Based on observation, interview, and record review the facility failed to ensure respiratory care services were provided for oxygen administration for 1 of 3 Residents, Resident #5, reviewed for respiratory services. Findings include: Record review of Resident #5's clinical record documented the resident was admitted with diagnosis that included: anemia, atherosclerosis heart disease, pulmonary hypertension, and chronic obstructive pulmonary disease. Review of Resident #5's physician orders dated 3/3/2025 read, Oxygen at 4LPM [liters per minute] via NC [nasal cannula] every shift. Review of Resident #5's care plan dated 2/6/2025 read, Focus: The resident has oxygen therapy r/t [related to] COPD [chronic obstructive pulmonary disease]. Interventions/Tasks: Give medications as ordered by physician. During an observation on 3/3/2025 at 10:08 AM of Resident #5, the resident was sitting at bedside. Oxygen was being administered at 3 liters per minute via nasal cannula. (Photograph evidence obtained). During an interview on 3/3/2025 at 1:16 PM Resident #5 stated, I do not change the settings [oxygen]., Normally I am on 4 liters when I am up walking around and 3 liters when I'm resting. During an observation on 3/3/2025 at 1:16 PM with Staff A, Registered Nurse (RN) Resident #5 was observed sitting at bedside with oxygen administered at 3 liters per minute via nasal cannula. During an interview on 3/3/2025 at 1:16 PM Staff A, RN verified the physician orders were for oxygen to be administered at 4 liters per minute via nasal cannula. During an interview on 3/3/2025 at 1:30 PM the Director of Nursing (DON) stated, The physician orders have to be followed, and the rate should be 4 liters a minute. Review of the policy and procedure titled Oxygen Therapy dated 1/22/2025 read, Policy: III. A. 1. Specific delivery device, liter flow or concentration .Procedure: IV. A. Set up oxygen utilizing appropriate delivery device according to physician's order, or according to protocol.

Based on record review and interview, the facility failed to ensure a rationale was in the medical record for psychotropic PRN (pro re nata/as needed) medications being prescribed for greater than 14 days for 1 of 5 residents, Resident #84, reviewed for unnecessary medications. Findings include: Review of the pharmacist's consultation report, dated 2/17/2025, read [Resident #84's Name] has a PRN order for a sedative/hypnotic, without a stop date: Zolpidem 10mg [milligrams] q [every] HS [hour of sleep] PRN for insomnia. Recommendation: Please discontinue PRN Zolpidem, or a stop date that is less than 14 days from initiation. If the medication cannot be discontinued at this time, document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Review of Resident #84's physician's orders dated 2/17/25 read Zolpidem Tartrate Oral Tablet 10MG [milligrams] (Zolpidem Tartrate) *Controlled Drug* Give 1 tablet by mouth every 24 hours as needed for Difficulty Sleeping for 30 days. The physician's order did not contain documented rationale for prescribing the medication for more than 14 days. Review of a physician's visit encounter note, dated 2/17/2025, read Zolpidem Tartrate 10mg 1 tab [tablet] q24 [every 24] hours PRN x 30 days (end 3/19/25). During an interview on 3/4/2025 beginning at 12:04 PM, the Director of Nursing stated she was unable to answer whether or not the physician had documented in Resident #84's clinical record the rationale for prescribing hypnotic medication for more than 14 days. Review of the policy titled Drug Regimen Review, last reviewed 1/22/2025, read, I. PURPOSE: This department process explains how this facility follows State and Federal Regulations, by having the Consultant Pharmacist review each resident's clinical chart monthly. Apparent irregularities will be reported in writing to the Director of Nursing, Medical Director, Attending Physician, Provider and Administrator. The facility will review and follow through on the Consultant Pharmacist's recommendations to ensure all residents maintain the highest practicable level of functioning .D. Follow up on Consultant Pharmacist Recommendations: .b. Clinical justification will be documented in the chart if a recommendation is declined by the physician/provider.

