Based on interview and record review the facility failed to administered physician ordered medications in accordance with professional standards for 2 of 6 residents, Residents #10 and #18, reviewed for medication administration. Findings include: Review of Resident #10's Medication Administration Record (MAR) for November of 2024, the physician's order read, Insulin Glargine Subcutaneous Solution: 100 UNIT/ML (Insulin Glargine) Inject 12 unit subcutaneously at bedtime for diabetes mellites (DM). Start Date 09/19/2024 9:00 PM (2100). Review of Resident #10's physician orders did not provide parameters to hold the Glargine long-acting insulin. Review of the Resident #10's MAR for November 2024 documented the physician ordered Glargine Insulin was held on 11/15/2024 and 11/17/2024 and documented 4: Vitals outside of parameters for administration. Review of Resident #10's Care Plan documented Focus Area - [Resident #10's name] has a physician's order for insulin or hypoglycemic r/t [related to] DM. Goal - Resident will be free of adverse drug reactions from insulin administration through the next review date. Interventions - administer insulin as ordered. Monitor/document for side effects and effectiveness. Monitor and report blood glucose levels per physician's order. Date Initiated: 09/19/2024. Review of Resident #10's Progress Notes did not provide documentation on 11/15/2024 or 11/17/2024 of the blood sugar values at bedtime, notification to the physician when not administering the physician ordered Glargine long-acting insulin, and the reason for not administering the insulin. During an interview on 11/20/2024 at 2:15 PM, the Director of Nursing (DON) stated, For medications that do not have parameters, such as long-acting insulin, the expectation is that if they hold the medication, they notify the doctor. During an interview on 11/21/2024 at 8:40 AM, Physician A stated, I don't recall getting any calls about [Resident #10's name] or giving any orders to hold the long-acting insulin. Usually, we don't hold the long-acting insulin. It's the short-acting [insulin] that's usually the culprit [for dropping blood sugar levels]. If it was just a couple of days, there wouldn't be any significant harm. During an interview on 11/21/2024 at 8:50 AM, Physician B stated, I haven't gotten any calls about [Resident #10's name] insulin, and I did not give any orders to hold her long-acting insulin. If it was held a couple of times, it shouldn't have caused any harm. Review of Resident #18's Medication Administration Record (MAR) for October 2024 documented a physician order which read, Metoprolol Tartrate Tablet 25 MG [milligrams] - Give 1 tablet by mouth two times a day for HTN [hypertension] HOLD for SBP [systolic blood pressure] <110 [less than] OR HR [heart rate] <60 - Start Date 05/23/2020 1700 [5:00 PM]. Review of the documentation of the administration of the Metoprolol documented the medication was held, with a 4: vitals outside of parameters for administration, on 10/19/2024 at 9:00 AM, 10/23/2024 at 5:00 PM, and 10/26/2024 at 9:00 AM. On 10/26/2024 at 5:00 PM documented was 9. 9: Other/See progress notes. Review of Resident #18 vital signs when the medication was held documented on 10/19/2024 the B/P was 110/54; the HR/pulse was 73, dated 10/23/2024 at 4:10 PM B/P 110/50; HR/pulse 88, dated 10/26/2024 at 7:58 AM B/P 110/54; HR/pulse 73 and on 10/26/2024 at 3:33 PM B/P 119/69; HR 76. During an interview on 11/20/2024 at 1:15 PM, Staff C, RN stated, The aids do vital signs at the beginning of the shift. If the blood pressures are low, like with [Resident #18's name] they will let me know. If the reading is off, I will re-take it myself. The certified nursing assistants will tell me all of the vital signs. If [Resident #18's] blood pressure was 112/54 and her pulse rate was 64, I would hold her Metoprolol. I know her and know that she bottoms out. I would check her vital signs again. If it starts getting to be a routine, like three days in a row, I would go ahead and tell the doctor. During an interview on 11/20/2024 at 2:15 PM, the DON stated, The expectation for medications with parameters for metoprolol for example, that would have an order to hold for a [systolic] blood pressure of less than 110, if the blood pressure was below 110, they would hold the medication. If they are holding the medication [outside of the parameters] they will let the doctor know. During an interview on 11/21/2024 at 8:40 AM, Physician A stated, I don't recall getting any calls about [Resident #18's name]. I think we need to do some education with the nurses about Beta Blockers. For Beta Blockers we go with the heart rate, not the systolic blood pressure. We don't hold for B/P, it is the heart rate. If it was just a couple of days, there wouldn't be any significant harm. Review of the policy and procedure titled Medication Administration, last reviewed on 01/17/2024, read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . 8. Obtain and record vital signs, when applicable or per physician's orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters . 10. Ensure that the six rights of medication administration are followed: . c. Right dosage . f. Right documentation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure food was stored in a safe and sanitary manner in the main kitchen and in 2 of 2 nourishment rooms. Findings include: A tour of the main kitchen was conducted on 11/18/2024 beginning at 9:44 AM with the Certified Dietary Manager. There was a case of individual serving ice cream containers stored below meat products in the meat freezer. There was a plate of thawed nutritional drinks stored in the walk in refrigerator with no thawed on date inscribed on the individual supplement cartons. There was an undated bag of corn and an undated/unlabeled plastic bags of cookies stored in the walk in freezer. During an interview on 11/18/2024 beginning at 9:44 AM, the Certified Dietary Manager confirmed the individual serving ice cream containers should not be stored below meat products. She confirmed all food products should be dated and labeled. She acknowledged there was no thawed on date inscribed on the thawed nutritional supplements. A tour of Nourishment room [ROOM NUMBER] was completed on 11/18/2024 beginning at 9:59 AM with the Certified Dietary Manager. There were brown