including frontotemporal neurocognitive disorder (a group of conditions that occur when the frontal and temporal lobes of the brain are damaged, causing them to shrink), age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), and long-term use of anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart). During a review of Resident 15's History and Physical (H&P), dated 4/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 7/7/2024, the MDS indicated the resident had the ability to makes self-understood and understand others and the resident mostly required substantial to maximal assistance on mobility and activities of daily living (ADLs, are essential and routine tasks that most young, healthy individuals can perform without assistance). During a review of Resident 15's Order Summary Report, dated 4/3/2024, the report indicated an order for low bed with left sided floor mat every shift. During a review of Resident 15's Fall Risk Assessment (FRA), dated 4/3/2024, the FRA indicated the resident was high risk for falls. During an observation on 10/1/2024, at 9:18 a.m., observed Resident 15's fall mat placed on the right side of the bed, with a side table and an oxygen concentrator (a medical device that removes nitrogen from the air and produces oxygen for breathing) resting on top of the mat. During a concurrent observation and interview on 10/3/2024, at 9:17 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 15's room, observed the resident's fall mat 15's fall mat placed on the right side of the bed, with a side table and an oxygen concentrator resting on top of the mat. CNA 1 stated the side table should not be on top of the fall mat to prevent injury if the resident falls. During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's recent policy and procedure (P&P) titled, Floor Mat Application, last reviewed on 4/12/2024, the P&P indicated to apply the ordered floor mat using the appropriate procedure. Follow the instructions provided by the manufacturer. During a review of the facility provided Manufacturer's Guideline on the use of Beveled Floor Mat 1 (BFM 1), undated, the guideline indicated to never leave heavy materials on the mat for an extended amount of time and may cause a permanent indentation. 1.b. During a Review of Resident 144's admission Record (AR), the AR indicated the facility admitted the resident on 9/25/2024, with diagnoses including lack of coordination, muscle weakness, and dementia (a chronic condition that causes a decline in cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life). During a review of Resident 144's H&P, dated 9/27/2024, the H&P indicated the resident was old, frail, confused, and agitated. The H&P indicated the resident does not have the capacity to make decisions. During a review of Resident 144's MDS, dated [DATE], the MDS indicated the resident usually make self-understood and understand others and the resident was mostly dependent on mobility and activities of daily living (ADLs). During a review of Resident 144's Order Summary Report, dated 9/30/2024, the report indicated an order for low bed with left sided floor mat every shift. During a review of Resident 144's Side Rail Assessment (SRA), dated 9/26/2024, the SRA indicated the resident had medical symptoms of weakness, balance deficit, and had intermittent confusion/forgetfulness. During a review of Resident 144's Care Plan (CP) titled Psychotropic drug (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) use, last revised on 9/30/2024, the CP indicated an intervention to provide a safe and hazard-free environment. During an observation on 10/1/2024, at 9:43 a.m., observed Resident 144 lying in bed with bilateral (relating to two sides) floor mats. The side table was resting on the left mat, and the oxygen concentrator on the right mat. During a concurrent observation and interview on 10/3/2024, at 9:27 a.m., with CNA 1, inside Resident 144's room, observed Resident 144 lying in bed with bilateral (relating to two sides) floor mats. The side table was resting on the left mat, and the oxygen concentrator on the right mat. CNA 1 stated there should be no equipment or furniture on top of the fall mat to prevent injury if the resident falls. During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's recent policy and procedure (P&P) titled, Floor Mat Application, last reviewed on 4/12/2024, the P&P indicated to apply the ordered floor mat using the appropriate procedure. Follow the instructions provided by the manufacturer. During a review of the facility provided Manufacturer's Guideline on the use of BFM 1, undated, the guideline indicated to never leave heavy materials on the mat for an extended amount of time and may cause a permanent indentation. c. During a review of Resident 31's admission Record, the admission Record indicated the facility admitted the resident on 8/9/2024 with diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and mild protein-calorie nutrition (a type of undernutrition when a person does not consume enough protein and calories which may lead to muscle loss, fat loss, and the body not working as it usually would). During a review of Resident 31's History and Physical (H&P) dated 8/10/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 31's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating, and oral hygiene, and substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 31 had impairment on both lower extremities. During a review of Resident 31's care plan (CP), the CP on risk for falls related to but not limited to balance problem with standing, balance problem with walking, joint pains, mental status initiated 8/14/2024 with target date 11/10/2024 indicated an intervention for low bed with right mat to prevent or minimize falls. During a review of Resident 31's Order Summary Report, the Order Summary Report indicated a physician's order dated 8/9/2024 for low bed with right floor mat. During a concurrent observation and interview on 10/1/2024 at 9:37 a.m., inside Resident 31's room with the Director of Nursing (DON), the DON verified Resident 31's wheelchair and overbed table were placed on top of the floor mat. The DON verified an indentation was evident when the wheelchair was removed on top of the floor mat. The DON stated leaving heavy equipment for an extended period of time on top of the floor may affect the integrity of the floor mat. During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's policy and procedure (P&P) titled, Accidents & Hazards, last reviewed 4/12/2024, indicated: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: f. Objects in the hallways that obstruct a clear path. j. Furniture that is unstable or positioned at an improper height for residents. During a review of the facility's policy and procedure(P&P) titled, Floor Mat Application, last reviewed on 4/12/2024, the P&P indicated to apply the ordered floor mat using the appropriate procedure. Follow the instructions provided by the manufacturer. During a review of the facility provided manufacturer's guideline for Bed Floor Mat 1 (BFM 1), undated, the manufacturer's guideline indicated to never leave heavy materials on the mat for an extended amount of time and they may cause permanent indentation. D. During a review of Resident 6's admission Record, the admission Record indicated the facility admitted the resident on 11/29/2011 and readmitted in the facility on 6/7/2022 with diagnoses including but not limited to dementia, blindness left eye, and schizophrenia (a mental disorder characterized by delusions [a fixed false belief that conflicts with reality], hallucinations [sensory experiences that only exist in the mind], disorganized thoughts, speech and behavior). During a review of Resident 6's History and Physical (H&P) dated 5/13/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set, dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision/touching assistance with eating; partial/moderate assistance with oral hygiene and toileting hygiene, roll left to right, sit to lying, and lying to sitting onside of bed; substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 6 had impairment on both lower extremities. During a review of Resident 6's care plan (CP), the CP on risk for falls related to but not limited to balance problem with standing, balance problem with walking, psychiatrics medication use initiated 6/9/2022 last revised 9/7/2023, indicated floor mat as one of the interventions to minimize falls. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated a physician's order dated 8/17/2022, indicated to monitor for placement of low bed with right floor mat. During a concurrent observation and interview on 10/1/2024 at 9:46 a.m. inside Resident 6's room with Licensed Vocational Nurse 2 (LVN 2), observed resident lying in bed, with the wheelchair and overbed table resting on top of the right floor mat. LVN 2 stated leaving the wheelchair and overbed table on top of the floor mat could create dents, reducing the mat's effectiveness in preventing injury during a fall. During an interview on 10/3/2024, at 1:06 p.m., with the Director of Nursing (DON), the DON stated there should be no equipment or furniture on top of the fall mat to prevent damaging the fall mat, creating a permanent dent, and defeating the purpose of lessening the impact of a fall. The DON stated placing equipment or furniture on top of the mat increases the resident's risk of injury if the resident hits the equipment or furniture in the event of a fall. During a review of the facility's policy and procedure (P&P) titled, Accidents & Hazards, last reviewed 4/12/2024, indicated: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: f. Objects in the hallways that obstruct a clear path. j. Furniture that is unstable or positioned at an improper height for residents. 2. During a review of Resident 12's admission Record, the admission Record indicated the facility admitted the resident on 8/30/2024 with diagnoses including but not limited to history of falling, right knee osteoarthritis (inflammation of one or more joints; a condition that occurs when the joints gradually deteriorates). During a review of Resident 12's History and Physical (H&P) dated 9/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 12's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial/moderate assistance with eating and oral hygiene; dependent on staff with sit to stand and transfers; substantial/maximal with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 12 had impairment on the right lower extremity. During a concurrent observation and interview on 10/1/2024 at 10:26 a.m., inside Resident 12's room, observed the resident in the wheelchair using an electronic tablet device. Observed the right side of the bed placed against the wall, with a portable air conditioning unit duct (tubes or pipes that carry air in and out of the building) going through the window to the exterior of the building. When checked, the panel or sleeve covering the opening on the window dropped on top of Resident 12's bed at the foot part . Resident 12 stated she did not know why there is a portable AC was in the room when she did not have any issues with temperature. During an interview on 10/1/2024 at 10:40 a.m., the Maintenance Supervisor (MS) stated the piece of panel or sleeve that fell on top of Resident 12's bed was a hard piece of plastic. During a follow up interview on 10/2/2024 at 3:45 p.m., the MS stated the piece of panel or sleeve was part of the installation kit for the portable AC that should have been secured properly to prevent from falling onto the resident and causing injury. During an interview on 10/3/2024 at 1:39 p.m., with the Director of Nursing (DON), the DON stated the panel for the portable AC exhaust should have been secured properly on the window to prevent from falling onto the resident and causing injury. During a review of the facility's policy and procedure (P&P) titled, Policy for Portable HVAC Usage, last reviewed 