Based on observation, interview, and record review, the facility failed to secure medications for 1 of 3 wings, the south. Findings included: During an observation on 3/3/2025 at 10:08 AM of Resident #5's room there was one bottle of Saline Nasal Mist and one bottle of normal saline eye solution on the bedside table unsecured. (Photograph evidence obtained). During an observation on 3/3/2025 at 12:18 PM of Resident #5's room there was one bottle of Saline Nasal Mist and one bottle of normal saline eye solution on the bedside table unsecured. During an interview on 3/3/2025 at 12:22 PM Resident #5 stated, My wife brought them to me and I use them as needed at least daily. During an interview on 3/3/2025 at 12:30 PM Staff A, Registered Nurse (RN) verified the Saline Nasal Mist and bottle of normal saline eye solution medications unsecured at Resident #5's bedside. Staff A, RN stated, Medication cannot be kept at the bedside, all medications have to be secured. During an interview on 3/3/2025 at 1:16 PM the Director of Nursing stated, Medications cannot be at the bedside unsecured. Review of the policy and procedure titled Medication Storage dated 1/22/2025 read, This department process explains how medications and biologicals are stored safely, securely, and properly . B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended to by persons with authorized access.

Based on record review and interview, the facility failed to ensure transmission-based precautions were implemented for 1 of 3 residents reviewed, Resident #5, to prevent the possible spread of infections and communicable diseases. Findings include: Review of Resident #5's progress note, dated 7/12/24 at 8:51 PM, revealed the resident was noted with congested cough. The progress note documented Resident #5's physician ordered COVID-19 PCR [polymerase chain reaction] test. Review of Resident #5's COVID-19 test result, received by the facility on 7/15/2024 at 2:20 PM, revealed the resident had been tested for COVID-19 on 7/13/2024 at 8:27 AM and had been positive for COVID-19 on 7/13/2024 at 10:08 AM. Review of Resident #5's physician orders revealed no order for transmission-based precautions on 7/12/2024 after the resident was symptomatic with congested cough. Review of Resident #5's physician orders revealed orders for Zinc Sulfate oral capsule 50 milligrams one capsule by mouth one time a day for COVID-19 prophylaxis for 10 days (start date 7/15/2024 at 2:24 PM); Zyrtec Allergy Tablet 10 milligrams 1 tablet by mouth one time a day for allergy (start date 7/15/2024 at 2:24 PM); and Vitamin C 500 milligrams by mouth one time a day for immune health (start date 7/15/2024 at 2:24 PM). Review of Resident #5's physician orders failed to reveal an order for transmission-based precautions on 7/15/2024 after the facility was notified that Resident #5 had tested positive for COVID-19. Review of Resident #5's physician order showed the resident was placed on transmission-based precautions on 7/16/2024 at 9:41 AM. During an interview on 8/20/2024 at 11:36 AM, the Director of Nursing stated that an agency nurse was working with Resident #5 when Resident #5 was noted with a congested cough. She stated Resident #5 should have been placed on transmission-based precautions when she became symptomatic. She confirmed Resident #5 had tested positive for COVID-19 on 7/13/2024, the facility had not received the positive test results until 7/15/2024 and the physician had not ordered Resident #5 to be placed on transmission-based precautions until 7/16/2024. She acknowledged the facility's infection prevention policy requires residents to be placed on transmission-based precaution if there is reasonable suspicion of an infectious disease. Review of the facility policy and procedure titled Isolation- Initiating Transmission-Based Precautions with the last review date of 3/13/2024, showed the policy read, Policy Statement: Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions . Policy Interpretation and Implementation: 1. If a resident is suspected of, or identified as, having a communicable infectious disease, the Nurse or Nursing Supervisor shall notify the Infection Preventionist (or (designee) and the resident's Attending Physician for appropriate Transmission-Based Precautions. 2. If the Attending Physician or his/her alternate fails to respond appropriately to notification of a suspected or confirmed communicable infectious disease, the staff will inform the Medical Director and Administrator. 