and black substances spattered on the interior upper surface of the microwave. There were brown and red substances pooled on the bottom of the refrigerator bins. During an interview on 11/18/2024 beginning at 9:59 AM, the Certified Dietary Manager stated the microwave oven and refrigerator bins needed cleaning. A tour of Nourishment room [ROOM NUMBER] was completed on 11/18/2024 beginning at 10:04 AM with the Certified Dietary Manager. There were brown and black substances spattered on the interior upper surface of the microwave. There was a yellow substance pooled on the bottom shelf of the refrigerator. During an interview on 11/18/2024 beginning at 10:04 AM, the Certified Dietary Manager stated the microwave oven and refrigerator needed cleaning. Review of the policy and procedure titled Food Receiving and Storage, last reviewed 1/17/2024, read 1. Food Services, or other designated staff, will maintain clean food storage areas at all times .8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .13. Uncooked and raw animal products and fish will be stored separately in drip proof containers and below fruits, vegetables and other ready to eat foods.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a safe, secure, and orderly manner for 1 of 6 residents reviewed for medication (Resident #98). Findings include: During an observation on 9/11/2023 at 10:15 AM, a medication cup with four white round pills was on the bedside table in Resident #98's room. During an interview on 9/11/2023 at 10:16 AM, Resident #98 stated, That's just Tylenol. During an observation on 9/12/2023 at 8:03 AM, two medication cups were observed on Resident #98's over bed table. One cup contained 9 white round pills and the second cup contained one round yellow scored pill and a round pink pill. During an interview on 9/12/2023 at 8:03 AM, Resident #98 stated, The pill lady brought those pills to me this morning so I can take them with my breakfast. Review of the clinical record for Resident #98 showed no medication self-administration assessment, no resident-centered care plan related to medication or self-administration of medications and no physician's order for self-administration of medications. During an interview on 9/13/2023 at 10:20 AM, Staff A, Licensed Practical Nurse (LPN), stated, She does not have an order to have medications at her bedside, and that medication shouldn't be there. During an interview on 9/13/2024 at 10:25 AM, the Director of Nursing stated, Residents should not have medication at their bedside. Review of the policy and procedure titled Storage of Medications, last reviewed on 1/17/23, read, Policy Statement. The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

2) During an observation of Resident #76 on 3/21/2022 at 9:45 AM the resident was resting in bed with oxygen being administered at 3.5 liters per minute via nasal cannula. During an observation of Resident #76 on 3/24/2022 at 10:00 AM, the resident was resting in bed with oxygen infusing at 3.5 liters per minute via nasal cannula. (Photographic evidence obtained) Review of the physician's order dated 11/02/2021 for Resident #76 read, Oxygen at 2 liters per minute via nasal cannula continuous every shift for shortness of breath. During an interview with Staff B, RN on 3/24/2022 at 10:10 AM she verified Resident #76 has a physician order for oxygen therapy to infuse at 2 liters per minute via nasal cannula. She stated, The oxygen concentrator should be set at 2 liters per minute and is currently running at 3.5 liters per minute. During an interview with Staff C, Licensed Practical Nurse (LPN) on 3/24/2022 at 10:15 AM she verified Resident #76's oxygen concentrator was set at 3.5 liters per minute. During an interview with the Director of Nursing (DON) on 3/24/2022 at 10:30 AM she stated it is her expectation that the nurses on the floor would follow the physicians' orders related to oxygen therapy. Review of the policy and procedure titled Administering Medications Last Reviewed: 03/10/2022 read: Facility standard of practice 4. Medications are administered in accordance with prescriber orders, including any required time frame. Based on observation, interview, and record review the facility failed to ensure respiratory services were provided in accordance with professional standards for 2 of 5 residents, Residents #89 and #76 reviewed for respiratory care in a total sample of 36 residents. Findings: 1) During an observation on 03/21/2022 at 10:17 AM, Resident #89 was observed in her room lying in bed. Oxygen was being administered to the resident at 2.5 liters via nasal cannula. Review of Resident #89's physician's order summary report, the active medication orders as of 03/23/2022, did not document a physician's order for oxygen. During an interview on 3/23/2022 at beginning 8:06 AM, Staff A, RN (Registered Nurse) stated she could not find a current physician's order for Resident #89 to be administered oxygen. Resident #89 had an order for oxygen a long time ago, that order had been discontinued.

Based on observation, interview, and record review the facility failed to ensure food was stored in a safe and sanitary manner in 1 of 2 nourishment rooms, Station 2. Findings: An observation of the Station 2 nourishment room was completed with the Certified Dietary Manager on 03/21/2022 at 9:30 AM. There were three individual containers of pudding stored in the refrigerator with expiration dates of 03/16/22. There was brown speckled debris covering the interior bottom of the refrigerator. During interview on 03/21/2022 at 9:30 AM, the Certified Dietary Manager confirmed the pudding in the three individual containers had expired on 03/16/2022. She confirmed that there was brown speckled debris covering the interior bottom of the refrigerator and that the refrigerator needed to be cleaned. Record review of the facility policy titled Food Safety for Your Loved One Last Reviewed: 03/10/2022 read: The facility standard of practice Foods or beverages that have past the manufacturer's expiration date should be thrown away. Record review of the facility policy titled Refrigerators and Freezers Last Reviewed: 03/10/2022 read: The facility standard of practice 8. Refrigerators and freezers will be kept clean, free of debris, and wiped with sanitizing solution on a scheduled basis and more often as necessary.