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe and effective use of portable HVAC units within the skilled nursing facility, ensuring a comfortable environment for the residents while maintaining compliance with health and safety regulations. During a review of the facility's policy and procedure (P&P) titled, Accidents & Hazards, last reviewed 4/12/2024, indicated: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: f. Objects in the hallways that obstruct a clear path. j. Furniture that is unstable or positioned at an improper height for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for four of four sampled residents (Residents 11, 144, 33, and 28) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area by failing to ensure licensed nurses rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross Reference F658 Findings: a. During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted the resident on 8/12/2024, with diagnoses including type 2 diabetes mellitus (DM2, a chronic disease characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), and long-term use of insulin. During a review of Resident 11's History and Physical (H&P), the H&P indicated the resident had the ability to make his needs known but cannot make medical decisions. During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident receiving hypoglycemic (a class of drugs that help lower blood sugar levels) medications. During a review of Resident 11's Order Summary Report, dated 8/12/2024, the report indicated an order for Humalog Injection Solution 100 units per milliliters (unit/ml, a milliliter is a unit of fluid volume equal to one-thousandth of a liter) (Insulin Lispro). Inject as per sliding scale (progressive increase in premeal or nighttime insulin doses): if 150-200= 2 units (the standard amount required for a precise measured activity); 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units call MD if blood sugar (BS) greater than (>) 400 or less than (<) 60, subcutaneously before meals and at bedtime for DM2. During a review of Resident 11's Location of Administration Report for Insulin for 8/2024 to 10/2024, the report indicated Humalog injection solution 100 unit/ml was administered on the following dates and sites: 8/13/2024 at 8:20 p.m. on the Abdomen - Right Upper Quadrant (RUQ) 8/14/2024 at 11:18 a.m. on the Abdomen - RUQ 8/15/2024 at 11:21 a.m. on the Abdomen - Right Lower Quadrant (RLQ) 8/15/2024 at 9:09 p.m. on the Abdomen - RLQ 8/16/2024 at 11:31 a.m. on the Abdomen - RUQ 8/17/2024 at 12:35 p.m. on the Abdomen - RUQ 8/18/2024 at 5:52 p.m. on the Abdomen - RLQ 8/18/2024 at 8:33 p.m. on the Abdomen - RLQ 8/19/2024 at 4:34 p.m. on the Abdomen - RLQ 8/21/2024 at 12:28 p.m. on the Abdomen - RLQ 8/22/2024 at 11:30 a.m. on the Abdomen - RLQ 8/23/2024 at 10 p.m. on the Abdomen - RLQ 8/25/2024 at 8:15 p.m. on the Abdomen - RLQ 9/10/2024 at 8:12 p.m. on the Abdomen-RLQ 9/16/2024 at 9:28 p.m. on the Abdomen-RLQ 9/29/2024 at 12:41 p.m. on the Abdomen-RLQ 9/29/2024 at 8:22 p.m. on the Abdomen-RLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the Director of Nursing (DON), reviewed Resident 11's Order Summary Report and Location of Administration Record of insulin dated 8/2024 to 10/2024. The DON stated there were multiple instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. The DON stated not rotating insulin administration sites is a medication error. During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). b. During a review of Resident 144's admission Record (AR), the AR indicated the facility admitted the resident on 9/25/2024, with diagnoses including type 2 diabetes mellitus, chronic kidney disease (a long-term condition where the kidneys are damaged and cannot filter blood properly), and long-term use of insulin. During a review of Resident 144's H&P, dated 9/27/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 144's MDS, dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident was receiving hypoglycemic medications. During a review of Resident 144's Order Summary Report, dated 9/25/2024, the report indicated an order for Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro). Inject as per sliding scale: if 151-200= 2 units contact MD for blood sugar less than 70; 201-249= 4 units; 250-300= 6 units; contact MD for blood sugar above 400, subcutaneously two times a day for DM. During a review of Resident 144's Location of Administration Report for insulin for 9/2024 to 10/2024, the report indicated Insulin Lispro Injection Solution 100 unit/ml was administered on the following dates and sites: 9/29/2024 at 8:22 p.m. on the Abdomen - Left Lower Quadrant (LLQ) 9/30/2024 at 9:24 p.m. on the Abdomen - LLQ During a concurrent interview and record review on 10/3/2024, at 12:54 p.m., with the DON, reviewed Resident 144's Order Summary Report and Location of Administration Record of insulin dated 9/2024 to 10/2024. The DON stated there were instances when the licensed nurses did not rotate the resident's insulin administration sites. The DON stated the licensed nurses should have rotated the insulin administration sites to prevent discoloration, swelling, and trauma to the skin frequently administered with insulin. The DON stated not rotating insulin administration sites is a medication error. During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided Manufacturer's Guideline on the use of Lispro- Injection, last revised on 8/2024, the guideline indicated to change the injection site each time to lessen injury under the skin (for example, pits/lumps or thickened skin). c. During a review of Resident 33's admission Record, the admission Record indicated the facility admitted the resident on 3/7/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 -a disorder characterized by difficulty on blood sugar control and poor wound healing) and heart failure (a condition that develops when the heart does not pump enough blood to the body's needs). During a review of Resident 33's History and Physical (H&P) dated 3/8/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 33's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/10/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required set up assistance with eating, and oral hygiene; supervision or touching assistance with rolling left and right; substantial/maximal assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 33 received insulin. During a review of Resident 33's Order Summary Report, the Order Summary Report indicated the following physician's order dated 3/7/2024: Humalog injection solution (insulin lispro) [a hormone that works by lowering levels of sugar in the blood; a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours] inject as per sliding scale: if 150 - 200 = 2 units ( a unit of measurement); 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units. Call physician for blood sugar less than (<) 60 or more than (>) 400, subcutaneously (SQ) before meals and at bedtime for DM 2. During a review of Resident 33's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Humalog injection solution was administered as follows: 07/03/24 9:00 p.m. 07/03/24 8:12 p.m. SQ Abdomen - left lower quadrant (LLQ) 07/04/24 7:00 a.m. 07/04/24 6:13 a.m. SQ Abdomen - LLQ 07/14/24 5:00 p.m. 07/14/24 4:34 p.m. SQ Abdomen - right upper quadrant (RUQ) 07/14/24 9:00 p.m. 07/14/24 9:02 p.m. SQ Abdomen - RUQ 07/23/24 9:00 p.m. 07/23/24 8:14 p.m. SQ Abdomen - LLQ 07/25/24 5:00 p.m. 07/25/24 4:14 p.m. SQ Abdomen - LLQ 08/16/24 9:00 p.m. 08/16/24 8:32 p.m. SQ Abdomen - LUQ 08/17/24 7:00 a.m. 08/17/24 6:42 a.m. SQ Abdomen - LUQ 08/21/24 9:00 p.m. 08/21/24 9:35 p.m. s SQ Abdomen - LUQ 08/22/24 7:00 a.m. 08/22/24 6:22 a.m. SQ Abdomen - LUQ 08/29/24 7:00 a.m. 08/29/24 6:38 a.m. SQ Abdomen - LLQ 08/31/24 7:00 a.m. 08/31/24 7:19 a.m. SQ Abdomen - LLQ During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 33's physician's orders, MAR, and location of administration sites for Humalog injection solution from 8/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. The DON stated not rotating insulin administration sites is considered a medication error per the manufacturer's guideline and standards of practice. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility provided manufacturer's guideline for Humalog injection solution, last revised on 8/2024, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin. d. During a review of Resident 28's admission Record, the admission Record, the admission Record indicated the facility admitted the resident on 3/4/2021 and readmitted the resident on 7/28/2024 with diagnoses including but not limited to type two diabetes mellitus (DM 2 - a disorder characterized by difficulty on blood sugar control and poor wound healing), long term use of insulin, and lack of coordination. During a review of Resident 28's History and Physical (H&P) dated 7/29/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 28's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/3/2024, the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating, and oral hygiene; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 28 received insulin. During a review of Resident 28's Order Summary Report, the Order Summary Report indicated the following physician's order dated 7/28/2024: Lantus subcutaneous (SQ) solution 100 unit per milliliters (unit/ml - a unit of measurement) [insulin glargine - a long-acting type of insulin that works slowly over about 24 hours used to lower blood sugar in adults and children with diabetes] inject 18 units subcutaneously (SQ) one time a day for DM 2. During a review of Resident 28's Medication Administration Record (MAR) from 7/2024 to 9/2024, the MAR indicated Lantus SQ solution was administered as follows: 07/16/24 9:00 a.m. 07/16/24 9:04 a.m. SQ Abdomen - right upper quadrant (RUQ) 07/17/24 9:00 a.m. 07/17/24 9:21 a.m. SQ Abdomen - RUQ 07/20/24 9:00 a.m. 07/20/24 8:20 a.m. SQ Arm - Upper arm (rear) (left) 07/21/24 9:00 a.m. 07/21/24 8:42 a.m. SQ Arm - Upper arm (rear) (left) 08/18/24 9:00 a.m. 08/18/24 8:59 a.m. SQ Arm - Upper arm (rear) (right) 08/23/24 9:00 a.m. 08/23/24 9:40 a.m. SQ Arm - Upper arm (rear) (right) 09/06/24 9:00 a.m. 09/06/24 9:42 a.m. SQ Arm - Upper arm (rear) (left) 09/07/24 9:00 a.m. 09/07/24 8:43 a.m. SQ Arm - Upper arm (rear) (right) 09/27/24 9:00 a.m. 09/27/24 8:51 a.m. SQ Abdomen - left upper quadrant (LUQ) 09/28/24 9:00 a.m. 09/28/24 9:07 a.m. SQ Abdomen - LUQ 09/29/24 9:00 a.m. 09/29/24 8:37 a.m. SQ Arm - Upper arm (rear) (right) 09/30/24 9:00 a.m. 09/30/24 8:45 a.m. SQ Arm - Upper arm (rear) (right) During a concurrent interview and record review on 10/3/2024 at 1:30 p.m., with the Director of Nursing (DON), reviewed Resident 28's physician's orders, MAR, and location of administration sites for Lantus SQ solution from 7/2024 to 9/2024. The DON verified the insulin injection sites were not rotated. The DON stated the licensed nurses (LN) should have rotated insulin administration sites to prevent discoloration, swelling, trauma to the skin. The DON stated the LNs should observe the previous site and then rotate the site for the next dose of insulin, check the site if it is discolored or bruised and monitor the resident for pain. The DON stated the LNs should clean and disinfect the area, check the correct dose and route before administering the medication. The DON stated not rotating insulin administration sites is considered a medication error per the manufacturer's guideline and standards of practice. During a review of the facility's recent policy and procedure (P&P) titled Adverse Consequences and Medication Errors, last reviewed on 4/12/2024, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/12/2024, the P&P indicated a purpose to provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated: Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline for insulin glargine - injection, undated, the manufacturer's guideline indicated to change the injection site each time to lessen injury under the skin such as lumps or thickened skin.