3. In the event the Attending Physician fails to take appropriate action, the Infection Preventionist or Medical Director shall have the authority to implement appropriate Transmission-Based Precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice by not dating the oxygen tubing for 1 of 3 residents reviewed for oxygen administration, Resident #184 (photographic evidence obtained). Findings include: During an observation on 11/19/2023 at 10:50 AM, Resident #184 was sitting in her bedside chair with oxygen being administered at 2 liters per minute from the oxygen concentrator. There was no date labeled on the tubing. During an observation on 11/19/2023 at 1:18 PM, Resident #184 was sitting in her bedside chair with oxygen being administered at 2 liters per minute from the oxygen concentrator. There was no date labeled on the tubing. Review of Resident #184's admission record showed the resident was admitted to the facility on [DATE] with a diagnosis of, but not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation. Review for Resident #184's physician order dated 11/16/2023 reads, Change oxygen and or nebulizer tubing, every week every night shift every Sun [Sunday] for preventative. During an interview on 11/20/2023 at 11:15 AM, the Director of Nursing stated, When a patient enters the facility, a date should be placed on the oxygen tubing, and then changed every Sunday night. Review of the facility policy and procedure titled Oxygen Administration reads, Policy: The purpose of this procedure is to provide guidelines for safe oxygen administration. Reporting 2. Report other information in accordance with facility policy and professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the clinical records was accurate for 1 of 3 sampled residents, Resident #82. Findings include: Review of Resident #82's admission record showed the resident was most recently admitted to the facility on [DATE]. Review of Resident #82's progress note dated 11/18/2023 showed the progress note reads, 97 y/o [year old] female arrived on 9/18/2023 . During an interview on 11/20/2023 beginning at 11:49 AM, the Director of Nursing confirmed Resident #82 was admitted on [DATE]. She confirmed the progress note entry related to Resident #82's admission date was inaccurate. Review of Resident #82's wandering risk assessment dated [DATE] showed the assessment reads Medications 1. Taking antipsychotics. Review of Resident #82's current, discontinued and completed physician orders with the Director of Nursing did not show any documentation indicating Resident #82 was or had been prescribed with an antipsychotic medication. During an interview on 11/20/2023 beginning at 11:49 AM, the Director of Nursing confirmed Resident #82's wandering risk assessment documented Resident #82 was taking an antipsychotic medication. She confirmed Resident #82 was not or had not been prescribed with an antipsychotic medication and stated that Resident #82's wandering risk assessment was inaccurate.

**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 of practice for 2 of 6 residents, Residents #14 and #114, reviewed for unnecessary medications. Findings: Review of the medical record for Resident #14 documented the resident was admitted to the facility on [DATE] with the following diagnoses: spondylosis, history of falling, atherosclerotic heart disease of native coronary artery without angina pectoris (chest pain), chronic obstructive pulmonary disease, benign prostatic hyperplasia without lower urinary tract symptoms, type 2 diabetes mellitus without complications. Review of the medical record documented vital signs dated 4/21/2022 at 10:53 PM oxygen saturation of 94% on room air. Review of the nursing progress note dated 4/22/22 at 12:20 AM authored by the Director of Nursing (DON) reads: O2 [oxygen] at 2 liters applied secondary to patient requested CPAP [continuous positive airway pressure] to be turned off. Review of the medical record vital signs dated 4/22/2022 at 12:02 AM documented an oxygen saturation of 87% on room air. Review of the physician orders document no orders for oxygen administration. During an interview conducted on 6/15/2022 at 12:00 PM the DON stated, I was the nurse that worked the 11-7 shift the night that [Resident #14's name] refused to wear his CPAP and I started him on oxygen. I was not informed immediately that his oxygen saturation was low, and he was refusing his CPAP. I did administer the oxygen at two liters and attempted to get him to wear his oxygen and CPAP. There is no assessment of his lung sounds when I put him on the oxygen and his saturation dropped to 87%, there should have been. There are no other vital signs or oxygen saturation and there should have been. I should have called the doctor and gotten an order for the oxygen after I started it. We do need a doctor's order for oxygen, but we can start it if we feel we need to and call the doctor after that. I should have called the doctor. During an interview conducted on 06/16/22 at 3:38 PM Medical Doctor (MD) stated, I want to be notified if any patient has an oxygen saturation less than 90% so that I can determine if I need to add any further treatments. I would expect that the nurses would call with any other assessment such as lung sounds. I want to be notified immediately to determine the need to possibly return the patient to the hospital. Review of the policy and procedure titled Oxygen Administration approval date of 7/8/2021 reads, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order or facility protocol for oxygen administration. Assessment. Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs and symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes). 2. Signs and symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion). 4. Vital signs. 5. Lung sounds. 6. Arterial blood gas and oxygen saturation, if applicable. Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 6. All assessment data obtained before, during, and after the procedure. 2. Review of the medical record for Resident #114 documented the resident was admitted to the facility on [DATE] with the following diagnoses: aftercare following joint replacement, presence of artificial shoulder joint, essential (primary) hypertension, hyperlipidemia, heart failure, unspecified. Review of the physician orders dated 6/10/2022 reads, Lovenox Solution Prefilled syringe (Enoxaparin Sodium) inject 0.9 ml [milliliters]/hr [hour] subcutaneously two times a day for DVT [a blood clot]. Review of the physician order dated 6/10/2022 reads, Lovenox solution prefilled syringe 80 mg (milligrams)/0.8 ml [Enoxaparin Sodium] inject 0.8 ml subcutaneously two times a day for PE [pulmonary emboli] d/c [discontinue] once INR [international ratio] is therapeutic above 2.0. Review of the Medication Administration Record documented Lovenox was not administered on 6/10/2022 at 9:00 PM, 6/11/2022 at 9:00 AM and 6/11/2022 at 9:00 PM as prescribed by the physician. Review of the administration note dated 6/11/2022 at 8:24 AM authored by Staff A, Licensed Practical Nurse (LPN) reads, pending pharmacy delivery. Review of the administration note dated 6/11/2022 at 8:28 PM authored by Staff C, LPN reads awaiting delivery. During an interview conducted on 6/15/2022 at 1:50 PM Staff A, LPN stated, If there is an order for Lovenox and we are unable to administer it, we should call the doctor to see if they want any other orders. I did not call the doctor about the Lovenox and that I could not administer it. I should have called with the missed dose. During an interview conducted on 6/15/2022 at 4:10 PM Staff C, LPN stated, I was not able to administer Lovenox when the doctor ordered it. I should have notified him that it couldn't be given because we didn't have it. It is a routine practice to notify a doctor when we can't give a medication like a blood thinner. During an interview conducted on 6/16/2022 at 10:45 AM the Director of Nursing (DON) stated, I was not aware that the staff did not administer the Lovenox when it was ordered. We should have notified the doctor when they were not able to administer the Lovenox. During an interview conducted on 6/16/22 3:35 PM the Medical Doctor (MD) stated, When I am bridging anticoagulant therapy of coumadin with Lovenox it is because the INR is subtherapeutic and the patient has a need for the additional therapy and I absolutely want to be notified that they cannot get the additional coverage needed. Review of the Policy and procedure titled, Adverse Consequences and Medication Errors with an approval date of 7/5/2021 reads, Policy interpretation and Implementation 5. A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturers specifications, or accepted professional standards and principles of the professional(s) providing services. 6. Examples of medication errors include: a. Omission-a drug is ordered but not administered. B. Unauthorized drug-a drug is administered without a physician's order.

Based on interview and record review the facility failed to ensure a qualified director of food and nutritional services was provided for oversight of the daily operations of the facility dietary services. Findings: During an interview on 06/15/22 at 10:00 AM the Dietary Manager stated he is not certified or licensed as a Dietary Manager. During an interview on 06/15/22 at 10:00 AM the dietitian stated she works for the hospital and does not work at the facility full time as a dietitian; she stated she works part time. During an interview on 06/15/22 at 02:12 PM the Administrator stated that the Dietary Manager does not have his Certified Dietary Manager certification. He does not have an associate degree in food service management or hospitality. The dietitian works at the hospital full time and comes to the Skilled Nursing Unit part time. Review of the Dietary Manager's application documented a high school diploma; there was no associates degree contained in the file. Review of the Learner Records for [Dietary Manager's name] did not document training in Certified Dietary Manager certification courses. Review of the Completed Training for [Dietary Manager's name] did not document training in Certified Dietary Manager certificate courses.

Based on interview and record review the facility failed to have a designated Infection Preventionist who completed specialized training in infection prevention and control. Findings: During an interview conducted on 6/16/2022 at 11:30 AM the Director of Nursing stated, I am the designated infection control nurse I complete all the tracking and trending of infections throughout the facility. I have not taken any special course on infection control. I am not certified in Infection control, and I did not know that I needed anything special to be the infection control nurse. During a review of the education and training for the Director of Nursing there was no specialized certifications for infection control. During an interview conducted on 6/16/2022 at 12:00 PM the Facility Administrator stated, I should have known that she needed to have the Infection control training, she is new, and our previous Director of Nursing had the training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide respiratory care services in accordance with professional standards of practice for 4 of 7 residents, Residents #12, #68, #118, and #119, reviewed for oxygen administration and respiratory equipment. Findings: 1. During an observation on 6/14/2022 at 9:44 AM Resident #119 was observed sitting at the bedside with oxygen being administered at 2 liters per minute by nasal cannula. Review of the medical record for Resident #119 documented the resident was admitted to the facility on [DATE] with the following diagnoses: type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease, chronic kidney disease stage 4, hypertensive chronic kidney disease, hyperlipidemia (high cholesterol}, history of falling, fracture of third thoracic vertebra, pulmonary embolism (a blood clot) without acute cor pulmonale (a form of sudden right sided heart failure), traumatic subarachnoid hemorrhage (bleeding in the brain). Review of the physician's orders dated 6/3/2022 reads Oxygen at 3 L [liters] via NC [nasal cannula]. During an observation on 6/15/2022 at 8:32 AM Resident #119 was sitting in a wheelchair at the bedside with no oxygen being administered. During an observation on 6/15/2022 at 11:37 AM Resident #119 was observed sitting at the bedside in a wheelchair with no oxygen being administered. During an interview on 6/15/2022 at 11:37 AM Staff B, Registered Nurse (RN) verified Resident #119 was not being administered oxygen and the physician's order was for continuous oxygen administration. Staff B, RN stated, I thought that her order was PRN [as needed]. I should get an order to have the oxygen prn. It should be administered as a doctor ordered it to be administered or we should get the order changed. 2. On 6/14/2022 at 9:39 AM Resident #118 was observed with oxygen being administered at 4 liters per minute by nasal cannula. Review of the medical record for Resident #118 documented the resident was admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery (heart disease) without angina pectoris (chest pain), unspecified dementia without behavioral disturbances, hyperlipidemia, major depressive disorder, anxiety disorder, malignant neoplasm (cancer) of colon, encounter for surgical aftercare, and unspecified severe protein calorie malnutrition. Review of the physician's order dated 6/3/2022 reads Oxygen 2 L/M [liters per minute] via n/c [nasal cannula] every shift for shortness of breath. During an observation on 6/15/2022 at 9:09 AM Resident #118 was resting in bed, with no oxygen being administered and signs of mild shortness of breath; the Resident was unable to say more than two to three words before needing to take a breath. During an interview conducted on 6/15/2022 at 9:09 AM Resident #118 stated, I feel a little short of breath, but I'm always a little short of breath. During an observation on 6/15/2022 at 11:42 AM Resident #118 was observed sitting at the bedside in a wheelchair with no oxygen being administered. The Resident continued to say two to three words before needing a deep breath. On 6/15/2022 at 11:42 AM Staff B, Registered Nurse (RN) verified Resident #118 was not being administered oxygen and the physician order was for continuous oxygen administration. Staff B, RN stated, No oxygen was running per orders and there should be oxygen running if there is an order otherwise, they need a physician order for PRN oxygen use. Review of the policy and procedure titled, Oxygen Administration with an approval date of 07/07/21 reads, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order or facility protocol for oxygen administration. Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs and symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes). 2. Signs and symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion. 4. Vital signs. 5. Lung sounds. 6. Arterial blood gas and oxygen saturation, if applicable. Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 6. All assessment data obtained before, during, and after the procedure. 