**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 by failing to ensure: 1. Resident 15's nasal cannula oxygen tubing (a thin, flexible tube that delivers oxygen to a patient through two prongs that fit into the nostrils) was labeled with the date it was last changed for one of two sampled residents investigated under respiratory care. 2. Resident 32's nasal cannula oxygen tubing was off the floor and the nebulizer tubing (a tube that connects the compressor of a nebulizer to the medication cup) was labeled with the date it was last changed for one of two residents investigated under respiratory care. 3. The facility discarded two opened enteral feeding kit (a tube that delivers nutrition or hydration into the stomach or small intestine of a patient who is unable to eat or drink enough) mixed with unopened enteral feeding kit inside the medication room. 4. Licensed Vocational Nurse 1 (LVN 1) cleaned the glucometer (a small, portable device that measures the amount of glucose, or blood sugar, in the blood) used on a resident with an antiseptic wipe (a single-use wipe that contains an antiseptic solution to clean and sterilize wounds and surfaces) prior to returning the glucometer to the medication cart. 5. The temperature of water in the resident's room were above 113 degrees Fahrenheit (F, a temperature scale) to prevent the growth of Legionella (a severe form of pneumonia- lung inflammation usually caused by infection) in the facility's water system. The deficient practices had a potential to spread infections and illnesses among residents. Findings: 1. During a review of Resident 15's admission Record (AR), the AR indicated the facility admitted the resident on 4/2/2024, with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic lung disease that makes it difficult to breathe by restricting airflow) and dependence on supplemental oxygen (a medical treatment that provides extra oxygen to people who have trouble breathing or low blood oxygen levels). During a review of Resident 15's History and Physical (H&P), dated 4/3/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/7/2024, the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on oxygen therapy (a treatment that provides extra oxygen to people with breathing problems or lung diseases). During a review of Resident 15's Order Summary Report, dated 4/3/2024, the report indicated an order for oxygen (O2) at 2 liters per minute (LPM, a measurement of the velocity at which air flows into the sample probe) via nasal cannula (NC, a medical device that provides supplemental oxygen or increased airflow to a patient through the nose), may titrate (evaluates the oxygen needs at rest and at exercise) to maintain O2 greater than (>) 92%. Every shift. During an observation on 10/1/2024, at 9:18 a.m., with the Certified Nursing Assistant 4 (CNA 4), inside Resident 15's room, the oxygen via nasal cannula tubing of the resident was not labeled with the date it was last changed. CNA 4 stated there was no date on the oxygen tubing and it was supposed to be changed daily. During an interview on 10/3/2024, at 1:18 p.m., with the Director of Nursing (DON), the DON stated the staff should date the oxygen tubing of when it was last changed to know when the oxygen tubing needed to be replaced for infection control purposes. During a review of the facility's recent policy and procedure (P&P) titled, Oxygen Tubing Labeling, last reviewed on 4/12/2024, the P&P indicated appropriate infection prevention and control of oxygen tubing and supplies are obtained, stored, and used in accordance with current guidelines and manufacturer instructions. Nurse will ensure all tubing is labeled with the date when using it. Tubing that touches the floor or any unclean surface will be removed and change with a new tubing. 2. During a review of Resident 32's admission Record (AR), the AR indicated the facility admitted the resident on 7/25/2022, and readmitted the resident on 9/22/2024, with diagnoses including acute respiratory failure with hypercapnia (a condition where the lungs have trouble removing carbon dioxide from the blood, causing a buildup of carbon dioxide in the blood), pleural effusion (a condition where too much fluid builds up in the space between the lungs and chest wall), and dependence on supplemental oxygen. During a review of Resident 32's H&P, dated 9/23/2024, the H&P indicated the resident had acute hypoxemic respiratory failure (a severe condition that occurs when the body does not have enough oxygen in the blood, but carbon dioxide levels are normal or low). The H&P indicated the resident had the capacity to make decisions. During a review of Resident 32's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was on continuous oxygen therapy. During a review of Resident 32's Order Summary Report, the report indicated an order for: 9/22/2024 O2 at 2-3 LPM via NC, may titrate to maintain O2 >92%. Every shift. 10/1/2024 Budesonide inhalation suspension 0.5 milligrams (mg, a unit of weight)/2 milliliters (ml, a unit of volume) (Budesonide Inhalation). 2 ml inhale orally two times a day for anti-asthmatic (a medication or drug that helps treat asthma by relieving symptoms and improving breathing). Rinse mouth after each use and spit out. 9/22/2024 DuoNeb (Ipratropium-Albuterol 0.5-3 mg/ 3 ml Amp). 1 application inhale orally every 6 hours for shortness of breath (SOB)/wheezing (a high-pitched, whistling sound that can occur during breathing when airways in the lungs become narrowed or blocked). Administer for at least 15 minutes via nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece). During a review of Resident 32's Care Plan titled Respiratory risk related to COPD, acute hypoxemic hypercapnia respiratory failure, last revised on 9/27/2024, the CP indicated an intervention of appropriate equipment at bedside for emergency use, breathing treatment as ordered, and medication as ordered: Budesonide, DuoNeb. During a concurrent observation and interview on 10/1/2024, at 3:35 p.m., with the Infection Preventionist (IP), observed Resident 32's oxygen via nasal cannula tubing was on the floor. The IP stated the oxygen tubing should be off the floor and if the tubing was on the floor, it should have been replaced with a new one to prevent infection to residents. The IP also stated the nebulizer tubing should be dated with the day it was last changed to know when to change them again to prevent infection to residents. During an interview on 10/3/2024, at 1:20 p.m., with the DON, the DON stated the staff should keep the oxygen tubing off the floor and when seen touching the floor, it should be replaced immediately for infection control. The DON also stated the nebulizer tubing should be dated with the date it was last changed to know when to change them again and for infection control purposes. During a review of the facility's recent policy and procedure (P&P) titled, Oxygen Tubing Labeling, last reviewed on 4/12/2024, the P&P indicated appropriate infection prevention and control of oxygen tubing and supplies are obtained, stored, and used in accordance with current guidelines and manufacturer instructions. Nurse will ensure all tubing is labeled with the date when using it. Tubing that touches the floor or any unclean surface will be removed and change with a new tubing. During a review of the facility's recent policy and procedure (P&P) titled, Administering Medications through a Small Volume (Handheld) Nebulizer, last reviewed on 4/12/2024, the P&P indicated after attaching the tubing to the source gas, label the tubing with the date. Change equipment and tubing every seven days, or according to facility protocol. 3. During a concurrent observation and interview on 10/3/2024, at 9:40 a.m., with LVN 1, inside the Medication Room, two opened enteral feeding kit mixed with unopened enteral kits inside the Medication Room was observed. LVN 1 stated the opened enteral kits should have been discarded to prevent infection to residents. During an interview on 10/3/2024, at 2:22 p.m., with the DON, the DON stated the staff should have disposed the opened enteral kit to prevent infection to residents. During a review of the facility's recent policy and procedure (P&P) titled Enteral Feedings- Safety Precautions, last reviewed on 4/12/2024, the P&P indicated to maintain strict aseptic techniques at all times when working with enteral nutrition systems and formulas. 4. During a concurrent observation and interview on 10/2/2024, at 11:48 a.m., with LVN 1, LVN 1 was observed performing a finger stick blood sugar (FSBS, is a method for monitoring blood glucose levels) on a resident and returned the glucometer back to the medication cart without wiping the glucometer with an antiseptic wipe. LVN 1 stated he should have wiped the glucometer with an antiseptic wipe to prevent infection among residents. During an interview on 10/3/2024, at 1:44 p.m., with the DON, the DON stated the licensed staff should clean the glucometer before and after in between patient use to prevent blood borne diseases from spreading. During A review of the facility's recent policy and procedure (P&P) titled, Obtaining a Fingerstick Glucose Level, Glucometers, Cleaning and Storage, last reviewed on 4/12/2024, the P&P indicated to always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. 5. During a concurrent interview and record review on 10/2/2024, at 3:24 p.m., with the Administrator (ADM), Maintenance Supervisor (MS), and Maintenance Consultant (MC), the ADM stated the Water Management Committee meets monthly and they do maintenance rounds. The ADM stated they follow the Centers for Disease Control and Prevention (CDC, a U.S. federal agency that protects public health) guidance on preventing Legionella in their water system. The ADM stated they keep the water temperature in the facility above 113 degrees F to prevent Legionella in the facility. Reviewed the facility's Water Temperature Log for 9/2024. The waterlog indicated a random room water temperature measurement from 9/1/2024 to 9/30/2024 with consistent 109 degrees F readings. The ADM acknowledges the Water Temperature Logs with temperatures below 113 degrees F and stated the failure to keep the water temperature above 113 degrees F predisposes the facility's water system to develop Legionella. During a concurrent interview and record review on 10/3/2024, at 1:45 p.m., with the DON, the DON stated the whole 9/2024 Water Temperature Log indicated a temperature of 109 degrees F which predisposed the facility water system to developing Legionella. During a review of Water Management Program, last reviewed on 4/12/2024, the program indicated Title 22 (is a set of rules and regulations that govern community care facilities in California) indicated resident water temperatures for hot water should be between 105 and 120 degrees. Centers for Medicare and Medicaid Services (CMS, a federal agency that provides health coverage to millions of Americans) states temperature should be below 120 degrees. Temperatures between 77 F and 113 F are best to grow Legionella. Legionella tends to grow slower at temperatures under 68 F and begin to die at temperatures between 113 F and 120 F. Preferably Hot to be above water above 113 F.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for one of five sampled residents (Resident 1), by failing to ensure Registered Nurse 1 (RN 1) perform hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before and after providing care to Resident 1 and after touching unclean surfaces. RN 1 also did not wear gloves during the blood pressure monitoring procedure on Resident 1. These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 5/28/2018. Resident 1 ' s diagnoses included hemiplegia (paralysis that affected one side of the body) and hemiparesis (weakness or inability to move one side of the body) on the left side, heart failure (a condition that develops when the heart does not pump enough blood for the body ' s need), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 1/17/2024, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. The MDS indicated that Resident 1 had range of motion limitation on both upper (shoulder, elbow, wrist, or hand) and lower extremity (hip, knee, ankle, or foot). Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on toileting, bath, upper and lower body dressing, and personal hygiene. On 1/29/2024 at 9:30 a.m., during a concurrent observation and interview, observed RN 1 enter Resident 1 ' s room without performing hand hygiene. RN 1 placed the blood pressure (BP) machine on Resident 1 ' s right arm and touched the resident ' s bed linen without gloves on. RN 1 removed the BP machine from Resident 1 ' s right arm and placed it on the medication cart. RN 1 did not perform hand hygiene and proceeded to document on the medication cart computer. RN 1 opened the medication cart drawer and touched the medication packets without performing hand hygiene. RN 1 stated that he should wear gloves when providing care for residents. RN 1 stated that he should sanitize his hands before and after touching Resident 1, before and after gloves use, and after touching the resident ' s surroundings. RN 1 stated that not performing hand hygiene and not wearing gloves had the potential to spread infections to other residents. On 1/29/2024 at 11:20 a.m., during an interview, the Infection Preventionist Nurse (IPN) stated that hand hygiene should be done before and after entering the resident ' s room and in between resident care. The IPN stated that gloves should be worn when providing care to the residents, changing linens going in the isolation rooms, or any contact with the residents. The IPN stated that not following the infection prevention and control practices had the potential to expose residents and staff to infection such as Covid-19, bacteria, and germs. A review of the facility ' s policy and procedure titled, Handwashing / Hand Hygiene, dated 2/3/2023, indicated that the facility considers hand hygiene the primary means to prevent the spread of infections. The policy indicated that all personnel shall; follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy indicated to use an alcohol-based rub at least 62% alcohol, or alternatively soap and water before and after direct contact with residents, after contact with resident ' s intact skin, after handling contaminated equipment, and after contact with objects in the immediate vicinity of the resident. A review of the facility ' s policy and procedure titled, Personal Protective Equipment – Gloves, dated 2/3/2023, indicated that gloves must be worn when handling blood, body fluids, secretions and excretions, mucous membranes and /or non-intact skin. The policy indicated that the use of disposable gloves was indicated when handling soiled linen or items that may be contaminated.

Based on observation, interview and record review facility failed to maintain privacy of confidential information when Certified Nursing Assistant 3 (CNA 3) left an electronic health record (EHR- a digital version of a patient's paper chart) open , unattended, and out of view for one of one resident sampled (Resident 25). This deficient practice violated Resident 25's right to privacy and confidentiality of their medical records. Findings: A review of Resident 25's admission Record indicated the facility admitted the resident on 2/21/2020 and readmitted the resident on 10/7/2020 with diagnoses that included Parkinson's disease (), essential (primary) hypertension (the blood is pumping with more force than normal through your arteries [blood vessels that distribute oxygen-rich blood to your entire body]), and unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to an extent that it interferes with a person's daily life and activities). A review of Resident 25's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 8/20/2023 indicated Resident 25 was usually able to understand and usually understood. Resident 25 required extensive assistance with bed mobility, locomotion off and on unit, dressing, toilet use, and personal hygiene. During a concurrent observation and interview on 9/30/2023 at 6:53 p.m., with the Director of Nursing (DON) and Administrator (Adm), outside the dining room, observed CNA 3's computer with Resident 25's EHR open and visible, unattended, and out of CNA 3's line of sight. The DON stated it is a violation of privacy of confidential information to leave the resident's EHR open and unattended. During an interview on 9/30/2023 at 7:13 p.m., CNA 3 stated that he is aware to close resident's EHR when he walks away from the computer but forgot to do so. CNA 3 stated leaving the resident's EHR open and unattended placed Resident 25's information at risk for being accessed by someone who is not authorized. During an interview on 10/2/2023 at 11:10 a.m., the DON stated leaving EHR open and unattended is a violation and a risk for resident information to be exposed. The DON stated the staff need to log out of the computer if they walk away from it so that no resident information is visible to anyone else. A review of facility's policies and procedures titled Computer Terminals/Workstations, last revised on 2/3/2023 indicate computer terminals and workstations will be positioned/shielded to ensure that protection health information (PHI) and facility information is protected from public view or unauthorized access. A user may not leave his/her workstation or terminal unattended unless the terminal scree is cleared/shut and/or the user is logged off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement resident-centered care plans for two of 14 sampled residents (Resident 25 and Resident 87) by failing to: 1. Ensure Resident 25 had a care plan addressing the use of Cefdinir (an antibiotic [medicines that treat or prevent bacterial infections] medication). 2. Ensure Resident 87 had a care plan addressing the use of a cervical collar (C-collar, a medical device used to restrict movement whenever spinal motion restriction is indicated). These deficient practices placed the residents at risk for not receiving the necessary services and treatment to meet their medical, physical, mental and psychosocial needs. Findings: a. A review of Resident 87's admission Record indicated the facility originally admitted the resident on 9/1/2023 and readmitted on [DATE] with diagnoses including intraspinal (being within the spine) abscess (buildup of pus) and granuloma (a cluster of white blood cells and other tissues) and cervical (neck) region discitis (inflammation of disc due to infection). A review of Resident 87's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/28/2023, indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance with bed mobility, transfer, walk in room and corridor, locomotion on and off unit, dressing, toilet use, bathing, and personal hygiene with one-two person physical assist. A review of Resident 87's History and Physical, dated 9/25/2023 indicated was wearing a C-collar neck brace. A review of Resident 87's Physician Order, dated 9/22/2023, indicated the resident may have C-collar on at all times, may remove when showering, every shift. During a concurrent observation and interview, at Resident 87's bedside with the Director of Nursing (DON), on 9/30/2023 at 11:32 a.m., the DON stated Resident 87's neck brace should be adjusted to ensure the resident's chin is on top of the chin pad. During a concurrent interview and record review of Resident 87's Care Plans, on 10/2/2023 at 11:23 a.m., with the DON, the DON stated Resident 87 did not have a care plan related to the use of the C-collar. The DON stated care plans are developed to provide the resident the plan of care needed for a good or better outcome. The DON stated there should have been a care plan with interventions that included frequent checks to ensure the c-collar was applied correctly to prevent misalignment of her spine. The DON stated education on the proper use of the C-collar improve resident outcomes. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. b. A review of Resident 25's admission Record indicated the facility readmitted the resident on 10/7/2020 with diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors [shaking movements in one or more parts of the body, most often in the hands]) and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). A review of Resident 25's Situation Background Assessment and Request (SBAR, a communication tool that allows health care professionals to communicate a resident's condition) and progress note, dated 9/27/2023, indicated the resident with right lower back skin abscess. The SBAR indicated Resident 25's physician was made aware, and the physician gave new orders. A review of Resident 25's Physician Order, dated 9/27/2023, indicated an order for Cefdinir oral capsule 300 milligrams (mg, a unit of measure) give one capsule by mouth two times a day for right lower back skin abscess (a buildup of pus) for 10 days. During a concurrent interview and record review of Resident 25's Care Plans on 10/1/2023 at 10:26 a.m., with the Director of Nursing (DON), the DON stated there were care plan interventions developed for the use of cefdinir. During a concurrent interview and record review of Resident 25's Care Plans on 10/1/2023 at 2:16 p.m., with Licensed Vocational Nurse 5 (LVN 5), LVN 5 stated he did not develop a care plan specific to the antibiotic use, Cefdinir. During an interview on 10/2/2023 at 11:25 a.m., the DON stated care plans are developed to provide the resident the plan of care needed for better outcomes. A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, approved 2/3/2023, indicated that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.

Based on observation, interview, and record review, facility failed to meet professional standards of quality for a resident who has a gastrostomy tube (GT- a tube inserted through the abdomen and into the stomach used to deliver nutrition or medication)) by failing to verify the route of administration for a supplement, pro-stat (a ready-to-drink concentrated liquid protein medical food) prior to administration for one of one sample resident (Resident 27). This deficient practice had the potential to result in Resident 27 receiving the medication orally causing the resident to aspirate. Findings: A review of Resident 27's admission Records indicated the facility admitted the resident on 1/6/2021 and readmitted the resident on 11/25/2022 with diagnosis that included unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to an extent that it interferes with a person's daily life and activities), essential (primary) hypertension (the blood is pumping with more force than normal through your arteries [blood vessels that distribute oxygen-rich blood to your entire body]), and gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach) A review of Resident 27's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/3/2023 indicated the resident was never able to understand or be understood. Resident 27 was totally dependent on staff for bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. MDS further indicated nutritional approaches as feeding tube. A review of the Physician's Order for Resident 27 dated 6/15/2023 indicated an order for prostat sugar free give 30 millimeters (ml a unit of measurement) by mouth two times a day for supplement. A review of Resident 27's Care Plan developed on 12/1/2022 indicated the resident required tube feeding related to dysphagia (swallowing difficulties). The interventions included resident needs (total) with tube feeding and water flushes and check tube placement and gastric contents/residual volume per facility protocol. During a concurrent observation, interview, and record review with Licensed Vocational Nurse 5 (LVN 5), on 10/1/2023 at 8:11 a.m., observed LVN 5 during Resident 27's medication administration pass administer prostate via g-tube. LVN 5 reviewed the resident's order for prostat and stated that the order indicated to administer prostat via mouth. LVN 5 stated he should have verified the order with the doctor. During an interview on 10/2/2023 at 11:11 a.m., the Director of Nursing (DON) stated medication needs to be administered by ordered route. The DON stated nursing staff should have verified with the doctor if the route is appropriate for the resident. The DON stated administering the medication orally as ordered instead of g-tube placed Resident 27 at risk for aspiration. A review of the facility's policies and procedures, titled, Administering Medications, last revised on 2/3/2023 indicate medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 27's admission Records indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses including unspecified dementia (the loss of cognitive functioning such as thinking, remembering, and reasoning to an extent that it interferes with a person's daily life and activities), essential (primary) hypertension (the blood is pumping with more force than normal through your arteries [blood vessels that distribute oxygen-rich blood to your entire body]), and long term (current) use of anticoagulants (a group of medications that decrease your blood's ability to clot). A review of Resident 27's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated [DATE] indicated the resident was never able to understand or be understood. Resident 27 was totally dependent on staff for bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene. A review of the Physician's Order for Resident 27 dated [DATE] indicated MiraLAX 17 grams (GM- unit of measurement) give 1 packet via g-tube one time a day for bowel management. During a concurrent observation and interview on [DATE] at 8:11 a.m. with Licensed Vocational Nurse 5 (LVN 5), observed during medication pass MiraLAX with no open date indicated. LVN 5 stated medications must be labeled with an open date, to make sure the medication is not old. During an interview on [DATE] at 11:14 a.m., the Director of Nursing (DON) stated house supplies medications must be labeled with open date. The DON stated if medications do not have an open date, they may not be able to verify if the medication is expired, and this can place the residents at risk for adverse side effects. A review of the facility's policy and procedure titled, Labeling of Medication Containers, dated [DATE], indicated all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations. Labels for each floor's stock medication shall include all necessary information, such as: e. open date. Based on observation, interview, and record review, the facility failed to implement its policy and procedure on labeling and storage of drugs and biologicals by: 1. Failing to label two Aplisol (a sterile aqueous solution of a purified protein fraction for intradermal [done within the layers of skin] administration as an aid in the diagnosis of tuberculosis [disease caused by germs that are spread from person to person through the air]) multi-dose (multiple doses) vials with an open date for one of one medication storage reviewed. 2. Failing to label MiraLAX (a brand-name, over-the-counter product that is typically used to treat short-term constipation) with an open date during medication pass observation for one of one sampled resident (Resident 27). These deficient practices increased the risk that the facility's residents could have received medication that had become ineffective or toxic due to improper storage or labeling resulting in a negative impact to their health and well-being. Findings: a. During concurrent observation and interview on [DATE] at 6:37 p.m. with the Director of Staff Development (DSD), in the the medication storage room, observed, two Aplisol vials without a cap. The DSD stated she does not know if the vials are open and used because it did not have an open date label. The DSD stated the Aplisol vial's handling instructions indicated that once entered the vial should be discarded after 30 days. The DSD stated the facility's policy and procedure is to label a medication with open date when opened. During an interview on [DATE] at 7:16 p.m., the Director of Nursing (DON) stated she will follow-up with pharmacy to find out if the Aplisol vials come with a cap, and request for a change/reorder. The DON stated it is the facility's practice for the licensed nurses to date medications including medication vials when opened. During an interview on [DATE] at 9:14 a.m., the DON stated that according to the pharmacy, an Aplisol vial comes with a cap. A review of the facility's policy and procedure titled, Labeling of Medication Containers, dated [DATE], indicated that labels for each floor's stock shall include all necessary information, such as open date.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices for one of one sampled resident (Resident 138), by failing to label Resident 138's oxygen tubing and humidifier with a placement (the action of putting something in a particular place) date. This deficient practice had the potential for staff to not timely change oxygen tubing and humifidier, placing the resident at risk for respiratory infection. Findings: A review of Resident 138's admission Records indicated the facility admitted the resident on 9/14/2023 with diagnosis that included chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems) with acute exacerbation (the process of making something that is already bad even worse), dependence on supplemental oxygen, and depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities). A review of Resident 138's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/20/2023 indicated the resident was able to understand and be understood. Resident 138 required extensive assistance from staff with bed mobility, transfer, walking in room and corridor, locomotion on and off unit, dressing, toilet use, and personal hygiene. A review of the Physician's Order for Resident 138 dated 9/14/2023 indicated an order for oxygen at 2 liters per minute (LPM) via nasal canula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) may titrate to maintain oxygen above 92% (oxygen saturation values of 95% to 100% are generally considered normal). A review of Resident 138's Care Plan developed on 9/15/2023 for the resident respiratory risk related to COPD indicated an intervention to administer oxygen as ordered, monitor oxygen saturation as ordered, and observe vital signs as needed. During an observation on 9/30/2023 at 2:11 p.m. observed Resident 138's humidifier and oxygen tubing not dated. During a concurrent observation and interview on 9/30/2023 at 6:32 p.m., with Certified Nursing Assistant 4 (CNA 4) at Resident 138's bedside, CNA 4 stated the humidifier was empty and there was no date indicated on the oxygen tubing and humidifier. During a concurrent observation and interview on 9/30/2023 at 6:34 p.m., with Licensed Vocational Nurse 1 (LVN 1) at Resident 138's bedside, LVN 1 stated the humidifier is empty and can dry out the resident's nasal cavity placed the resident at risk for being uncomfortable and having a nosebleed. LVN 1 stated the humidifier and nasal canula did not have a date on them. LVN 1 stated the oxygen tubing and humidifier should be dated so the staff know when they were last changed. LVN 1 stated it is the facility's protocol to change the oxygen tubing and humidifier once a week or as needed for infection control. During an interview on 10/2/2023 at 11:15 a.m., the Director of Nursing (DON) stated oxygen tubing is changed once a week on Thursday nights or early Friday mornings and as needed if it is soiled or contaminated. The DON stated humidifiers get changed as needed and when they run out. The DON stated both humidifier and oxygen tubing must be labeled with a date so the staff will know when it was last changed and for infection control. The DON stated the humidifier is to prevent dryness and leaving it empty may cause residents to experience nosebleeds. A review of the facility's policies and procedures, titled, Oxygen supplies, last revised on 2/3/2023 indicate changing tubing should be done weekly bases. Oxygen tubing should be labeled with date when placed, humidifier replacement should be done in as needed bases, when placed humidifiers should be labeled.

**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 regarding Coronavirus 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for three of 13 sampled residents (Residents 1, 2, and 9), by failing to: a. Ensure Activity Director (AD) perform hand hygiene before and after performing activities with Resident 1 and Resident 2 in the yellow zone (area where residents who were exposed to COVID-19 or are showing symptoms are placed). AD did not wear gown and gloves before entering Resident 1 and Resident 2's room. b. Ensure that Occupational Therapy Assistant (OTA) perform hand hygiene after pushing Resident 9's wheelchair into the hallway. c. Ensure that Housekeeping 1 wore a face shield/googles while cleaning in the red zone restroom and the hallways. These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19. Findings: a. A review of Resident 1's admission Record indicated the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including cerebrovascular accident (CVA - a loss of blood flow to part of the brain, which damages brain tissue), osteoarthritis (inflammation or swelling of one or more joints), and gout (a common form of inflammatory arthritis that is very painful and usually affects the big toe). A review of Resident 1's History and Physical, dated 5/20/2022, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 11/24/2022, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. A review of Resident 1's Progress Notes, dated 11/18/2022, indicated the resident was placed on isolation precaution for probable Covid 19 exposure. Resident 1 was tested for Covid-19 on 11/18/2022 with a negative result. A review of Resident 2's admission Record indicated the resident was admitted on [DATE] with diagnoses including right femur fracture (a break in the thighbone) and hypertension (high blood pressure). A review of Resident 2's History and Physical, dated 10/28/2022, indicated the resident had the capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated the resident's cognition was intact. A review of Resident 2's Progress Notes, dated 11/18/2022, indicated the resident was placed on isolation precaution for probable Covid 19 exposure. Resident 2 was tested for Covid-19 on 11/18/2022 with a negative result. During an observation on 11/23/2022 at 9:55 a.m., the AD came out of Resident 1 and Resident 2's room (roommates) without gown or gloves on holding a rolled-up gown on the left hand and a plastic bag with soiled linen on the right hand. AD went across the hallway to the shower room where AD placed the plastic bag and the gown in the bin. AD did not use hand sanitizer or handwashing and reentered the residents' room without donning (putting on) a gown and gloves. AD exited the residents' room and wiped the doorknob of the residents' room and the shower room then proceeding to enter Resident 1 and Resident 2's room again without performing hand washing or use of hand sanitizer and without donning gown and new gloves. During a concurrent interview, the AD stated she did not use proper personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) upon multiple entry and exit to the residents' room. AD stated that infection control procedures were not followed. During an interview on 11/23/2022 at 12:03 pm, the Director of Nursing (DON) stated that staff are expected to perform hand washing or use hand sanitizer before and after resident care. DON stated that other residents and staff can get infected if infection control measures are not followed. b. A review of admission Record indicated that the facility admitted Resident 9 with diagnoses of diabetes mellitus type II (a condition that affects the way the body processes the blood sugar), hypertension, and dysphagia (difficulty swallowing). Resident 9 also tested positive for COVID-19 on 11/18/2022. A review of Resident 9's MDS, dated [DATE], indicated the resident was cognitively intact but occasionally forgetful. MDS also indicated Resident 9 needed one person assist in transferring. On 12/12/2022 at 10:38 a.m., during observation, OTA pushed Resident 9's wheelchair into the lobby. After the resident's wheelchair was parked, the OTA proceeded to go into the dining/activities room but did not her sanitize hands. The hand sanitizer was located outside the door of the rehabilitation room, right next to the dining/activities room. During a concurrent interview, OTA stated she was going to sanitize inside the dining room. OTA stated that she was supposed to sanitize hands prior to touching the resident. On 12/13/2022 at 10:54 a.m., during an interview, the Infection Preventionist Nurse (IPN) stated that hand hygiene must be done before and after and sometimes, in-between care, before and after using gloves to prevent cross contamination. c. On 12/12/2022 at 10:52 a.m., during an observation, Housekeeper 3 (HKP 3) was observed not wearing a face shield/googles while cleaning in the red zone restroom and the hallways. During an interview, HKP 3 acknowledged that he was not wearing face shield/googles but only his eyeglasses. HKP 3 stated he could get infected with COVID-19 for not properly wearing PPE (personal protective equipment). On 12/13/2022 at 10:54 a.m., during an interview, IPN stated that following the latest guidelines, all staff are supposed to use goggles and N-95 inside the facility. Not just CNAs, LVNS, it is for everyone, to protect themselves and the residents from COVID-19 and Influenza. A review of the facility's policy and procedure titled, Hand Hygiene, revised on 8/2015, indicated that facility considers hand hygiene the primary means to prevent the spread of infections All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. A review of the facility's policy and procedure titled, Personal Protective Equipment, revised on 10/15/2022, indicated that staff will use a new isolation gown every time they enter a room and in between each resident if a roommate is present and on isolation precaution. The policy also indicated that eye protection is needed in green, yellow, and red areas.

Based on observation, interview, and record review, the nursing staff failed to ensure the call light button was within reach of Resident 141's right arm that was immobilized as a result of a right humerus fracture (an injury to the bone of the upper arm that connects to the shoulder), for one of one resident (Resident 141). This deficient practice had the potential to result in Resident 141 unable to summon health care workers for assistance. Findings: A review of the admission Record indicated Resident 141 was admitted to the facility, on 11/03/2201, with diagnoses including unspecified displaced fracture of surgical neck of right humerus and history of falling. A review of the History and Physical (H&P), dated 11/05/2021, indicated Resident 141 had the capacity to understand and make decisions. The H&P indicated Resident 141 had recently been hospitalized for a right humerus fracture after a fall and was admitted to the facility for physical and occupation therapy (services to help improve physical strength and mobility). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 11/08/2021, indicated Resident 141 had the ability to make self-understood and understand others. The MDS indicated Resident 141 required extensive assistance by staff with bed mobility, transfer, walking, dressing, and toilet use, and personal hygiene. A review of the care plan titled The Resident has an ADL (activities of daily living) self-care performance deficit and requires extensive assistance initiated on 110/5/2021, indicated Resident 141 would have her ADL needs identified and met with staff assistance and intervention. The care plan's interventions were to encourage the resident to use the call light to call for assistance. During a concurrent observation and interview, on 11/16/2021 at 8:36 a.m., Resident 141 was lying in bed wearing a black sling (medical device used to immobilize arm during injury) on the right arm. Resident 141's right arm was elevated on a pillow, the bed's side rail was lowered under the pillow, and the call light hung from the rail towards the floor. Resident 141 stated she broke her shoulder, and she could not reach the call light. Resident 141 stated she would like to use the restroom but was not able to call for assistance. During an interview, on 11/17/2021 at 08:05 a.m., Licensed Vocational Nurse 2 (LVN 2) stated he was caring for Resident 141 on 11/16/2021. He stated the call light was not within reach when it was hanging from the rail, under the pillow, on the right side of the bed. LVN 2 stated the facility policy was to place the call light within reach while the resident was in bed. LVN 2 stated it was preferable that Resident 141 did not use the right arm due to her condition. During an interview, on 11/17/2021 at 11:02 a.m., the Director of Nursing (DON) stated the facility policy was t ensure that the call light was within reach of the resident. The DON confirmed it was not acceptable to have the call light placed out of reach on the right side of a resident with a right arm fracture. A review of the facility's policy titled, Answering the Call Light, approved 02/05/2021, indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed ensure appropriate treatment and services that meet professional standards of quality for enteral medications, for one of three sample residents (Resident 27) by: 1. Failing to ensure medications were adequately dissolved prior to administration via the g-tube (GT, a tube inserted through the abdomen wall into the stomach used for feeding and medication administration). 2. Failing to ensure proper GT placement prior to medication administration. 3. Failing to ensure there was a physician's order prior to pushing (the act of placing the plunger in the medication syringe and gently applying pressure to overcome resistance in the GT) medication via the GT. These deficient practices has the potential to result in Resident 27's transfer to the hospital due to a clogged GT. Findings: A review of the admission Record indicated Resident 27 was admitted to the facility, on 06/16/2021 with a readmission date of 07/04/2021 with diagnoses that included surgical aftercare following surgery of the digestive system and gastrostomy (a surgery to place a GT). A review of Resident 27's History and physical (H&P), dated 07/05/2021, indicated the resident was recently admitted from the hospital for a GT placement for severe malnutrition. The H& P indicated Resident 27 did not have the capacity to understand and make decisions. A review of the MDS (Minimum Data Set - a standardized assessment and care screening tool), dated 07/10/2021, indicated Resident 27 rarely/never had the ability to make self-understood and understand others. The MDS further indicated Resident 27 was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 27's care plan titled The resident required tube feeding related to depression, weight loss, initiated on 07/06/2021, indicated Resident 27 would remain free of side effects or complications related to tube feeding. The care plan's interventions for staff to check for GT placement and gastric contents/residual volume per facility protocol and record. A review of Resident 27's care plan titled The resident has impaired cognitive function / dementia (brain disease) or impaired thought processes initiated on 07/05/2021, indicated Resident 27 would have medications administered as ordered. A review of Resident 27's physician orders indicated the following: - check for GT residual (the volume of fluid remaining in the stomach measured to ensure the stomach is emptying) every shift, dated 07/04/2021. - check for GT placement every shift, dated 07/04/2021. - may crush all crushable medications given via GT every shift, dated 07/04/2021. - Magnesium Oxide Tablet 400 mg (milligrams-unit of measurement), give 1 tablet via GT one time a day for supplement, dated 07/04/2021. During a concurrent interview and medication pass observation for Resident 27, on 11/17/2021 at 08:09 a.m., Licensed Vocational Nurse (LVN 2) individually crushed seven medications and added water to dissolve them. The medication was observed floating on top of the water for approximately five of the seven medications. LVN 2 removed the plunger from the medication syringe, connected the syringe to Resident 27's GT, administered 30 cc (cubic centimeters-unit of measurement) of water by gravity (syringe contents flow into the GT without the use of the syringe plunger) without checking GT placement. LVN 2 then administered six of seven crushed medications into the GT by gravity. The seventh medication failed to flow into the GT by gravity. Pieces of medication were observed lodged in the GT. LVN 2 placed the plunger on the syringe and attempted to push and stated there was resistance. LVN 2 removed the medication from the syringe, attempted to dissolve the medication in more water, placed water in the syringe, placed the plunger on the syringe, and attempted to push water into the GT. After approximately 4 unsuccessful attempts to unclog the GT by alternating squeezing the GT between his fingers and pushing on the syringe plunger, LVN 2 called for the Director of Nursing (DON) and requested assistance. The DON entered the room, assessed the GT, left the room, and returned. The DON stated she spoke with the physician and requested an order to push to the speed of gravity. The DON stated there must be a physician's order prior to pushing. The DON attempted to unclog the GT and stated she was not successful. The DON stated she would notify the physician to transfer Resident 27 to the hospital. A review of the SBAR Communication and Progress record, dated 11/17/2021 at 9:19 a.m., indicated during the med pass the resident's (Resident 27) GT noted not flushing to the speed of gravity. (Doctor's name) gave order may push to the speed of gravity. Attempted to push H2O (water) to the speed of gravity to flush the line however resistance was felt. GT checked for placement and heard in place. (Doctor's name) with n.o. (new order) to hold the magnesium and transfer the resident to the hospital for GT malfunction. During an interview, on 11/17/2021 at 9:30 a.m., LVN 2 stated he was unable to administer Magnesium Oxide to Resident 27 because the GT was clogged. LVN 2 stated he often has trouble dissolving Magnesium Oxide and confirmed it was not adequately dissolved prior to the attempted administration. During a concurrent interview and record review, on 11/17/2021 at 10:40 a.m., LVN 2 stated he did not remember if he checked for GT placement prior to medication administration via the GT. During an interview, on 11/17/2021 at 11:02 a.m., the DON stated Resident 27's medications did not appear adequately dissolved. During a concurrent interview and review of the facility's policy regarding GT medication administration, on 11/17/2021 at 1:05 p.m., the DON stated the policy indicated medications should be crushed finely prior to administration and medications should be documented after the medication pass is completed. During a concurrent interview and record review, on 11/19/2021 at 11:24 a.m., the DON stated the facility protocol was to check GT placement by auscultation (a method of listening with a stethoscope to the abdomen as air is injected into the GT) prior to medication administration. The DON stated Resident 27 returned from the hospital on [DATE] and the hospital discharge records indicated the GT could not be unclogged and was replaced. A review of the facility's policy titled, Administering Medications through an Enteral Tube, approved 02/0520/21, indicated the purpose of this procedure is to provide guidelines for the safe administration of medication through an enteral tube. Verify there is a physician's order for this procedure. Dilute medications. This procedure is contraindicated if the tube is obstructed or improperly positioned. Check tubing placement. Observe for a change in the external tube length. Observe for signs of respiratory distress. Auscultate the abdomen, but do not rely on this as the singular method to differentiate between respiratory, gastric, esophageal and bowel placement: 1. Attach 60 mL syringe, syringe containing approximately 10cc air., 2. Auscultate the abdomen (approximately 3 inches below the sternum) while injecting the air from the syringe into the tubing., 3. Listen for whooshing sound to check placement of the tube in the stomach; .If any of the above suggests improper tube positioning, do not administer feeding or medication Administer medications by gravity flow; a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion., b. Open the clamp and deliver medication slowly., c. Clamp tubing (or begin flush) before tubing drains completely. A review of the facility's policy titled Medications Administration - General Guidelines, approved 02/05/2021, indicated medications are administered and prescribed in accordance with good nursing principles and practices. If the resident is tube-fed, medications are crushed finely to prevent clogging the tube. The individual who administers the medication dose records the administration on the resident's MAR after the medication pass is completed. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. A review of the facility's policy titled, General Guidelines for Administering Medication Via Enteral Tube, approved 02/05/2021, indicated the facility assures the safe and effective administration of enteral formulas and medications via enteral tubes.

Based on observation, interview, and record review, the kitchen staff failed to ensure the proper storage, preparation, and distribution of food was in accordance with professional standards for food service safety for 40 of 44 residents by: 1. Failing to ensure three full cups in Refrigerator Two were labeled with the contents, date of preparation, and the best used by date (a date indicating the expiration). 2. Failing to ensure one large, opened box of juice was labeled with the date it was received and opened. These deficient practices had the potential to result in foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) of residents that may cause causing symptoms of nausea, vomiting, stomach cramps, and diarrhea. Findings: During an initial kitchen tour observation and interview on 10/16/2021 at 7:49 a.m. with the Dietary Manager (DM) the following occurred: a. On the middle shelf of Refrigerator Two, there were three unlabeled, full cups of white liquid. The DM stated the cups were full of milk and should have been labeled to indicate the contents, date of preparation, and best used by (a date indicating the expiration) date. b. On a middle shelf near the juice dispensing machine, there was one large box of orange juice without a label indicating the date it was opened and best used by. The DM assessed all sides of the box of juice and stated he could not find a label. The DM stated the box of juice should have been labeled with the date it was received, opened, and the best used by date. The DM stated these dates are important to follow for food safety. During an interview on 11/17/2021 at 01:05 p.m., the Director of Nursing (DON) stated all food should be labeled per facility policy. During a concurrent interview and review of the facility food storage policies and procedures on 11/17/2021 at 3:06 p.m., the DM stated the facility policy is to label the contents of all containers, the date the item was received at the facility, the date the item was opened, and the best used by date. During a review of the facility policy and procedures titled, Procedure for Refrigerated Storage, approved 2/5/2021, indicated, Food items should be arranged so that older items will be used first. Dating the packages or containers will facilitate this practice .Leftovers will be covered, labeled, and dated .Milk, cottage cheese, cream and soft cheese are to be used by the pull date on the carton .Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. During a review of the facility policy and procedures titled, Storage of Food and Supplies, approved 2/5/2021, indicated, Food and supplies will be stored properly and in a safe manner.Labels should be visible, and the arrangement should permit rotation of supplies so that oldest items will be used first. All food will be dated - month, day, year.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 27's admission Record indicated the resident was admitted on [DATE] and was re-admitted on [DATE] with diagnoses including surgical aftercare following surgery of the digestive system and gastrostomy (a surgery that places a gastric tube, GT or g-tube, through the abdomen wall into the stomach and is used for feeding and medication administration). A review of the physician Initial History and Physical (H&P) dated 6/5/2021, indicated Resident 27 had recently been admitted from the hospital for a GT placement for severe malnutrition (lack of proper nutrition). The H&P indicated the resident did not have the capacity to understand and make decisions. A review of Resident 27's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 7/10/2021, indicated Resident 27 rarely/never had the ability to make self understood and understand others. The MDS indicated Resident 27 was totally dependent on staff for bed mobility, dressing, eating, toilet use, and personal hygiene. A review of the Medication Administration Record (MAR, a legal record of the drugs administered to a resident) indicated Resident 27 received folic acid tablet daily, via the GT route of administration. During an observation on 11/17/2021 at 8:09 a.m., Licensed Vocational Nurse 2 (LVN 2) removed a folic acid bubble pack (a package that contains multiple sealed compartments with a medication) from Medication Cart 2. The bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) label indicated the route of administration for Resident 27 was by mouth. LVN 2 removed one tablet from the bubble pack, crushed the pill, and administered it via the GT. During a concurrent interview and review of Resident 27's physician orders on 11/17/2021 at10:40 a.m., LVN 2 stated the order indicated Folic acid tablet 1 milligram (mg - unit of measurement), give 1 tablet via g-tube one time a day for anemia (condition characterized by lowered ability of blood to carry oxygen), dated 8/6/2021. LVN 2 confirmed the medication label indicated the incorrect route of administration. During a concurrent observation and interview on 11/17/2021 at 11:02 a.m., the Director of Nursing (DON) stated eight tablets of folic acid had been administered from the bubble pack with the label indicating the wrong route of administration. The DON stated the charge nurse or medication nurse should have caught the label error when the medication was loaded in Medication Cart 2 or during administration when the label was compared with the MAR. The DON stated a Change in Directions sticker should have been placed on the label and the pharmacy notified. During a concurrent interview and review of the facility policy and procedures titled, Labeling of Medication Containers, on 11/1720/21 at 1:05 p.m., the DON stated the policy and procedures indicated medication labels should have the correct directions for use including the route of administration. A review of the facility policy and procedures titled, Labeling of Medication Containers, approved 2/5/2021, indicated, All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations .Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. Labels for each single unit dose package shall include all necessary information, such as; .directions for use.Only the dispensing pharmacy can label or alter the label on a medication container or package.The nursing staff must inform the pharmacy of any changes in physician orders for a medication. A review of the facility policy and procedures titled, Storage of Medications, approved 2/5/2021, indicated, Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. A review of the facility policy and procedures titled, Administering Medications through an Enteral Tube, approved 2/5/2021, indicated Check the label and confirm the medication name and dose with the MAR. c. A review of the admission Record indicated Resident 140 was admitted on [DATE] with diagnoses including fracture of left pubis (a break in the bone of the pelvis) and type 2 diabetes mellitus (a long-term disease that causes high blood sugar and can lead to heart, kidney, eyes, and nerve damage). A review of the physician Initial History and Physical (H&P) dated 11/05/2021 11/3/2021, indicated Resident 140 did not have capacity to understand and make decisions. A review of Resident 140's Minimum Data Set (MDS - standardized assessment and care screening tool) dated 7/1/2021, indicated Resident 140 had the ability to make self understood and understand others. The MDS indicated Resident 140 was totally dependent on staff for bed mobility, dressing, and toilet use. The MDS further indicated Resident 140 received daily insulin injections. A review of Resident 140's care plan titled, At risk for hypoglycemia and hyperglycemia, uncontrolled blood sugar, related to diabetes mellitus, initiated 11/5/2021, indicated the resident would have no signs and symptoms of hypoglycemia /hyperglycemia. The care plan further indicated to administer medication as ordered. A review of Resident 140's physician's order indicated an order for Lantus Solution (insulin glargine), inject 8 units (unit of measurement) subcutaneously (under the skin) one time a day for diabetes, start on 11/6/2021. During a concurrent observation, interview, and record review of Resident 140's Medication Administration Record (MAR, a legal record of the drugs administered to a resident) on 11/17/2021 at 12:41 p.m., Licensed Vocational Nurse 2 (LVN 2) removed the insulin glargine pen from Medication Cart 2 with a label that indicated insulin glargine, inject 4 units, subcutaneously, in the morning for diabetes. LVN 2 stated the MAR indicated to inject 8 units daily at 12 p.m. LVN 2 stated the label was incorrect and he would place a change in directions sticker and notify the pharmacy. LVN 2 stated the insulin pen was opened on 11/4/2021 and had been administered daily starting 11/6/2021 (while labeled with an error in the dosage and administration time). During an interview on 11/18/2021 at 10:46 a.m., the Director of Nursing (DON) stated the facility policy is the insulin glargine label should have been labeled with a change in directions sticker by the medication nurse when the MAR was compared with the medication label during medication passes. A review of the facility policy and procedures titled, Labeling of Medication Containers, approved 2/5/2021, indicated, All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations.Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy. Labels for each single unit dose package shall include all necessary information, such as; .directions for use.Only the dispensing pharmacy can label or alter the label on a medication container or package The nursing staff must inform the pharmacy of any changes in physician orders for a medication. A review of the facility policy and procedures titled, Storage of Medications, approved 02/05/2021, indicated, Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Based on observation, interview, and record review, the facility failed to storage and labeling of drugs and biologicals in accordance with accepted professional principles by: 1. Failing to ensure Resident 30's expired medication was removed from one of one medication storage room (Med Room) and discarded right away. This deficient practice increased the risk Resident 30 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications. 2. Failing to ensure Resident 23's tramadol bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) slot #24 with broken seal was in one of two medication carts (Med Cart 1) was discarded right away. This deficient practice increased the risk Resident 23 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications. 3. Failing to ensure the supplement folic acid (a vitamin that helps the body make healthy red blood cells) was labeled with the proper route of administration (the location at which a drug is administered) for Resident 27. This deficient practice had the potential to place the resident at risk for adverse effects of medication administered via the incorrect route such as choking. 4. Failing to ensure the medication insulin glargine (a medication that lowers the amount of blood sugar in the body) was labeled with the correct dose and time of administration for Resident 140. This deficient practice had the potential to place Resident 140 at risk of hypoglycemia (side effects of too low blood sugar) or hyperglycemia (side effects of too high blood sugar) including sweating, faintness, headache, trembling, difficulty awakening, weakness, nausea/vomiting, or rapid breathing. Findings: a. During a concurrent observation and interview in medication storage room (Med Room) on 11/16/2021 at 9:27 a.m., the Director of Staff Development (DSD) confirmed Resident 30's Forteo (used to treat osteoporosis [brittle bones] who are at high risk for bone fracture [break-in bone]) 20 microgram (mcg - unit of measurement) dose with expiration date of 10/2021. The DSD confirmed the medication was expired. During a concurrent interview and observation of Med Cart 1 on 11/16/2021 at 3:50 p.m., Licensed Vocational Nurse 1 (LVN 1) confirmed Resident 23's tramadol (a medication used to treat moderate to severe pain) #24 slot in the bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) was tampered with a broken seal. LVN 1 stated he will waste medication with the Director of Nursing (DON) because it was contaminated During an interview on 11/19/2021 at 2:28 p.m., the DON stated for expired medication, the licensed nurse had to immediately separate it to avoid giving the medication to the resident and to avoid having any reaction. The DON stated as soon as the licensed nurses identified the broken seal or the contaminated medication, it has to be accounted for to prevent diversion of medications. A review of the facility's policy and procedures titled Expired Medications, reviewed and approved on 02/05/2021, indicated that the nursing staff is responsible for checking medications for expiration dates and discard them appropriately. The facility shall not use discontinued, outdated, or deteriorated drugs. All such drugs shall be destroyed. A review of the facility's policy and procedures titled Controlled Substances, reviewed and approved on 02/05/2021, indicated when a dose of a controlled medication is either removed from the container for administration but refused by the resident, or contaminated, or the integrity is compromised, or not given for any reason, it is not placed back in the container. It must be witnessed and documented in the presence of two licensed nurses and attached to current container then documented on the accountability record in the line presenting that dose.