3. Review of the admission Record documented Resident #12 was admitted to the facility on [DATE] with diagnoses that included fracture of upper end of right humerus, atrial fibrillation, unsteadiness on feet, muscle weakness and history of falling. On 06/14/22 at 12:45 PM, Resident #12 was observed sitting at the bedside wearing a nasal cannula. The oxygen tubing was observed along the floor from the resident to the bathroom. The oxygen concentrator was located inside the bathroom door. The oxygen concentrator was off. During an interview on 06/14/22 at 12:45 PM, Resident #12 stated therapy was trying to wean her off oxygen, but she was usually on 1-2 liters. On 06/15/22 at 04:09 PM, Resident #12 was observed with oxygen being administered at 4 L (liters) via an oxygen concentrator. During an interview on 6/14/22 at 4:10 PM Staff A, Licensed Practical Nurse (LPN) confirmed the oxygen was being administered at 4 L and stated, She is not supposed to be on 4 liters, I think it's supposed to be at 2 liters. You know she is a retired nurse and I think she adjusts it herself. During an interview on 06/16/22 at 10:49 AM, Resident #12 when asked if she ever changes her oxygen for her own comfort she stated, There is no way I can do that. I can't bend over, plus just trying to get to it [the concentrator inside the bathroom]. Besides I want to get off oxygen. I was not on it prior to being here at the facility. Review of the physician orders dated 6/1/22 documented, Oxygen @ [at] 2 L [liters] via NC [nasal cannula] every shift. 4. Review of the admission Record documented Resident #68 was admitted to the facility on [DATE] with diagnoses that included obstructive sleep apnea, sepsis, and type 2 diabetes mellitus. On 6/15/22 at 12:05 PM Resident #68 was observed sitting at bedside in a chair eating lunch. On the resident's nightstand was a CPAP (continuous positive airway pressure) machine. During an interview on 6/15/22 at 12:05 PM Resident #68 stated that he uses the CPAP at night. Review of the physician orders for Resident #68 dated 06/08/22 read, Oxygen @ 2 L via nasal cannula at HS [hour of sleep] (CPAP machine not available) as needed for OSA [obstructive sleep apnea]. During an interview on 06/15/22 at 2:45 PM Staff B, RN stated that it was a standard of practice to obtain physician orders for CPAP therapy. She confirmed Resident #68 has a CPAP and there was no physician's order. During an interview on 06/15/22 at 2:52 PM the Direction of Nursing (DON) confirmed Resident #68 does not have an order for CPAP therapy. She confirmed that it was a standard of practice to obtain a physician's order for CPAP therapy. Review of the policy titled CPAP/BiPAP [bilevel positive airway pressure] Support revised October 2010, last reviewed on July 7, 2021, reads: Purpose. 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. Preparation. 3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP (Positive end-expiratory pressure) pressure (CPAP, IPAP [inspiration] and EPAP [expiration]) for the machines.

Based on observation, interview and record review the facility failed to label and store all medications available for use in accordance with professional standards in 2 out of 2 medications carts reviewed. Findings: During an observation conducted on 6/14/22 at 8:22 AM with Staff A, Licensed Practical Nurse (LPN) medication cart #1 contained one opened Aspart insulin pen with no date opened or expiration date, and two Aspart insulin pens unopened with a label from the pharmacy to refrigerate until opened. During an interview conducted on 6/14/2022 at 8:28 AM Staff A, LPN stated, I haven't gotten to check these yet and all insulin if it is on the cart should have the date opened on them or be kept in the refrigerator until they are opened During an observation conducted on 6/14/22 at 8:36 AM with Staff B, Registered Nurse (RN) medication cart #2 contained one opened Toujeo insulin pen with no date opened or expiration date, and two unopened Aspart insulin pens with a label from the pharmacy to refrigerate until opened During an interview conducted on 6/14/2022 at 8:40 AM Staff B, Registered Nurse stated, These should not be on the cart if they haven't been opened yet and once they are opened we need the dates on them. During an interview conducted on 6/15/22 at 2:34 PM, The Director of Nursing (DON) stated, All insulin should be labeled when they are taken from the refrigerator otherwise, they should stay in the refrigerator until we need them. Review of the policy and procedure titled, Storage and Expiration of Medications, Biologicals, syringes and needles with an approval date of 7/5/2021 reads, Procedure: 4. Facility should ensure that medications and biologicals: 4.1 Have an expiration date on the label. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility should record the date opened on the medication container when the medication has a shortened expiration date once opened. 11. Facility should ensure that all medications and biologicals for each resident are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges.