**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to complete the Discharge- Return Non-Anticipated Minimum Data Set (MDS) to Centers of Medicare and Medicaid (CMS) within 14 days for one (Resident # 103) out of one resident was discharged to the community who was investigated for Resident Assessment. This deficiency has the potential to affect 116 residents residing in the facility at the time of survey. The findings included: Record review of the clinical records for Resident #103 revealed the resident was admitted to the facility on [DATE] and was discharged home on [DATE]. Review of the Discharge-Return Non-Anticipated MDS assessment dated [DATE] was in progress. Section C and E-K were not completed. Interview with MDS Coordinator on 01/24/2024 at 12:17 PM. She stated that the assessment was not completed. She stated they did not realize the assessment was not completed until Tuesday January 23 when the system alerted them. She stated the assessment will be completed today. Further review after the above interview indicated the Discharge Non-Anticipated MDS dated [DATE] was completed on 01/24/2024. Review of policy and Procedures non dated for Minimum Data Set Completion and Submission Timeframes revealed Policy Statement: Our facility will conduct and submit resident assessment in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation: 1-The assessment coordinator or designee is responsible for ensuring that resident assessment is submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2-Timeframes for completion and submission of assessment are based on the current requirements published in Resident Assessment Instrument Manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to electronically transmit the Discharge- Return Non-Anticipated Minimum Data Set (MDS) to Centers of Medicare and Medicaid (CMS) within 14 days for one (Resident # 103) out of one resident whose Resident Assessments was investigated that was discharged to the community. There were 116 residents residing in the facility at the time of the survey. The findings included: Record review of the clinical records for Resident #103 revealed the resident was admitted to the facility on [DATE] and was discharged home on [DATE]. Review of the Discharge-Return Non-Anticipated MDS assessment dated [DATE] was completed and transmitted on 01/24/2024. Interview with MDS Coordinator on 01/24/2024 at 12:17 PM. She stated that the assessment was not completed in a timely manner. She stated they did not realize the assessment was not completed until Tuesday January 23 when the system alerted them. She stated the assessment will be completed and transmitted today. Follow up review after the above interview of Discharge Non-Anticipated MDS dated [DATE] was transmitted on 01/24/2024. Review of policy and Procedures non dated for Minimum Data Set Completion and Submission Timeframes revealed Policy Statement: Our facility will conduct and submit resident assessment in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation: 1-The assessment coordinator or designee is responsible for ensuring that resident assessment is submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2-Timeframes for completion and submission of assessment are based on the current requirements published in Resident Assessment Instrument Manual

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the provision of a safe environment related to safety floor mats to prevent accidents in the event of a fall for one Resident (#83) out of 27 sampled residents. There were 116 residents residing at the facility at the time of the survey. The findings included: On 01/22/24 at 09:31 AM, during the initial observation Resident # 83 was in bed asleep, no distress noted, one fall mat was observed on the left side of bed and one safety floor mat was against the wall behind the head of the bed, (Photographic evidence available). On 01/23/24 at 09:15 AM Resident observed in bed awake watching television, call light on bed, one floor mat on left side of the bed on the floor, right side floor mat against the wall, behind the head of the bed, (Photographic evidence available). On 01/24/24 at 10:17 AM Resident #83 was observed seated in a wheelchair in the therapy room with therapist, no distress noted. During observation on 1/24/23 at 09:00 AM Resident #83 was not in bed, the bilateral safety floor mats were beside bed. On 01/25/24 at 08:24 AM Resident # 83 was observed in bed eating breakfast, the bilateral safety floor mats were beside the bed. Review of the medical records for Resident #83 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] and 12/29/23. Clinical diagnoses included but not limited to: History of falling, Unspecified intracapsular fracture of left femur, subsequent encounter for closed fracture with routine healing, Unspecified fracture of right acetabulum, subsequent encounter for fracture with routine healing, and Fracture of superior rim of right pubis, subsequent encounter for fracture with routine healing. Review of the Physician's Orders Sheet for January 2024 revealed Resident #83 had orders that included but not limited to: Tramadol HCL oral tablet 50 milligram (mg)-give 50 mg by mouth every 8 hours as needed for mild to severe pain level 4-10. Record review of Resident #83 's Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive patterns documented Brief Interview for Mental Status Score 4, on a 0-15 scale indicating the resident is cognitively impaired. Section E for behavior documented Physical behavioral symptoms directed towards others occurred 1-3 days. Section GG for Functional Abilities documented resident requires partial/moderate assistance for Activities of daily living. Section H for Bowel and Bladder documented Resident is always incontinent of bowel and bladder. Section J for Health Conditions documented resident had a fall with major injury since admission, received scheduled pain medications in the last five days, and experienced no shortness of breath. Section N for Medications documented resident is taking antidepressants and opioids and Section O for Special Treatments and Procedures documented no special treatments received. Review of Resident #83's Care Plans Reference Date 01/02/24 revealed: Resident is at risk for falls and/or fall related injury related to: impaired balance, cognitive deficits, requires staff assist with transfers, is non ambulatory, is impulsive; attempts transfer self independently, uses wheelchair as primary mode of locomotion, has a history of falls, has poor safety awareness, receives psychotropic medications, use of anticoagulants. Resident will minimize the risk of falls with staff intervention through the next review date. Target Date: 04/01/2024. Interventions included- Floor mats to both sides of the bed when in bed, Quarter side-rails up in bed as an enabler, assist to wheel to destinations, Low bed, keep call light within reach, Report falls to physician and responsible party as needed, invite to activities of interest and escort to activity as needed. Review of the physical medicine and rehabilitation follow up note dated 1/12/2024, timestamped 15:32 stated: On 11/6/23 patient had fall and was sent to Emergency Department for further evaluation. Suffered laceration to the right forehead. On 12/26/23 patient was sent to Emergency Department due to fall on 12/23/23 and x-ray confirmed left femur fracture. The patient underwent surgical intervention of left hip arthroplasty. Patient was medically stabilized but not strong enough to return home. Patient admitted to the facility on [DATE] for skilled nursing and rehab. Patient asked to be seen by primary team to optimize therapy, pain control and discharge planning. Patient's plan and progress was discussed with nursing staff and therapy. Interview on 01/24/24 at 08:40 AM, the Director of Nursing (DON) stated: the resident was admitted on 10/2 23, he has had 2 falls in the facility on 11/06/23 and 12/23/23. On 11/06/23 the resident bumped his head and had to get stiches on his forehead, he was in the day room on the subacute side, the resident was in wheelchair watching television, the resident was observed 5 minutes prior by staff, two nurses that were counting their medication cart observed the resident on the floor, he had fallen forward, we placed an order through Therapy for wheelchair adequacy and positioning, completed labs on the resident. The resident was sent out to the hospital for stitches to the right forehead and came back later that night on the same day with four staples to his right forehead. On 12/23/23 the resident was sitting in the common room watching television, the Certified Nursing Assistant (CNAs) and the nurse witnessed the resident getting up out of the chair suddenly, took two steps and fell on his left side, the staff was unable to get to the resident on time to prevent the fall. A complete assessment was done, resident denied pain and was able to move all extremities. On 12/26/23 the resident was in therapy and was grimacing holding his left side, we did an in-house x-ray of the resident's left hip, results showed a hairline fracture of the femur on the left side, the resident was sent to the emergency room for evaluation and was admitted for surgical repair to the left hip. The resident was re-admitted on [DATE], we completed pertinent labs on the resident, kept resident in common areas when out of bed, and completed follow up x-rays. The was shown the photos taken by the surveyor; after seeing photos of multiple days observations of the resident's right floor mat against the wall at the head of the bed while the resident was in bed sleeping. The DON stated that she will get the matter corrected as soon as possible and get training and education started immediately with the nursing staff. Interview on 01/24/24 at 10:45 AM Certified Nursing Assistant (CNA) (Staff B) stated: I have been working here since August 2023, I became a CNA in July 2023, I am fairly new to this profession, I do my rounds several times during my shifts checking on each of my residents, I am usually assigned about 10 residents, this week I am assigned on the unit this resident is on. If the resident has any special equipment that needs to be placed in a certain way the DON would let us know about the care, regarding the resident's floor mats I have been educated today by the DON that when the resident is in bed, both resident's floor mats must be placed on the sides of the bed for safety. ` Interview on 01/24/24 at 11:07 AM Licensed Practical Nurse (LPN), (Staff C) stated: I do my rounds several times during my shifts, we placed the floor mats behind the bed at breakfast time so we can get the overbed table close to the resident for him to eat his breakfast, we all should be following up to make sure the floor mats get replaced beside the bed after the resident is done eating. The DON did a teachable moment with me about making sure the mats are in place when the resident is in bed. Moving forward, when I do my rounds if the resident is in bed, I will make sure that the floor mats are in place beside the bed. Review of the facility's policy titled Safety and Supervision of Residents revision date March 2023 states: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Individualized, Resident- Centered Approach to Safety 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff. b. Assigning responsibility for carrying out interventions. c. Ensuring that interventions are implemented; and d. Documenting interventions

Based on observations, interviews, and record review the facility failed to ensure pharmaceutical procedures were followed during medication administration. As evidenced by during medication administration the Registered Nurse signed off on Resident #2's medication as given before administering the medications for one out of four residents observed, and left the medication cart unlocked in the hallway during medication administration in Resident #2's room. There were 116 residents residing in the facility at the time of the survey. The findings included: On 1/23/24 at 9:35AM, during medication administration observation Registered Nurse (Staff A), prepared all the medications for administration to Resident #2, signed off all the medications as given on the Electronic Medication Administration Record, locked the computer and entered the room to give Resident # 2 the medications. Staff A entered the room, gave Resident #2 the medications and exited the room. On 1/23/24 at 9:43AM, the Surveyor apprised Registered Nurse, Staff A that she was observed signing off on Resident's #2's medications as given before she went into the room to administer the medications. Staff A stated she did check off and saved the medications as given to the resident on the system before she administered the medications to the resident. Staff A further stated that she does the check off based on how she knows the residents, the resident usually does not refuse the medications, that is why she checked off the medications before administering. The surveyor showed the Staff A a picture of her cart with the bingo cards (medication packets) turned face-side down on top of the medication cart and the cart unlocked. The picture was taken when the nurse was in the room administering medications to Resident # 2. Staff A stated: I was supposed to lock my cart when I went to give the resident the medications, and the bingo cards that were on top of the medication cart turned face-side down were empty. The surveyor checked the bingo cards that were face-side down on the top of the cart and confirmed they were empty. Review of the facility's policy titled Administering Medications revision date April 2019 states: Medications are administered in a safe and timely manner, as prescribed. Policy Interpretation and Implementation 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on the top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones

Based on observation, interview and record review, the facility failed to store food under sanitary condition by not ensuring the walk-in refrigerator and the milk box cooler contained thermometers on the inside. This has the potential to affect 108 out of 116 residents who eat orally residing in the facility at the time of the survey. The findings included: Observation of the initial kitchen tour on 1/22/24 at 8:42 AM with the Certified Dietary Manager Dietitian (CDM) revealed the following: 1) Walk-in refrigerator temperature outside was 40 degrees F and for the inside temperature, there was no thermometer noted. The walk-in refrigerator contained dairy products, cheese, pasteurized eggs in the shell, liquid pasteurized eggs, milk, vegetables, fruits, and preparation lunch items and 2) Milk Box temperature inside, there was no thermometer noted. The milk box contained milk cartons. Record review of the facility's Food Storage Policy indicated: Cold Policy and Procedure (revision date October 2019); Policy Statement-It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the [ ] federal organization Food Code; Action Steps: 2) The Dining Services Director/Cook ensures that all perishable foods will be maintained at temperature of 41 degrees Fahrenheit (F) or below and 4) The Dining Services Director/Cook insures that an accurate thermometer will be kept in each refrigerator and freezer. Interview with the CDM on 1/22/24 at 8:43 AM. She acknowledged that the thermometers were missing in the walk-in refrigerator and the milk box. She stated: There should be a thermometer in here.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of the admission Record for Resident #43 revealed that the resident was admitted into the facility on [DATE] with diagnoses that included renal dialysis and end stage renal disease. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #43 had a Brief Interview for Mental Status (BIMS) score of 99 indicating that the resident was unable to complete the interview. A review of the Order Summary Report revealed the following active active physician orders as of 10/13/21: Dialysis Monday, Wednesday, and Friday at 5:00 a.m. Nepro 1 can- one time a day for nutritional support Prostat Sugar Free- one time a day for nutritional support 30 ml Aspirin Tablet 325 MG- Give 1 tablet by mouth (po) one time a day for generalized pain Atorvastatin Calcium Tablet 80 MG- Give 1 tablet po at bedtime for hyperlipidemia Calcium Carbonate Tablet- Give 750 mg po three times a day for gastroesophageal reflux disease (GERD) Carvedilol Tablet 6.25 MG- Give 1 tablet po two times a day for hypertension Cholecalciferol Tablet 5000 unit- Give 1 tablet po one time a day for supplement FerrouSul Tablet- Give 325 mg po two times a day for anemia Hydralazine HCL Tablet 50 MG- Give 1 tablet po three times a day for hypertension Losartan Potassium Tablet 50 MG- Give 1 tablet po two times a day for hypertension Pantoprazole Sodium Tablet Delayed Release 40 MG- Give 1 tablet po one time a day for GERD Sevelamer Carbonate Packet 0.8 GM- Give 2 packets po with meals for hypocalcemia mix with 8oz thickened fluid of choice There was no order related to holding the medications or giving the medications at an alternative time on scheduled dialysis days. Review of the Medication Administration Record (MAR) for August, September, and October 2021 reflected the following physician ordered medications and supplements were not administered on scheduled dialysis days: Aspirin Adult Tablet (0900) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. Atorvastatin Calcium Tablet (0900) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, and 10/11. Pantoprazole Sodium Tablet Delayed Release (0900) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. Carvedilol Tablet (0900 and 1700) - 08/20, 08/25, 08/27, and 08/30, 09/01, 09/03, 09/06, 09/08, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. Ferrous Sulfate Tablet (0900 and 1700) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. Losartan Potassium Tablet (0900 and 1700) - 08/20, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/08, 10/11, and 10/13. Calcium Carbonate Tablet (0900, 1400, 2100) - 08/20, 08/23, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/24, 09/27, 10/08, 10/11, and 10/13. Hydralazine HCL Tablet (0900, 1400, and 2100) - 08/18, 08/20, 08/23, 08/25, 08/27, 08/30, 09/01, 09/03, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/24, 09/27, 10/08, 10/11, and 10/13. Renvela Packet (Sevelamer Carbonate) (0800, 1200, and 1700) - 08/30, 09/01, 09/06, 09/08, 09/10, 09/13, 09/15, 09/17, 09/20, 09/22, 09/27, 10/06, 10/08, 10/11, and 10/13. Sevelamer HCL Tablet for phosphate control 800 MG - (0800, 1200, and 1700) - 08/18, 08/20, 08/25, and 08/27. Trazodone HCL Tablet 50 MG for depression (2100) - 09/08, 09/10, 09/13, 09/15, 09/24, and 09/27. Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG related to vascular dementia with behavioral disturbances - 09/17, 09/20, 09/22, 09/24, and 09/27. Cholecalciferol Tablet 5000 unit for supplement (0900) - 10/08, 10/11, and 10/13. Nepro 1 can was not administered on 10/11 and 10/13. The boxes for each medication was blank, had an X, the number three, the number five, the number nine, or the number ten. Per the Chart Codes, there was no code for X, the number three indicated away from facility without meds, the number five indicated to hold/see nurse notes, the number nine indicated other, and the number ten indicated out for dialysis. A review of the nurses' notes indicated the notes only indicated that the resident was out for dialysis. A review of the care plan for dialysis included the following intervention: adjust medication schedule as required to accommodate for dialysis treatments. On 10/14/21 at 8:40 a.m., Staff A/Licensed Practical Nurse (LPN) stated she had suggested to management that the medications be given on the night shift. She stated that she believed that the dialysis center was able to give blood pressure medications. Staff A stated that when Resident #43 goes out for dialysis, they must make a note for the medication that she was in dialysis. By the time she comes in for her shift, Resident #43 was already gone to dialysis because she leaves at 5:00 a.m. Staff A stated that she can't hold the medicine until she comes back. On 10/14/21 at 9:00 a.m., Staff B/LPN Unit Manager stated that to her knowledge, the dialysis center does not give medications. She stated that the medication should be given prior to her leaving or the nurses should ask if the medications can be given later. Staff B confirmed that there was no order from the doctor to hold medications. On 10/14/21 at 1:08 p.m., the Director of Nursing (DON) stated the nurses should be communicating with the dialysis center if the physician did not give orders to hold medications. She stated a lot of times the doctor would say confer with the dialysis center. The DON confirmed that there was no documentation related to holding or rescheduling of the medications. Based on observation, interview, and record review the facility failed to provide care and treatment in accordance with professional standards of practice, the plan of care, and physician orders for four (#91,#28, #79, #43) of 41 sampled residents related to removal of surgical staples as ordered for Resident #91, weekly weights as ordered for Resident #28, administration of ordered medication for a non-pressure related skin condition for Resident #79, and lack of modification to the medication schedule to accommodate for scheduled dialysis for Resident #43. Findings included: 1. Review of the admission Record for Resident #91 revealed an initial admission date in 2016, a most recent hospital stay of 9/28/21 to 10/5/21, a most recent re-admission date of 10/5/21, and a diagnosis to include unspecified fracture of Left femur and subsequent encounter for closed fracture with routine healing dated 9/23/21. A review of a physician progress note, dated 10/6/21 at 1:00 p.m., identified that Resident #91 was readmitted for continuation of care following a Left hip fracture that required surgical repair on 9/19/21 and staples in place. Further review of the resident's record indicated that the Primary Care Physician had written an order on 10/8/21 at 10:13 a.m., that instructed staff to discontinue left hip staples every day shift for 1 day. The October 2021 Treatment Administration Record (TAR) indicated that Resident #91's left hip staples were discontinued on Sunday, 10/10/21 during the day shift. A review of progress notes written by nurses identified the following: - 10/9/21 at 9:13 p.m., .Skin is warm/dry. No surgical wound noted. No open wounds noted . - 10/10/21 at 9:13 p.m., .Skin is warm/dry. No surgical wound noted. No open wounds noted . - 10/11/21 at 9:13 p.m., .Skin is warm/dry. No surgical wound noted. No open wounds noted . Review of Resident #91's care plan identified that on 10/11/21 a focus was initiated indicating that the resident was noted to have skin impairment as follows: surgical wound: left hip. The interventions related to this focus included, perform wound treatments as ordered. The October TAR identified that nursing staff had applied Eucerin cream topically to Resident #91's body twice daily for dry skin as scheduled at 9:00 a.m. on 10/7 - 10/13/21 and at 9:00 p.m. on 10/6 - 10/13/21 and had Monitor 4 staples to the left hip for signs of infection/redness every shift beginning on the evening shift of 10/6 and continued three times daily through the day shift on 10/14/21. During an interview with Resident #91 on 10/14/21 at 11:15 a.m., the resident identified that he had injured himself back in September when he tried to transfer himself from the bed and fell. The resident stated, I knew I had done something to my hip. The resident stated he currently had four surgical staples that the staff assessed. On 10/14/21 at 11:17 a.m., Staff Member H, Licensed Practical Nurse (LPN), was asked about Resident #91's surgical staples. Staff H stated, staples, let me check. She reviewed the physician orders and stated she did not have anything. An observation was conducted with Staff H of Resident #91's left hip. The observation identified four intact surgical staples to the resident's left hip. The staff member confirmed the presence of 4 surgical staples to the resident's left hip. On 10/14/21 at 11:32 a.m., Staff H stated that she spoke with the Director of Nursing (DON) and that the scheduler was trying to schedule Resident #91 to return to the orthopedist (Ortho) but had been notified that the resident did not have to go back to their office, and the facility could remove the staples. The staff member reported that the DON was going to schedule Resident #91's staple removal for Sunday (10/17/21). On 10/14/21 at 12:53 p.m., the DON reported that Resident #91 had two (2) falls related to transferring independently and had to have a left hip replacement. She stated the facility did not have any order to remove the staples and that the facility concierge had informed her yesterday that she had attempted to get an appointment with the Ortho and that the staples could come out on Sunday. She stated she would expect staff to monitor the incision site, document the status of the staples, and describe how the wound looked. She reviewed the October TAR indicating staples had been discontinued. The DON stated she wanted to check to see if the resident's stapled were still in. At 1:05 p.m. on 10/14/21 the DON observed and confirmed that the resident did have 4 surgical staples in the left hip. She stated her expectation was if the staples had been documented as removed that they would have been removed. Continued review of Resident #91's October TAR identified that the facility had received a physician order at 3:04 p.m. on 10/14/21, OK to remove left hip staples, STAT. 2. A review of the admission Record revealed Resident #28 was admitted on [DATE] and had diagnoses to include acute on chronic diastolic (congestive) heart failure and unspecified chronic obstructive pulmonary disease. A review of Resident #28's active physician orders revealed an order to obtain Weekly Weights in the morning for Congestive Heart Failure (CHF) monitoring. This order was obtained on 6/29/21 and did not have an end date. The review of the order details indicated that the order type was Standard Other. A review of Resident #28's care plan, initiated on 9/25/19 indicated that the resident had the potential for complications related to an alteration in cardiac function due to diagnoses of hypertension (HTN), congestive heart failure (CHF), Atrial Fibrillation, Coronary Artery Disease (CAD), and hyperlipidemia, also has diagnosis of medical non-compliance with a history of polysubstance abuse. The interventions related to this issue included .Provide diet as ordered. Observed for compliance with diet. Weights as scheduled Vital signs as ordered and as needed . Continued review of the care plan identified that the resident required a therapeutic diet due to CHF, Diabetes Mellitus, and HTN diagnoses and that the resident refuses monthly weights. The interventions instructed staff to obtain weights as ordered and as needed and to notify the physician of significant weight changes if noted. Review of the electronic Weight Summary, reviewed on 10/12/21 at 2:36 p.m., indicated that the following weights were obtained: - 4/9/21: 281.0 pounds (lbs) - 6/7/21: 278.5 lbs. - 8/9/21: 286.0 lbs. - 8/11/21: 286.0 lbs. - 9/6/21: 283.0 lbs. - 10/6/21: 284.0 lbs. The review of the weights that were obtained for Resident #28 did not indicate any weights were obtained from 6/29 (the day the order was written) until 8/9/21, five weeks after the order was written. The review identified that weekly weights had not been obtained per the Primary Care Physicians' order. A review of the October Treatment Administration Record (TAR), printed on 10/14/21 at 3:52 p.m., indicated the following: - weekly weight one time only for CHF for 1 day, order date 10/14/21. Documentation indicated that a weight was obtained on 10/14 at 10:29 a.m. - Weekly weights every day shift every Thursday (Thu) for CHF monitoring, order date 10/14/21 at 10:11 a.m. The TAR indicated that staff were to obtain a weekly weight on 10/21 and 10/28/21. - Weekly weights every day shift for CHF monitoring, order date 10/13/21 at 6:20 p.m. and discontinued on 10/14/21 at 10:11 a.m. The October 2021 Medication Administration Record (MAR) identified that Resident #28 received the diuretic medications Furosemide 40 milligrams twice daily and Spironolactone 25 milligrams twice daily for CHF. The review of the October 2021 MAR and TAR did not include the order, dated 6/29/21, for the resident's Weekly weights. The [NAME] for the resident's care did not include the order for weekly weights. A progress note, dated 6/26/21, indicated that the Advanced Registered Nurse Practitioner (ARNP) was notified of edema in legs. The note identified that the resident refused to elevate legs. Resident #28 was observed and interviewed, on 10/11/21 at 12:22 p.m., while he was sitting in a wheelchair in his room. Multiple observations from 10/11 to 10/14/21 identified that the resident was observed sitting in the wheelchair. During an interview with the Director of Nursing, on 10/13/21 at 3:45 p.m., she stated that a lot of residents had triggered for weight loss. The DON reported that she and the Dietary Manager were reviewing the monthly weights, and she was also reviewing the weekly weights. She reviewed Resident #28's order for weekly weights and did not know if the resident was on the weekly weight list. The facility policy, Charting and Documentation, revised July 2017, identified that All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy indicated that Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. and that Documentation of procedures and treatments will include care-specific details, including: Whether the resident refused the procedure/treatment. 3. Review of the admission Record revealed Resident#79 was admitted to the facility on [DATE] with diagnoses to include cellulitis of right and left lower limbs and Extended Spectrum Beta Lactamase (ESBL) Resistance. Observations of Resident #79 on 10/11/21 at 1:59 P.M. revealed numerous crustaceous lesions on his arms and forehead along with what appeared to be dried blood on his bed sheets and underneath his fingernail bed. On 10/12/21 at 10:44 A.M., Resident #79 was observed in bed. His arms and face appeared to have a rash along with crustaceous lesions. Resident #79 reported that he has been scratching due to itching of his bilateral arms and face. The resident reported that facility staff should be aware because his physician ordered an ointment for itching, and they have not applied it on his arms or face. Resident #79 reported that he was admitted to the facility with the itching and rash. The resident was observed picking at his scabs and had blood on his right arm during the interview. A review of the Medication Administration Record (MAR) from the date of admission 9/14/2021 through the current date of 10/12/2021 revealed a physician's order for Hydrocortisone cream 1% for itching with an effective date of 9/14/2021. The order read: Hydrocortisone cream 1% every 24 hours as needed for itching. Review of the MAR/TAR (Treatment Administration Record) revealed no indications that Resident #79 had received his physician ordered treatment. A review of the resident's [NAME] indicated that the Certified Nursing Assistants were to notify the nurse of any noted skin issues. Review of the medical record for any skin issues on his bilateral arms and face revealed no documentation. Only one weekly skin assessment was present in the resident's medical record. The assessment was dated 9/15/2021 and indicated no issues with his skin. There was no other information present related to skin assessments. A review of weekly skin notes revealed that on 10/10/21, 10/2/21, and 9/25/21 Resident #79 had no new skin impairments. An additional observation and interview was conducted on 10/13/21 at 11:44 AM in which Resident #79 stated that his arms have been itching and no cream has been put on his arms. On 10/13/21 at 1:16 P.M., an interview was conducted with the DON regarding Resident #79's itching and the medication ordered (Hydrocortisone cream 1% every 24 hours as need for itching). The DON checked the treatment cart and was able to confirm that the medication was not present for the resident. The DON was asked to observe the residents' arms and face which was noted with scabs and a rash throughout his bilateral arms and face. The DON stated that she had not made this observation before. The DON stated that nursing was responsible for following through on physicians' orders and should have applied the medication on the resident for itching.

Based on observation, interview, and record review, the facility failed to ensure physician orders were received for monitoring and care of an intravenous (IV) site for one (#54) of one resident sampled for intravenous (IV) care out of two facility residents receiving IV therapy. Findings included: Review of Resident #54's admission Record revealed an admission date of 9/3/21 and admitting diagnoses to include multiple pressure ulcers and two pressure induced deep tissue damaged areas. Review of wound culture 1 dated 9/26/21 and reported on 9/30/21 revealed gram positive cocci, staphylococcus aureus (isolate1) penicillin resistant staphylococcus aureus (MRSA) isolated, moderate growth, gram negative rods, Proteus mirabilis, providencia stuartii. Review of physician orders revealed the following orders dated 9/30/21: Ok to insert midline for IV antibiotic therapy x 10 days may use lidocaine 1% for insertion and Ceftriaxone sodium solution 1 gram Intravenous every 24 hours for 10 days for multiorganism wound infection. No additional orders were present related to the IV. On 10/12/21 at 4:00 p.m., Resident #54 was observed with an IV on the left upper arm dated 10/12/21. On 10/13/21 at 11:00 am., Resident #54 was observed with an IV to the left upper arm intact. On 10/13/21 at 3:24 p.m., Resident #54's wound care for pressure areas was observed with Staff B, Unit Manager and the Assistant Director of Nursing (ADON). After completion of the wound care on 10/13/21 at 4:24 p.m., Staff B confirmed the resident had a wound infection, finished antibiotics recently, and had orders for his IV in the left upper arm. On 10/13/21 at 4:26 p.m., the ADON checked Resident #54's orders and confirmed the resident did not have orders associated with the care and monitoring of the IV. The ADON stated that these orders should have been put in when the physician originally ordered the IV for the wound infection. Following the interview with the ADON, the following orders were added for Resident #54 on 10/13/21: Change midline IV dressing 24 hours post insertion, then weekly and as needed every 24 hours as needed for IV site care. Use securement device with each dressing change. Flush IV port with 10 ml normal saline (NS) one time a day every 7 days for IV maintenance. Number of lumens: single Observe site for signs and symptoms of infiltration, infection and extravasation every shift and as needed. Review of facility policy for administration set/tubing changes, Revised April 2016 revealed: The purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV equipment. Assessment: inspect intravenous catheter for any signs/symptoms of IV related complications at scheduled intervals. Documentation: 6. The condition of the IV site.

Based on observation, interview and record review, the facility failed to provide wound care in accordance with professional standards for two (#54, #21) of three residents sampled for pressure ulcers out of 11 total residents with pressure ulcers related to failure to change Resident #54's dressings daily as ordered for two of four days, failure to provide positioning and offloading for wound healing for Resident #54, and failure to ensure weekly wound measurements were taken for Resident's #54, and #21. Findings Included: 1. Review of Resident #54's admission Record revealed an admission date of 9/3/21 and admitting diagnoses to include type 2 diabetes mellitus, paraplegia, pressure ulcer left hip unstageable, pressure ulcer of right buttock stage 4, pressure ulcer of right heel unstageable, pressure induced deep tissue damage of right heel, pressure ulcer of left heel, unstageable, pressure induced deep tissue damage of left heel, and pressure ulcer of other site stage 4. Review of the physician progress note dated 9/16/21 at 9:24 p.m. detailed the chief complaint as comprehensive skin and wound assessment for new admission to the facility for multiple wounds: right heel, right lateral foot, right medial malleolus (cluster), left heel, left foot sole, left medial foot, right great toe, right buttock and left trochanter. Unstageable wounds included: right heel, right lateral foot, left sole and left trochanter. Deep tissue injuries included left heel and right treat toe. Stage 3 wounds included right medial malleolus. Stage 4 wounds included: left medial foot, right buttock. Plan of care: pressure reduction and turning precautions, including heel protection and pressure reduction to bony prominences. Staff educated on all aspects of care. Factors affecting healing: frequent incontinence which can decrease wound healing. Recommend providing incontinence care as needed, increased moisture at wound site can promote poor prognosis of wound healing. Please keep wound site covered and avoid contamination with feces at all times. Review of physician orders for Resident #54 revealed: Wound care consult dated 9/3/21 Cleanse left medial foot with normal saline, pat dry, and apply Santyl, calcium alginate and foam every day shift for wound care, dated 10/6/21. Cleanse left medial foot with normal saline, pat dry, and apply Santyl, calcium alginate and foam as needed for wound care dated 10/6/21. Left sole of foot: apply betadine and leave open to air every shift for wound care dated 9/22/21. Left heel: apply betadine and leave open to air every shift dated 9/22/21. Right great toe: apply betadine and leave open to air every shift for wound care dated 9/22/21. Right heel: Apply betadine and leave open to air every shift for wound care dated 9/22/21. Right lateral foot: Apply betadine and leave open to air every shift for wound care dated 9/22/21. Right medial malleolus Cleanse with normal saline, pat dry, Santyl, and foam dressing every day shift for wound care, dated 10/6/21. Apply house barrier cream to buttocks, peri area for protection dated 9/3/21. Cleanse left trochanter with normal saline, pat dry, apply Santyl and cover with foam dressing as needed for wound care dated 10/6/21. Cleanse Right buttock with normal saline, pat dry, apply Santyl, calcium alginate and cover with foam dressing every day shift for wound care dated 10/6/21. Cephalexin tablet 500 mg one time a day every 12 hours for infection dated 9/24/21, ended 10/1/21. Sulfamethoxazole-trimethoprim 800-160 mg one tab every 12 hours for 10 days for wound infection started on 9/30/21. Ceftriaxone sodium solution 1 gram Intravenous every 24 hours for 10 days for multiorganism wound infection dated 9/30/21. On 10/13/21 at 11:00 a.m., Resident #54 stated he had not had his brief changed since around 6 a.m. that morning and he had not had wound care for his feet completed in at least two days. During the interview, a pungent odor was noticed. The resident was lying on his left side. Additional observations of Resident #54 on 10/12/21 at 11:08 a.m., 10/12/21 at 4:00 p.m., 10/13/21 at 11:00 a.m., and 10/14/21 at 3:24 p.m. revealed the resident was lying on his left side. The resident confirmed on 10/14/21 at 3:24 p.m. that he stays primarily on the left side, and no one turns him every 2 hours or offers to turn him. The resident confirmed his feet were always touching and no one had offered to place anything between his feet, so they did not touch; however, they did place a pillow between his knees. An interview and observation of Resident #54's dressings with Staff B, Unit Manager, on 10/13/21 at 11:15 a.m., confirmed the resident was lying on his left side on an air mattress with his legs contracted. The visible wound dressings were not dated. The dressing on the left foot was observed with copious amounts of thick brown drainage, saturated through to the sheet folded beneath the resident's feet. The right medial side of the foot was without a dressing and observed resting on top of the left medial side of the foot placing pressure on the left foot. Resident #54 said, in the presence of Staff B, the dressings were not changed for at least 2 days. Staff B confirmed the pillow was only separating his knees. Staff B confirmed the wound care nurse practitioner was due to come in on this day but did not. On 10/13/21 at 3:24 p.m., wound care observation was conducted with Staff B and the Assistant Director of Nursing (ADON). They gathered supplies and placed disposable trays on a cleaned bedside table. The ADON held the right leg up to allow Staff B to remove the dressing on the left foot. Staff B completed the dressing removal for the left foot. The sole and lateral side of the left foot were observed with red granulation tissue, heavy drainage, and heavy slough with a strong odor. An unknown aide came in to assist Staff B and the ADON. Staff B cleansed the left foot using normal saline soaked gauze by tapping the wound and drying in the same fashion while the aide held the right foot. The aide let the right foot down which touched the area of the left foot that was cleaned. Staff B cleaned the left foot by tapping one time again and drying in the same fashion while the aide held the right foot up. Staff B applied Santyl in a thin layer to most of the wound and calcium alginate sheets, that were observed to not cover the wound completely, and then wrapped the left foot with one roll of gauze, leaving the heel and toe exposed to air. The aide lowered the right leg down on the left foot. Staff B measured the left sole wound as 8 cm x 5 cm, left medial foot wound as 8 cm x 4.5 cm. No dressing was observed on the right foot except one small white square on the top of the right foot. Staff B stated she was unsure why this white square was there since the right foot did not get a dressing. Staff B did not clean, assess, or apply a dressing to the medial malleolus of the right foot. The aide then prepared the resident for the coccyx dressing and left trochanter by removing the stool and urine saturated brief. The coccyx and left trochanter were observed uncovered without dressings. Staff B, set up for the dressing change of the coccyx and left trochanter and hand sanitized prior to donning gloves. Staff B soaked gauze and tapped the center of the coccyx wound that was observed with tunneling around 12 o'clock. Staff B measured the wound as 5 cm x 5 cm. Staff B removed gloves, hand sanitized and donned new gloves. Staff B confirmed the Coccyx wound had tunneling and stated, I should measure that. The ADON advised on how to measure the tunneling. Staff B, measured a wound depth of 4.5 cm, tunneling 3.5 cm at 12 o'clock. Staff B applied Santyl to the center of the wound only. Applied calcium alginate at the point of tunneling and the center of the wound then covered the area with a dated foam dressing. The resident was turned toward his right side complaining of pain and tenderness on his left trochanter. Staff B confirmed the coccyx and left trochanter did not have dressings present at the start of the wound care and should always have dressings on. Staff B, donned gloves and cleaned the left trochanter with saline soaked gauze by tapping the center of the wound one time. Staff B dried the wound by tapping after changing gloves. Measurements of the left trochanter were taken, Santyl was applied to the center of the wound, and a large piece of calcium alginate was laid over the left trochanter wound and covered with a dated dressing. A new brief was secured in place. The resident was turned back to the left side on the left trochanter and his legs were separated at the knees, but the feet remained touching. Staff B confirmed the resident needed a pillow between his feet for offloading and removed the pillow at his knees and placed it between his feet. A blanket was then used between his knees. The resident's bilateral heels, right great toe, and right lateral foot had betadine applied and were left open to air. During an interview with Staff B and the ADON, on 10/13/21 at 4:24 p.m. Staff B confirmed she normally just dabs the wound and does not clean from the inside to the outside. Staff B confirmed she did the best she could cleaning the left foot after the right one touched it multiple times. She confirmed the right medial foot wound was unchanged and she had not applied a dressing as ordered. Staff B confirmed the resident should be offloading his feet and turning every few hours. Staff B stated she would check to see why the resident was always on his left side when he needs staff to turn him. Review of the treatment administration record (TAR) for October 2021 revealed the dressings changes were signed by Staff F, Licensed Practical Nurse (LPN) as completed for the last 2 days (10/11 and 10/12). During an interview on 10/14/21 at 1:26 p.m. with Staff F, LPN she confirmed she did not change the dressings on 10/11/21 or 10/12/21. Staff F confirmed she checked the wound care as being completed and stated she usually checked them off as done since she does the dressings last and will let the oncoming nurse know that she did not finish. Staff F, LPN then said she forgot to change the dressings as the resident required several people for the dressing change and she was busy. Review of wound culture 1 dated 9/26/21 and reported on 9/30/21 resulted in gram positive cocci, staphylococcus aureus (isolate1) penicillin resistant staphylococcus aureus (MRSA) isolated, moderate growth, gram negative rods, Proteus mirabilis, providencia stuartii. Review of progress notes dated 10/13/21 at 4:56 p.m. revealed: wound care performed on resident, cleaned and dressed as ordered. Resident pre-medicated prior to procedures. Resident calm and cooperative during care, verbalized comfort levels throughout procedure. Resident complaint of pain and tender to touch on left trochanter, redness, serosanguineous drainage, Doctor notified. Wound care areas include heavy slough, drainage of left foot and sacrum. Previous dressings saturated. Measurements of wounds as follows: Left middle foot (sole) 8 cm x 5 cm. Left lateral foot (medial) 8 cm x 4.5 cm, left heel 1 cm x 1 cm dry, necrotic tissue, Sacrum 5 cm x 5 cm, depth 4.5 cm, tunneling 3.5 cm @ 12 o'clock, right heel 2.3 cm x 2 cm dry, necrotic tissue, right great toe 2 cm x 2.5 cm. On 10/13/21 at 4:37 p.m., a phone interview with the wound care nurse revealed the nurse practitioner assesses the resident's wounds and this should be completed as ordered by the physician. Typically, the order says what to clean the wound with and the expectation would be to clean it from the inside to the outside, throwing the gauze away with each rotation. Review of the physician progress notes dated 9/29/21 at 7:01 p.m. revealed the plan of care as heel protectors or floating heels. Plan of care: turning precautions, heel protection, incontinence care as needed. Increased moisture at wound site can promote poor prognosis of wound healing. Keep wound site covered and avoid contamination with feces at all times. Review of wound evaluation documentation revealed the following for the Medial Left Foot: 10/6/21 stage IV, measurements: Area - 9.8 cm2 (centimeters squared), Length - 3.9 cm (centimeters), Width - 3.4 cm, depth 0.2 cm. No odor. Progress documented as improving. 9/29/21 stage IV, no wound measurements. Continuous pain. Pain management provided prior to wound care. Moderate odor. Wound improving. 9/15/21 stage IV, measurements: Area - 12.8 cm2, Length - 4.5 cm, Width - 4.2 cm. Moderate pain. No odor. Mattress with pump. Wound stable. Review of wound evaluation documentation revealed the following for the sole to the left foot: 10/6/21 unstageable, measurements: Area - 11.66 cm2, Length - 6.61 cm, Width - 2.29 cm, Depth 0.1 cm. 9/29/21 unstageable, measurements: Area - 12.6 cm2, Length - 6.3 cm, Width - 2.9 cm. Pain at site. Patient received pain management prior to wound care. Healing stalled. 9/23/21 unstageable, measurements: 2.5 cm x 7 cm x 0.3 cm. The wound was debrided by the Certified Registered Nurse Practitioner (CRNP) for wound care post measurements. 9/15/21 unstageable, measurements: Area - 9.4 cm2, Length - 5.0 cm, Width - 2.7 cm. Applying betadine only. Review of wound evaluation documentation revealed the following for the left heel: 10/6/21 DTI, measurements: Area - 0.66 cm2, Length - 1.09 cm, Width - 0.8 cm. 9/29/21 DTI, no measurements documented. Resident continues to be in pain. Pain management provided prior to wound care. 9/15/21 DTI, measurements: Area - 0.6 cm2, Length - 1.1 cm, Width - 0.7 cm. Resident refuses pain management, betadine to left heel. Review of wound evaluation documentation revealed the following for the Right Medial Malleolus: 10/6/21 cluster stage 3, improving. No wound measurements were recorded. 9/29/21 stage 3, measurements: 2.2 cm x 2.1 cm x 1.3 cm x 0.2 cm in depth. 9/23/21 stage 3, measurements: 4 cm x 3.2 cm x 0.2 cm. 9/15/21 stage 3, no wound measurements recorded. Review of wound evaluation documentation revealed the following for the right heel: 10/6/21 unstageable, measurements: Area - 2.69 cm2, Length - 2.37 cm, width - 1.51 cm. 9/29/21 unstageable, measurements: 3.5 cm x 2.7 cm x 1.7 cm. 9/23/21 unstageable, measurements: 3 cm x 2 cm x 0. 9/15/21 unstageable, measurements: 6.6 cm x 3.3 cm x 2.8 cm. Review of wound evaluation documentation revealed the following for the lateral right foot: 10/6/21 unstageable, measurements: Area - 2.78 cm2, Length - 2.11 cm, width - 1.94 cm. 9/29/21 unstageable, measurements: 3.2 cm x 2.2 cm x 2. 0 cm. 9/23/21 unstageable, measurements: 3.5 cm x 2.5 cm x 0. 9/15/21 unstageable, measurements: 4.3 x 3.0 x 2.0 cm. Review of wound evaluation documentation revealed the following for the right buttock: 10/6/21 stage 4, no wound measurements recorded, and moderate drainage. 9/29/21 stage 4, measurements: Area - 7.5 cm2, Length - 4.9 cm, Width - 2.9 cm, Depth 1.2 cm, undermining- 3.0 cm. Moderate odor. Wound infection noted - currently on IV antibiotics. 9/23/21 stage 4, measurements: 5.5 cm x 4.5 cm x 4 cm, 6 to 3 o'clock. 9/15/21 stage 4, measurements: Area- 3.6 cm2, length- 2.8 cm, width- 2.1 cm. Review of wound evaluation documentation revealed the following for the left trochanter: 10/6/21 unstageable, no measurements documented. 9/29/21 unstageable, measurements: Area - 3.7 cm2, length- 2.6 cm, width- 1.9 cm. 9/23/21 unstageable, measurements: 2 cm x 2 cm x 0. 9/15/21 unstageable, measurements: Area - 2.6 cm2, Length- 2.2 cm, Width- 1.6 cm. During an interview with the Director of Nursing (DON) on 10/14/21 at 12:32 p.m. she confirmed the resident should have seen a physician related to wounds after admission and the wounds should be measured weekly. The DON confirmed the nurses document after the treatment is completed and should make sure that their documentation is accurate. The DON confirmed Staff F, did not change the dressings on 10/12/21 and only asked about 10/12/21. Review of the treatment administration record (TAR) for 10/11/21 and 10/12/21 showed the treatments were documented as completed by Staff F for wounds on Left medial foot, left trochanter, right buttock, right medial alveolus, betadine to left heel, betadine to left sole of foot, betadine to right great toe, betadine to right heel, betadine to right lateral foot. During an interview with Staff B on 10/14/21 at 12:55 p.m. she confirmed Resident #54 did not see a wound care physician or nurse practitioner from 9/3/21 to 9/15/21 and the wounds were not measured until the wound care nurse practitioner came in to see him. Staff B confirmed the aides should be offloading the resident and turning the resident every 2 hours and did not realize they placed the resident back on his left side where he was positioned prior to wound care. Staff B confirmed the resident was on an air mattress but was not sure who sets them up or what the correct setting should be. During a phone interview on 10/14/21 at 9:44 a.m. with the wound care Nurse Practitioner she stated she completes wound rounds weekly on Wednesday around 7:30 a.m. and Mondays were typically the days she sees new patients. She stated she conducts rounds with Staff B and the DON, completes the wound measurements with Staff B, gives verbal recommendations, and verifies later the orders were correct from the physician. The Nurse Practitioner stated she was a consultant and makes recommendations. The Nurse Practitioner stated she will make referrals to infectious disease and dermatology. She stated the wound measurements were captured with the camera which does not keep the picture but measures the wound. She confirmed the staff complete the dressing changes and should complete them as ordered. The Nurse Practitioner confirmed that staff should not be seeing thick brown odorous dressings on Resident #54 and if they did, she should be contacted and had not been as of this time. She stated she would expect the staff to call her. The Nurse Practitioner confirmed the resident's feet should be offloaded and not touching together. She confirmed the resident should be moved every couple hours to assist with healing and offloading of the left trochanter and should not be left on the side of the wound. They should be offloading every day. The Nurse Practitioner stated she would expect the nurse to clean the wound using a little pressure to get it clean and would expect it to be cleaned from the inside out in a clockwise motion, not tapped or dabbed. The Nurse Practitioner confirmed the wounds should be covered at all times as ordered. 2) During an interview with Resident #21 on 10/11/21 at 11:44 a.m. the resident stated he had no issues with his wound care. Review of Resident #21's skin and wound evaluation dated 10/6/21 revealed the stage 4 coccyx wound measured 2.0 cm x 2.9 cm x 0.5 cm. with moderate drainage and no odor. Wound improving. Review of Resident #21's skin and wound evaluation dated 9/29/21 revealed no measurements were taken for the stage 4 coccyx wound with moderate drainage and faint odor. Wound improving. Review of Resident #21's skin and wound evaluation dated 9/22/21 revealed the stage 4 coccyx wound measured 2.5 cm x 2.0 cm x 2.0 cm, moderate drainage. Wound stable. Review of physician orders revealed a 9/22/21 order to cleanse coccyx with normal saline, pat dry, apply collagen to wound base, calcium alginate with silver and foam dressing. During an interview with the Nurse Practitioner on 10/14/21 at 9:58 a.m. she stated she debrided the wound last week due to increased slough in the wound. Review of facility policy wound care, revised October 2010, 2 pages revealed: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Review of facility policy charting and documentation, revised July 2017, revealed: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. 2. c. treatments or services performed.

Based on observation and interview, it was determined that the facility did not ensure that one (#22) of fifty two residents reviewed was provided the right to make choices regarding her dining experience. Findings include: On 1/28/20 between 12:23 p.m. and 12:27 p.m., Resident #22 was observed to be seated at a table with another resident across from her. A placemat, silverware and napkin were observed on the table in front of her. An unknown dietary staff person was observed to approach Resident #22, pick up her placemat, silverware and napkin, and, in a loud voice heard by the surveyor across the room, stated to Resident #22, you don't eat here, your tray is in your room. She left Resident #22 seated at the table with no place setting. Resident #22 propelled herself up to another table which had a place setting. A lunch meal was eventually provided to Resident #22. Resident #22 was observed to independently eat her lunch meal. An interview was conducted with Resident #22 at 12:39 p.m. She stated she wants to eat in the dining room. On 1/30/20, at 11:47 a.m., Resident #22 was observed in her wheelchair seated at a table with a place setting in front to her. A dietary aide and a CNA where heard saying that she is second seating and another aide wheeled her away from the table and took her out of the dining room. On 1/30/20 at 12:25 p.m. Resident #22 was located in her room in her wheelchair, with her lunch tray on the overbed table in front of her. She was observed to be eating her lunch meal independently. She stated, I eat where I want to. An interview with the Administrator and the DON was conducted on 1/31/20 at approximately 4:30 p.m. The Administrator and DON stated that Resident #22 should be able to eat in the dining room if she wants to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff interview, it was determined that the facility did not ensure that the plan of care was followed related to Diabetes Mellitus, Type II, for one of five residents reviewed for unnecessary medications (#5). Findings Include: Review of the admission Record for Resident # 5 revealed that he was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus without Complications. Review of Physician orders on the Order Summary Report revealed an order, dated 12/17/19, for Humulin R U-500 Kwik-Pen Solution Pen-Injector 500 Unit/ML: Inject 90 unit subcutaneously with meals related to Type II Diabetes Mellitus without complications . Resident # 5 also had a physician's order, dated 11/13/19 for Novolog Solution 100 Unit/ML ( Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200. Review of a care plan with a focus of Is at risk for complication related to diagnosis of Diabetes Mellitus Type II (initiated 7/26/2017) revealed: Goal : Will remain free of s/sx (signs and symptoms) of hypo or hyperglycemic episode thru the next review date. Interventions: Administer oral medications and/or insulin per physician orders. Obtain blood sugar levels/ lab as ordered; report results to physician as needed. Review of Resident # 5's Medication Administration Record ( MAR) for December 2019 revealed the Novolog Solution 100 Unit/ML (Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200 was documented as administered when blood sugars (BS) were documented as under 200 on 20 of 93 occasions: 0630 am 12/1 BS 168, 12/2 BS 166, 12/6 BS 165, 12/11 BS 191, 12/12 BS 110, 12/13 BS 162, 12/14 BS 150, 12/16 BS 197, 12/18 BS 165, 12/22 BS 194, 12/25 BS 170, 12/28 BS 176, 12/30 BS 90, 12/31 BS 180 11:30 am 12/15 BS 132, 12/22 BS 107, 12/28 BS 135 16:30 pm (4:30 pm) 12/7 BS 108, 12/22 BS 124, 12/28 BS 158 Review of Resident # 5's MAR for January 2020 revealed the Novolog Solution 100 Unit/ML (Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200 was documented as administered when blood sugars were documents as under 200 on 8 of 91 occasions: 06:30 a.m. 1/1 BS 109, 1/5 BS 165, 1/6 BS 152, 1/11 BS 81, 1/12/ BS 188, 1/15 BS 110, 1/16 BS 171, 1/21 BS 134. An interview was conducted with the Director of Nursing, on 1/31/2020 at 11: 20 a.m. He reviewed the Medication Administration Records and confirmed that the Novolog insulin was being administered when it was supposed to be held for blood sugars under 200. He stated it looked like the nurses were not paying attention and clicking along too fast. A phone interview was conducted with the Consultant Pharmacist, on 1/31/20 at 4:15 p.m. He stated he does look at the blood sugars and insulin when he does his reviews. He stated he did not like this type of order as it put more stuff on for the nurses to do. He stated it is definitely an issue. He was unable at the time of the phone interview to access his records to see if he had previously identified this issue for Resident # 5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and policy review the facility failed to provide care and treatment in accordance with professional standards of practice for two(#34, #108) of 53 residents reviewed in regards to 1) not ensuring physician's orders were obtained for care and services for a urinary catheter, a nephrostomy tube, and a midline IV(intravenous) line and 2) failing to identify and obtain orders to treat a skin tear. Findings included: Resident #34 was readmitted to the facility on [DATE] with a diagnosis of neuromuscular dysfunction of the bladder and sepsis, according to the face sheet in the admission record. A review of the MDS (Minimum Data Set) assessment dated [DATE], Section H, bladder and bowel, indicated Resident #34 had an indwelling catheter. Upon review of the current physician's orders in the electronic medical record, no orders were found for catheter care. Review of the treatment administration record (TAR) for the month of January showed catheter care orders were not obtained. On 1/29/20 at 9:53 a.m.an observation and interview were conducted with Resident #34. Resident #34 said she has a UTI (urinary tract infection) that started in December. She also said she is getting IV antibiotics for the UTI. The surveyor observed that Resident #34 had a left upper arm midline IV line, and a leg bag of which the contents were unable to be observed. A review of nurse's notes in the medical record revealed that upon admission on [DATE], a urostomy and Foley catheter were noted. The nurse's note dated 1/27/20 reflected a new order to initiate contact isolation, insert midline, start Amakacin 10mg/kg daily x 7 days, pharmacy to dose, ID (Infectious Disease Physician) to consult and CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) on 1/30/20. IV team called for midline insertion. Further review of the nurse's notes showed a note entered on 1/29/20, which indicated Foley in place draining clear, amber urine, Precautions continue. IV site is CDI (clean, dry, intact) and flushes well. The 1/30/20 nurse's note showed Resident continues on IV antibiotic for ESBL ( extended spectrum beta-lactamase) in urine. Foley is in place and patent. Contact precautions continue. IV site is clean and dry. Flushes without difficulty. No other notes discuss catheter care, nephrostomy tube, or midline care. On 1/31/20 at 12:05 p.m. an observation was conducted with Staff L, CNA (Certified Nurses Assistant) during catheter care. Staff L, CNA entered Resident #34's room after knocking. Staff L, CNA explained the procedure to Resident #34. Staff L, CNA put on PPE (personal protective equipment) to include a gown and gloves. Staff L, CNA prepared a wash basin with water, which Staff L, CNA placed on the bedside table where there was a towel with supplies. Staff L, CNA used a soapy wash cloth to clean from the catheter insertion site downward. Staff L, CNA changed washcloths after each downward motion, wiping the catheter tubing from top to bottom. Staff L, CNA dried the areas with a dry wash cloth. The surveyor asked if she could look at the nephrostomy tube site. Resident #34 said it was okay. Staff L, CNA turned Resident #34 to her right side. The nephrostomy tube site was free from signs or symptoms of infection; no inflammation, redness, or drainage was observed. However, the dressing was wrapped around the tube beneath the site. There was also no odor present. Further review of physician's orders revealed there was also not an order for the midline IV site care and maintenance, or nephrostomy tube care. An interview was conducted with Staff K, LPN on 1/30/20 at 6:03 p.m. Staff K, LPN (Licensed Practical Nurse) confirmed Resident #34 had a midline in her left arm. Staff K, LPN also confirmed Resident #34 does have a catheter. The surveyor asked who provided care to the catheters and midline. Staff K, LPN said IV care would be herself. Staff K, LPN said it's documented on the resident's MAR (Medication Administration Record), and she documents it on the skilled notes. She said both herself and the CNAs document catheter care. It's documented on the TAR and ADL (Activity of Daily Living) sheets. Normally I assist her at night when we turn and reposition her. We do the Foley care. Staff K, LPN said there should be orders for the midline and catheters. Staff K, LPN reviewed the orders in the electronic record and confirmed there weren't any orders for the catheters or midline. Staff K, LPN also said they're not on the TAR either. Staff K, LPN said the midline gets flushes, and it requires dressing changes once a week. 2.On 01/28/20 at 10:01 a.m. Resident #108 was lying in bed and smiled with verbal stimuli. Her right hand was on top of the blanket that presented with a hematoma (localized bleeding outside of blood vessels, due to either disease or trauma including injury). Just lateral to the hematoma a crescent shape skin tear was noted with dried blood residual. The resident was asked if she knew what happened to the hand. She was unable to verbalize what had occurred. On 1/29/2020 at 11:10 a.m. Resident #108 was sitting in her wheelchair as a staff member was transporting her in the hallway. Resident #108 right hand was resting on her lap as it appeared the same as it had the day prior. On 01/29/2019 at 5:54 p.m. Resident #108 resident was observed in her bedroom with Certified Nursing Assistant N (CNAN) who was sitting next to her. Resident #108 was turned to her right in her wheelchair as the CNA was sitting to her right. CNAN at that time picked up the spoon off the plate that contained food. As the CNA attempted to assist the resident, the resident raised her left hand and swung her hand out blocking the spoon from going to her mouth. CNA N was asked if she knew what had happened to the resident's right hand. The CNA looked at the resident hand and said it looks like a skin tear. She said I don't care for Resident #108 that often indicating it had been a while and she didn't know what had happened. Medical record review was conducted for Resident #108 that revealed on the admission Record information form that she was in her early nineties and been residing at the facility for over a year. The diagnosis stated facial weakness following unspecified cerebrovascular disease and dementia without behavioral disturbance. The assessment section of the record included a weekly skin check/nurse form was reviewed that was dated on 1/27/2020. The box was checked 'no' indicating the resident doesn't have any new skin impairments that have not been previously noted. The resident's care plan was reviewed with a focus for a potential of skin impairment/ pressure ulcers related to impaired mobility, incontinence of bowel and bladder, fragile skin that was dated on 6/19/2018 with a goal date of 3/23/2020. Interventions included to observe skin for an s/sx (signs and/or symptoms) of breakdown during cares and notify physician of any s/sx of skin breakdown/pressure ulcer if noted. The nursing process notes were reviewed that were found without an entry related to the skin tear to Resident #108's right hand. On 01/30/20 at 10:33 a.m. an interview was conducted with CNA B as she was in Resident #108's bedroom. Resident #108 smiled when approached and was cooperative with the CNA as she combed her hair and placed a scarf around her neck. The CNA was asked about the resident's right hand. She stated I worked on Saturday and that wasn't there. I was off on Sunday and when I came in on Monday, I seen it right away it was torn. She stated I told the nurse right way. So, she could cover it up or put something on it. I wanted to know what happened. She was asked if she had found out what had happened. She said no one has told me anything. At 10:56 a.m. an interview was conducted with the Resident #108's Unit Manager (UM) about the process of skin checks. She said that there is a form that is performed weekly we call the skin sweep. And if there are concerns in between the weekly skin sweep it would be documented at that time. She was asked if there was one for Resident #108. The UM at that time reviewed the electronic medical record and stated, I didn't find one. She confirmed at that time it is her expectation that if a skin tear was found the MD(physician) is notified to obtain a treatment. The UM said additionally, an incident report would be started along with an investigation. The UM confirmed that there was no report or notification to the MD. A skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer). Skin tears are acute wounds, which have a high probability of becoming complex chronic wounds, if not properly managed. https://www.woundsource.com/patientcondition/skin-tears

Based on observation, interview, and medical record review the facility failed to ensure that a pressure injury for one (#103) out of four residents with a pressure injury were provided treatment without an active Physician order. Findings Included: On 1/30/2020 at 12:15 p.m. Resident #103 was observed lying in her bed and was receptive to an interview. She appeared comfortable and said she had received a pain medication. She indicated and was in agreement to the observation of her treatment to her pressure injury. LPN F walked over to the treatment cart that was positioned with the drawers facing inside the bedroom doorway entrance. She donned a clean pair of gloves and went to the left side of the resident bed. After the table was cleaned LPN F returned to the treatment cart and removed one package of calcium alginate pad 2 x 2-inch size, one 6 x 6 sterile adhesive bordered dressing, three normal saline ampules, five individual packaged gauze dressings, and two packages of skin preps. LPN F removed the dressing from the resident sacral area. The dressing was saturated in appearance with pale yellow and pink drainage. The dressing along with the nurse gloves were disposed of inside of the red bag. After she washed and dried her hands, she donned clean gloves while she approached the bedside. The wound bed still contained an old dressing that fell out with little manipulation. The nurse left the bedside and returned after hand hygiene was performed. The skin surrounding the wound bed was pink in color, the edges presented as epibole (refers to rolled or curled-under) and pale white in color. The wound appeared the size of small avocado with the bed beefy red in color. Undermining appeared between 11 and 1 o'clock. No active drainage nor odor were noted. LPN F removed a clean gauze dressing and saturated it with normal saline as she cleaned the surrounding skin to the left lateral area of the peri-wound. Disposed the gauze dressing and her gloves and washed and dried her hands. LPN F removed a second clean gauze dressing and saturated it with normal saline and cleaned the peri-wound on the right side. She disposed of the gauze and her gloves and washed and dried her hands. The LPN then removed a third clean gauze dressing and saturated it with normal saline and lightly patted the wound bed. And disposed the gauze dressing and her gloves and washed and dried her hands. LPN F returned to the bedside and applied the skin prep to the peri wound. She removed her gloves and washed and dried her hands. LPN F returned to the bedside and picked up the cup that contained crushed Flagyl and applied it directly to the calcium alginate pad. The pad was then placed flat to the wound bed as the edges of the pad laid on the peri-wound and not lightly packed to the undermining areas. Then the secondary dressing was applied. The Medical record was reviewed that revealed a wound care assessment was performed by the resident's wound care provider(Physician Assistant) on 1/29/2020. The assessment read sacral ulcer is chronic and nonhealing. Measurements 3 x 2.1 x 0.8 centimeters (cm) and undermining 1.5 cm at 11 o'clock. Plan: remove old dressing avoiding trauma to the wound bed and peri-wound skin cleanse wound and peri-wound with non-cytotoxio wound cleanser prior to each dressing change. Apply 500 mg of Flagyl to wound bed, skin prep to peri wound skin gently pack ulcer with calcium alginate and cover with dry dressing daily and as needed dislodgement/ soiled. Physician orders were reviewed that did not contain an active treatment order for the observed treatment. On 01/30/20 at 2:47 p.m. an interview was conducted with the DON, he confirmed that the treatment had been discontinued by the Physician Assistant on the 1/29, it was not reordered and there was no current order for wound care. The facility provided a copy of their policy titled Wound Care that contained a revision date of October 2010. Purpose: the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation: 1. Verify that there is a physician's order for this procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and medical record review, and policy review the facility failed to ensure that care was provided according to standards of practice for two (#277 & 29) out of ten residents with enteral tubing feedings who were not positioned appropriately to prevent possible aspiration. Findings included: 1. Resident #277 was admitted to the facility with a diagnosis of attention to gastrostomy, according to the facesheet in the admission record. On 1/28/20 at 4:53 p.m. an observation was conducted. Resident #277 was in his bed lying on his right side in a fetal position. The head of the bed was elevated less than 30 degrees. Resident #277 was huddled in the middle of the bed, with his body flat. A tube feeding was connected to Resident #277, running with Jevity 1.5 at 60 ml per hour. On 1/31/20 at 8:14 a.m. another observation was conducted. Resident #277 was in his bed with his eyes open. The head of the bed was down all the way. The tube feed was running at 60 ml per hour, and the tubing was connected to Resident#277. On 1/31/20 at 8:17 a.m. an interview was conducted with Staff D, RN unit manager. Staff D, RN unit manager confirmed Resident #277 was in the bed with the tube feed running and the head of the bed lowered all the way. She said the head of the bed needed to be raised. She put on a pair of gloves and raised the head of the bed. Staff E, CNA came into the room during the observation, and assisted with positioning Resident #277. Resident #277 was in a fetal position on his right side, the pillows for support were in the chair next to the bed. Upon review of the physician's orders in the electronic medical record, the following order was discovered: 1/22/20 HOB (head of bed) elevated at least 30 degrees every shift. Further review of the electronic medical record revealed a baseline care plan dated 1/23/20, and showed an intervention under Nutrition and Enteral Feed, Elevate HOB as ordered. The goal was resident will tolerate tube feeding without complications. The CNA(Certified Nurses Assistant) [NAME] (care instructions) dated 1/22/20 review showed under General Information, Keep head of bed elevated. Reposition frequently due to tendency to turn self sideways in bed. The treatment administration record in the electronic medical record was also reviewed. The order dated 1/22/20 HOB elevated at least 30 Degrees every shift, was signed by the nurses caring for Resident #277. On 1/31/20 at 6:02 p.m. an interview was conducted with the DON (director of nursing). He said my expectation is that my unit managers round and make sure the bed is up. I also make rounds. The NHA (nursing home administrator) was also present during the interview. He said the policy is that the bed has to be up when the tube feeding is running. The usual practice is to put the bed up after care. 2. On 01/29/20 at 2:16 p.m. Resident# 29 was observed lying in bed with the with feeding tube attached to the machine. The head of the bed was elevated but the resident's head was flat resting in the middle of the bed on her right side. She appeared comfortable with her eyes closed. Medical record review conducted for Resident #29 revealed the admission Record information sheet that showed her diagnosis of encounter for attention to gastrostomy and revealed she was in her late eighties. Physician orders dated on 3/21/2019 included nothing by mouth diet and enteral feed order two times a day jevity 1.5 at 65 ml per hour from 10:00 a.m. to 2:00 p.m. (10-2p) dated on 11/27/2019. Additional orders stated Head of Bed (HOB) elevated at least 45 degrees every shift dated on 5/31/2019. On 01/30/20 at 10:05 a.m. Resident #29 was observed with the tubing feeding machine running at 65 cc per hour. The head of the bed was positioned between a 10-15-degree angle. Resident #29's head was positioned toward the middle of the bed with her body in the fetal position. Her eyes opened for a moment with verbal stimuli. At 10:18 a.m. the Director of Nursing entered Resident #29's bedroom. He was asked about the resident positioning as the tube feeding machine was running. He indicated that the head of the bed was not high enough and that she needed to be repositioned at that time. At 10:20 a.m. Licensed Practical Nurse A (LPNA) said that she had given Resident #29 her medications at 8:00 this morning and her head of bed was up at that time. LPN A stated, if the tube came disconnected then it did. LPN A was asked about the resident positioning as the tube feeding machine was running. LPN A stated, she always repositions herself like that and walked out of the bedroom. The facility provided a copy of their policy titled Enteral Feedings - Safety Precautions that contained a revision date on May 2014. Purpose: To ensure the safe administration of enteral nutrition. Preparation: 1. All personnel responsible for preparing, storing and administrating enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. 2. The facility will remain current in and follow accepted best practices in enteral nutrition. Preventing aspiration: 3. Always elevate the head of the bed (HOB) at least 30 degrees- 45 degrees during tube feeding and at least 1 hour after. Monitor the tube-fed resident for signs and symptoms of respiratory distress during feedings and medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the facility did not ensure acceptable practices were implemented during care of a tracheostomy for one resident (#267) of one resident observed for tracheostomy care and services. Findings included: Resident #267 was admitted to the facility on [DATE] with a diagnosis of respiratory failure, according to the face sheet in the admission record. A review of the physician's orders in the electronic medical record revealed the following information: 1/21/20 change inner cannula daily and prn (as needed) (size 4 DIC) as needed for tracheostomy 1/21/20 cleanse stoma daily with NS (normal saline) and and apply T-dressing if needed every shift Review of the TAR (Treatment Administration Record) dated 1/22/20 revealed the inner cannula change was not signed on the 1/22 or 1/ 23. On 1/30/20 at 2:20 p.m. an interview was conducted with the DON (Director of Nurses). He said yes, it should be signed every day. On 1/31/20 at 12:21 p.m. an observation was conducted during tracheostomy care with Staff A, LPN. Staff A, LPN put on ppe (personal protective equipment). Then Staff A, LPN knocked on the door and announced herself before entering Resident #267's bedroom. Staff A, LPN explained the treatment. Then Staff A, LPN removed the vent collar from the tracheostomy site so she could access the tracheostomy. Next, Staff A, LPN put a pulse oximeter on Resident #267's right index finger. The oxygen saturation read 83%. Staff A, LPN removed the gloves and disposed of them. Then Staff A, LPN washed her hands and put on a clean pair of gloves. Staff A, LPN gathered the supplies needed for the treatment from the table where they were located, and brought them to the bed side table, where she placed them on paper towels. Then Staff A, LPN removed the inner cannula from the tracheostomy and disposed of it in the trash can at the bedside. Staff A, LPN also removed the gloves she was wearing and placed them in the trash can. Then Staff A, LPN put on a pair of sterile gloves. Staff A, LPN did not perform hand hygiene after removing the cannula and gloves. Next Staff A, LPN removed the new cannula from the tray and inserted it into the the stoma. The stoma was red and clean, without drainage, secretions, or inflammation. Staff A, LPN did not clean the stoma. Staff A, LPN disposed of the sterile gloves. Then Staff A, LPN washed her hands in the bathroom sink and put on new sterile gloves. Staff A, LPN poured cleaning solution into a sterile bag in a box. Then Staff A, LPN used a gauze 4x4 to clean the outside of the trach collar around the stoma. Staff A, LPN used another gauze 4x4 to pat dry. Next Staff A, LPN placed a new gauze drain dressing beneath the tracheostomy site. Finally, Staff A, LPN disposed of the supplies in the trash can at the bedside. Then Staff A, LPN removed her gloves, and disposed of them in the trash can. Next Staff A, LPN went to the bathroom where she washed her hands in the sink. Staff A, LPN did not return the vent collar to the tracheostomy site. She left it sitting on Resident #267's left neck side, away from the tracheostomy site. Staff A, LPN put on new gloves and placed the call light near the resident. Then Staff A, LPN moved the tubing from the vent so it wasn't pulling. Staff A, LPN still did not return the vent collar to the the tracheostomy stoma. Staff A, LPN had removed her gloves and was preparing to exit the room. The surveyor asked if the what the nurse thought about the oxygen saturation. Staff A, LPN said the oxygen saturation went up to 90. She said Resident #267's baseline is 90-94. The surveyor then asked if she was going to put the resident's oxygen back. Staff A, LPN said it wasn't there when she came in. Then Staff A, LPN returned to the bedside and placed the vent collar over the tracheostomy. Staff A, LPN put on another pair of gloves, and returned the pulse oximeter to Resident #267's right middle finger. It read 94%. After removing the pulse oximeter Staff A, LPN removed her gloves and gown. Then Staff A, LPN sanitized her hands. When Staff A, LPN exited the room she washed her hands in the soiled utility room. On 1/31/20 at 5:39 p.m. an interview was conducted with the DON. He agreed the nurse needs to remove the gloves and do hand hygiene prior to donning sterile gloves. A review of the policy Tracheostomy Care, revised August 2013, reflected the following information: Purpose The purpose of this procedure is to guide tracheostomy care in the cleaning of reusable tracheostomy cannulas. General guidelines 1. Aseptic technique must be used: a. During cleaning and sterilization of reusable tracheostomy tubes. b. During all dressing changes until the tracheostomy wound has granulated (healed) ; and c. During tracheostomy tube changes, either reusable or disposable. 2. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures. 5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomys, and at least every eight hours for residents with unhealed tracheostomys. Procedure Guidelines Preparation and Assessment 1. Check physician order. Clean the removable inner cannula 8. Put on sterile gloves. 9. Secure the outer neck plate with non-dominant gloved hand. 10. Unlock the inner cannula with gloved dominant hand. 11. Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident. 14. Remove and discard gloves into appropriate receptacle. 15. Wash hands and put on fresh gloves. 16. Replace the cannula carefully and lock in place. Sight and Stoma Care 1. Apply clean gloves. 2. Clean the stoma with two peroxide soaked gauze pads (using a single sweep for each side). 3. Rinse the stoma with Saline soaked gauze pads (using a single sweep for each side). 4. Wipe with dry gauze (using a single sweep for each side). 5. Disinfect the stoma with anti-septic soaked gauze pads (using a single sweep for each side). Allow to air dry or wipe with clean, dry gauze. 7. Apply a fenestrated gauze pad around the insertion site. 8. Replace supplemental oxygen mask over tracheostomy.

Based on resident interview, observation, record review and staff interview, it was determined that the facility did not ensure that consistent pain management was provided for one of fifty three residents reviewed ( # 165). Findings Included: An interview was conducted with Resident # 165, on 1/28/20 at 3:03 p.m. Resident # 165 stated he was in pain from a fractured knee and recent abdominal surgery. He stated the facility does not have his pain medications at times or it gets discontinued for a day or two then starts again. He stated he is in a lot of pain when he does not get his pain medication. Review of the record for Resident # 165 revealed that he was admitted to the facility for rehabilitation on 1/9/20. Diagnoses included Displaced comminuted fracture of left patella, Acute embolism and thrombosis of left popliteal vein. His diagnoses in physician notes also indicated recent Right Iliofemoral and profunda femoris endarterectomy with angioplast and Left iliofemoral endarterectomy and angioplast and aorto-bifemoral bypass. Review of care plans for Resident # 165 revealed a care plan initiated 1/27/20 for Has an alteration in comfort related to multiple surgical wounds, recent fracture of left patella, decreased mobility, chronic left extremity pain and muscular atrophy. Is able to communicate pain to staff. Has routine pain medication regimen. Goal : Will voice an acceptable level of comfort thru next review Interventions: Administer medication for discomfort as ordered, observe for effectiveness and for SEs(side effects), Activities as tolerated, Assess pain level as needed, Report changes in comfort level to physician as ordered. ' Review of physician orders for January 2020 revealed 1/9/20 Acetaminophen 325 mg as needed for mild pain level 1 to 3, not to exceed 3 gm/300/ mg in 24 hours 1/9/20 Percocet tablet 5-325 mg ( Oxycodone- Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for Acute Pain . Order was discontinued 1/10/20 1/9/20 Evaluate resident for pain by using the the appropriate scale: 0 - no pain, 1-3 - mild pain, 4-6 Moderate pain, 7-10 Severe pain, as needed for pain 1/9/20 Evaluate resident for pain by using the the appropriate scale: 0 - no pain, 1-3 - mild pain, 4-6 Moderate pain, 7-10 Severe pain, every shift 1/10/20 Percocet Tablet 5-325 Mg ( Oxycodone - Acetaminophen ) Give 1 tablet by mouth every 4 hours as needed for Acute Pain for 3 days. Order was discontinued 1/13/20 1/13/20 Oxycodone - Acetaminophen Tablet 5-325 mg Give 1 tablet by mouth every 4 hours as needed for pain . This order was discontinued on the day it was ordered 1/13/20 1/15/20 Oxycodone - Acetaminophen 5-325 mg Give 1 tablet every 6 hours for pain Discontinued 1/27/20 1/20/20 Consult for pain management per patient request 1/27/20 Oxycodone - Acetaminophen 5-325 mg Give 1 tablet by mouth every 6 hours as needed for pain 1/28/20 Gabapentin Capsule 100 mg by mouth three times a day for nerve pain Review of the January 2020 Medication Administration Record, revealed that the routine order for Oxycodone - Acetaminophen tablet 5-325 Give 1 tablet by mouth every 6 hours for pain was documented as not given and pain level was not assessed on 1/16/20 at midnight, 0600 a.m. and 12:00 pm; 1/20/20 0600 am, 1200 pm and 1800 pm; 1/26/20 0600 am , 1200 pm and 1800 pm, and 1/27/20 midnight and 0600 am Review of nursing progress notes for these dates indicated on 1/16/20 at 0016 am that the resident needed a new prescription and at 12:49 waiting for script. Documentation of the Controlled substance log form the emergency drug kit revealed that it was administered at 6:00 p.m. from the emergency drug kit For 1/20/20 nursing progress notes indicated the medication was not given as ordered at 6:00 a.m. as the resident needs a new script, not given at 1200 p.m. as script fax to pharmacy, awaiting delivery. At 1820 the nursing progress note indicated resident refused, stating his pain is not bad at this time and will take med later. For 1/26/20 nursing progress notes indicated that the medication was on order, and awaiting pharmacy For 1/27/20 nursing progress notes for ordered times of midnight and 0600 am indicated on order and then a refusal of the medication at 12:00 noon. A subsequent interview was conducted with Resident #165, on 1/29/20 at 5: 30 p.m. He stated that there is still an issue with his pain medications and he is not getting them as he is supposed to. On 1/28/20 , Resident # 165 was seen by a Physiatrist. Review of the Physiatrist progress note revealed Rehabilitation Medicine was asked to consult on the patient for recommendations on rehabilitation, pain, and therapy management, HPI: Present to (local hospital ) on 12/28/19 with complaints of left knee pain after a mechanical fall. He has a history of severe peripheral vascular disease. He had an angiogram which showed completely thrombosed infrarenal abdominal aorta, bilateral common and external iliac arteries, abrupt occlusion at the proximal left popliteal artery compatible with acute emboli. He had x rays which showed a left knee comminuted fracture of the patella and underwent right iliofemoral and profunda femoris endarterectomy with angioplasty, left iliofemoral endarterectomy and angioplasty and aorto- bifemoral bypass. I was asked to evaluate the patient for poorly controlled pain. He currently has orders for Percocet 5 mg every 6 hours as needed, but apparently was on a standing dose every 6 hours prior to day. Nursing staff reports that this change was ordered because they ran out of the medication and had to make it a PRN order in the computer for this reason. He reports acute pain in his abdomen and in the left knee, he stated that he fell several weeks ago and has had pain in the knee ever since then. The pain is sharp and worse with any movement. He reports decent pain control with the Percocet. He also has abdominal pain around his surgical site. This too is controlled with Percocet. He also repots chronic shooting pains in the feet and lower extremities. This has been present for several years. He reports numbness on the inner part of both legs from his thighs down to his feet. This is more of a shooting pain, moderate in intensity and seems to be worse in the evenings. He stated that he has been on the Percocet for some time, but has not really tried any other medications for pain. Review of depositaries note indicated that he has adequate control with Percocet and a trial of Gabapentin would be initiated. Gabapentin was ordered 1/28/20 An interview was conducted with the Director of Nursing on 1/31/20 at 2:25 p.m., regarding the Oxycodone - Acetaminophen 5- 325 not being available at times and the Physiatrist note regarding the pain medication being changed from routine to as needed per the nurses stating they kept running out of it. The DON stated he is not sure what occurred with the pain medication as it is available in the emergency drug kit. An interview was conducted with Resident # 165, on 1/31/20 at 2: 30 p.m. He stated he did receive his pain medication today and he is trying to make sure he asks for it every 6 hours to keep the pain down. He stated he knows he is on a new medication for the pain but it is not helping yet. He states his pain is not controlled yet. He stated he is also trying to coordinate his pain medication before therapy as he is in pain in therapy and after therapy.

Based on observation, interview, record review, policy review, and manufacturer's instructions the facility did not ensure that the medication error rate was below 5% for three (#5, #33, and #100) of six sampled residents who were administered medications. This resulted in five errors from twenty-five medication administration opportunities, for a medication error rate of 20%. Findings included: 1. Resident #5 was admitted to the facility with a diagnosis of essential hypertension, according to the face sheet in the medical record. On 1/30/20 at 7:54 a.m. an observation was conducted with Staff F, LPN. Staff F, LPN prepared Resident #5's medications. Staff F, LPN said she could not find Resident #5's Allegra-D. Staff F, LPN poured a capful of Miralax into a plastic cup. Then Staff F, LPN poured water into a 30 ml medication cup. She poured the 30 ml of water into the Miralax powder. The surveyor read the instructions on the Miralax which indicated to mix it in 6-8 ounces of water. Staff F, LPN knocked on Resident #5's door after preparing all of his medications. Staff F, LPN assessed his pain. Then Staff F, LPN gave Resident #5 his pills whole with water. Next Staff F, LPN gave him his lactulose and then Miralax mixture of 30 ml. Staff F, LPN shook the inhaler and handed it to Resident #5. Staff F, LPN instructed Resident #5 to blow out and take 2 puffs. Resident #5 took 2 puffs, consecutively, as instructed by the nurse. Staff F, LPN instructed him to rinse his mouth. Resident #5 said he didn't want to rinse his mouth. Staff F, LPN took the inhaler and exited the room. Then Staff F, LPN performed hand hygiene. On 1/30/20 at 4:07 p.m. an interview was conducted with Staff F, LPN. She said the Allegra was in the stock, and she got it and gave it to Resident #5. The surveyor asked to see the medication. It was Allegra 60 mg and not Allegra-D 60-120 mg. Staff F, LPN reviewed the order and confirmed it was not correct. The following physician's orders were found in Resident #5's medical record: 1/31/19 Allegra -D extended release 12 hour 60-120 mg give 1 tablet by mouth one time a day for allergies 6/26/19 Miralax powder give 17 gram by mouth one time a day every Tue, Thu, Sat, Sun for constipation 10/16/19 Symbicort aerosol 160-4.5 mcg/act 1 inhalation inhale orally two times a day for asthma Review of the policy, Administering Medications through a Metered Dose Inhaler, revised October 2010, revealed the follwoing information: Purpose The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications. General guidelines Follow the medication administration guidelines in the policy entitled Administering Medications. Steps in the Procedure 15. Repeat inhalation, if ordered. Allow at least one minute between inhalation of the same medication and at least two minutes between inhalations of different medications. The following was found at www.symbicorttouchpoints.com: Quick Guide 3. Breathe out fully, then place the mouthpiece cover into your mouth and close your lips around it. Make sure that the inhaler is upright and the opening of the mouthpiece is pointing towards the back of your throat. Inhale deeply and slowly while pressing down firmly on the top of the counter on the inhaler. 4. Continue to breathe in and hold your breath for about 10 seconds, or for as long as comfortable. Before you breathe out, release your finger from the top of the counter. Keep the inhaler upright and remove from your mouth. For your second puff, shake the the Symbicort inhaler again for 5 seconds and repeat steps 3 and 4. Review of the policy, Administering Medications, revised December 2012, revealed the following information: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 7. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 2. Resident #100 was admitted to the facility with a diagnosis of type 2 diabetes mellitus, according to the face sheet in the admission record. On 1/30/20 at 8:47 a.m. with Staff A, LPN. Staff A, poured Resident #100's medications. Then Staff A, LPN knocked on the door and entered the room. Next, Staff A, LPN washed her hands in the bathroom sink. Then Staff A, LPN put on a pair of gloves. Staff A, LPN placed the supplies and medications on paper towels on bed side table. She gave Resident #100 his medications whole with water. Then Staff A, LPN opened the needle for the insulin pen. Staff A, LPN attached the needle to the pen. Then Staff A, LPN dialed the Novolog insulin pen to 10 units. Staff A, LPN did not prime the needle with 2 units of insulin prior to dialing it to 10 units. Next, Staff A, LPN used an alcohol prep to clean Resident #100's left lower abdomen. She placed the insulin pen against the area she had cleaned, and pressed the top to inject the medication. Then Staff A, LPN removed her gloves and placed them in the trash can near the bedside, along with the other supplies she had used. She went into the bathroom and disposed of the insulin needle in the Sharp's container. Then Staff A, LPN washed her hands in the bathroom sink. Staff A, LPN returned to the medication cart where she cleaned the insulin pen with a germicidal wipe. A review of Resident #100's physician's orders in the electronic medial record revealed the following: 1/29/20 Novolog flexpen 10 units subcutaneously with meals 3. Resident #33 was admitted to the facility with a diagnosis of type 2 diabetes mellitus according to the face sheet in the admission record. On 1/30/20 at 11:40 a.m. an observation was conducted with Staff A, LPN during insulin administration. Staff A, LPN removed a glucometer, test strips, lancet, alcohol prep pad, Novolog flexpen, and a needle from the medication cart and placed the supplies on a foam plate. Then Staff A, LPN knocked on Resident #33's door. Staff A, LPN went to the bathroom and washed her hands in the sink. Next, Staff A, LPN put on a pair of gloves. After turning on the glucometer, Staff A, LPN placed a test strip in it. Then Staff A, LPN used an alcohol prep to clean Resident #33's left middle finger. Staff A, LPN poked the finger tip with the lancet and applied a droplet of blood to the test strip. The glucometer read a blood glucose of 99. Next Staff A, LPN attached the needle to the Novolog flexpen. Staff A, LPN removed the gloves and washed her hands in the bathroom sink. Then Staff A, LPN returned to the medication cart for another alcohol prep. When Staff A, LPN returned to the room, she washed her hands in the sink again. Then Staff A, LPN put on another pair of gloves. Staff A, dialed the insulin pen to 4 units. Staff A, LPN did not prime the insulin pen. Then Staff A, LPN cleaned Resident #33's right upper abdominal area with the alcohol prep pad. Staff A, LPN pressed the insulin pen against the area she had cleaned, and pressed the button to release the insulin. Next, Staff A. LPN disposed of the needle and lancet in the sharps container in the bathroom, and the supplies in the trash can. The Staff A, LPN removed the gloves and placed the in the trash can as well. Then Staff A, LPN washed her hands in the bathroom sink. Staff A, LPN exited the room and looked for a germicidal wipe in the medication cart. When she couldn't find one, she asked a staff member to bring her some. Then Staff A, LPN removed a germicidal wipe from the container, and cleaned the glucometer with it. She placed the glucometer in a drawer in the medication cart. Staff A, LPN removed another germicidal wipe and cleaned the flexpen. Then Staff A, LPN placed the flexpen in a plastic bag and returned it to the drawer. On 1/30/20 at 11:54 a.m. in an interview with Staff A, LPN she said she did not know she had to prime the insulin pen. She said she did not know what priming was. A review of the physician's orders in the electronic medical record reflected an order dated 8/20/19 for Novolog flexpen solution 4 units subcutaneously before meals A review of the manufacturer's instructions for Novolog Flexpen reflected the following information: Getting started on Novolg Flexpen A Guide to Using Your Novolog FlexPen Prepare you pen Remove the cap Pull off the pen cap and wipe the rubber stopper with an alcohol swab. Attach a ne needle Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps. Prime your pen Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Select your dose Turn the dose selector to select the number of units you need to inject. Give your injection Insert the needle. Press and hold the dose button. After the dose counter reaches 0, slowly count to 6. On 1/31/20 at 4:04 p.m. an telephone interview was conducted with the Consultant Pharmacist. The surveyor asked if the insulin pen wasn't primed, if that would be a significant medication error. He said I think it would be a med error. I don't think it would qualify as a significant med error since it's only 2 units. The surveyor asked about use of the Symbicort inhaler. The Consultant Pharmacist said, You want to wait a minute between puffs, absolutely. When the surveyor asked about the Allegra error, he said I don't like pseudophed for that population, but the only possible outcome would be a runny nose. If the order called for Allegra D they should give Allegra D. Then the surveyor asked what the outcome would be if the Miralax wasn't mixed in 6-8 ounces (oz) of water. The Consultant Pharmacist said, A small amount of water won't dissolve the miralax, so then you're not getting the full dose. On 1/31/20 at 5:39 p.m. an interview was conducted with the DON. The DON said he was not aware the insulin pens needed to be primed. The surveyor shared the Allegra error with him, and the DON said they called the physician and got the one time order for the Allegra. He said It should be available, yes, of course. When the surveyor shared the concern with the inhaler, the DON said The resident shouldn't be doing his own inhaler. There should be some wait time between. The nurse should have administered the medication.

Based on observation and resident record review, it was determined that the facility did not ensure all staff were aware of adaptive equipment required during meals for one of fifty three residents reviewed (#101). Findings Include : On 1/30/20 at approximately 12:40 p.m. Resident # 101 was observed to be seated at a square table in the main dining room. A sippy cup was on the square table across from Resident # 101 near the middle of the table. The Administrator in Training (AIT) was observed to be serving beverages to residents in the dining room. She approached Resident # 101 and asked her what she would like to drink. Resident # 101 was heard to choose cranberry juice. There was no meal ticket or tray slip on the table. She was not observed to determine what consistency and in what form Resident # 101's beverages should be. The AIT was heard to say to Resident # 101 oh you don't have a cup, let me get you a cup. She then walked toward the kitchen area and returned with a regular drinking cup, poured cranberry juice into the cup and placed the cup in front of Resident # 101. The surveyor intervened and indicated, by gesture, the sippy cup on the table. The AIT was then observed to call out to other staff in the dining room who were assisting residents Is she a sippy cup? to which the other staff who were assisting other residents verbally called out yes. She then transferred the cranberry juice from the regular cup to the sippy cup. Review of the record for Resident #101 revealed that she had diagnoses which included Dementia, Altered Mental Status , and Dysphagia. Review of physician orders for Resident # 101 revealed a diet order for Mechanical Soft Texture, Thin Consistency, dated 9/12/19 and an order, dated 11/12/19 for OT(Occupational Therapy) orders for pt(patient) to receive a sippy cup with all meals in order to decrease spillage of liquids. Review of a quarterly MDS(Minimum Data Set) assessment, dated 12/21/19 revealed a score of 3 on the Brief Interview for Mental Status, indicative of severe cognitive impairment, and limited assistance of one person required for eating. Review of the tray slip for Resident # 101, which arrived with her meal tray after beverages were served, revealed that sippy cup was listed on the tray slip.

Based on observations, interviews and record reviews the facility failed to implement their quality assessment and assurance measures for corrective action related to deficient practice identified on the annual survey conducted on 1/31/2020 Annual Survey. Continued non-compliance was identified for 2 (F810, F880) out of 12 deficiencies cited. Findings included: An annual survey was conducted on 1/31/2020 and deficient practice was identified at: F550, F561, F656, F684, F686, F693, F695, F697, F759, F760, F810, F880. A revisit to the annual survey was conducted on 3/04/2020 - 3/05/2020 and continued deficient practice was identified at: F810 and F880. A review of the facility's plan of correction for the recertification survey, ending 1/31/2020, revealed the following measures identified by the facility Quality Assurance Committee (QAC), would be taken to correct the deficient practice for F810 and F880. F 810: Resident #29 was given the correct consistency in her assistive device and the Administrator in Training was educated on the use of assistive devices and dignity. Other residents with assistive devices were reviewed for compliance. Guardian Angel program sheets were updated to observe one meal a day and ensure proper voice volume, dignity and assistive devices are being use. The facility Nursing Home Administrator (NHA) and Director of Nursing (DON) were interviewed on 3/05/2020 at 4:17 p.m., We provided education to 100% of Certified Nurses Aides and licensed staff, all staff were educated on dining with dignity and addressing residents appropriately, volume of voices and use of assistive devices. The facility failed to correct as evidenced by the facility failed to provide appropriate assistive devices for meals for 1 (#29), resident out of 3 residents sampled. For F880, Glucometers were cleaned and identified staff were immediately educated on the facility infection control policy. Education on infection control was initiated for all staff to ensure practices were not repeated or or continued. The Assistant Director of Nurses (ADON), educated all current staff on infection control guidelines. Education following infection control practices and competencies as appropriate will be included in newly hired employee orientation and annual education requirements for staff. Competencies will be completed and post tests conducted to determine understanding. At the conclusion of the revisit on 3/5/20, it was determined that the facility had current deficient practice in infection control in several areas including: Failing to follow professional guidelines for washing hands with soap and water or using hand sanitizer between patient contact; cleaning shared patient equipment after each resident use; ensuring staff used personal protective equipment (PPE) for 2 of 2 isolation rooms and failing to ensure pertinent isolation signage was posted for 2 of 2 isolation rooms; and use of hand sanitizer to meet the CDC (Centers for Disease Control) with 6 confirmed cases of the flu. The facility NHA and DON were interviewed on 3/05/2020 at 4:17 p.m., The NHA stated that as of 03/01/2020, 100 of facility staff infection control practices and competencies were performed, as needed. An interview was conducted on 3/05/2020 at 4:30 p.m., with the Nursing Home Administrator and the Director of Nurses. The DON stated, We will continue to educate the staff.

Based on observations, interviews, record review, policy review, manufacturer's instructions, and CDC (Centers for Disease Control) guidelines the facility did not ensure appropriate infection practices were implemented related to 1) glucometer disinfection for two (#15 and #33) of two residents observed during glucometer use, and 2) the facility did not ensure appropriate personal protective equipment (PPE) was worn during care for one resident (#34), on contact precautions, and appropriate hand washing after exiting a contact isolation room for Resident #267, of two residents on contact isolation, and 3) the facility did not ensure staff wore gloves during eye drop administration for one (#89) of six residents observed during medication administration. Findings included: 1) Resident #15 was admitted to the facility with a diagnosis of type 2 diabetes mellitus, according to the face sheet in the admission record. On 1/28/20 at 5:03 p.m. an observation was conducted with Staff G, LPN during glucometer use. Staff G, LPN explained the procedure to Resident #15 placed the glucometer and bottle of test strips on Resident #15's dresser, and on a pair of gloves. Staff G, LPN turned the glucometer on and placed a test strip in it. Staff G, LPN cleaned Resident #15's right index finger with an alcohol prep. Then she used a lancet to poke Resident#15's right index finger. Staff G, LPN applied a drop of blood from Resident #15's finger onto the test strip in the glucometer. The meter reading was a blood glucose of 111. Staff G, LPN removed her gloves and disposed of the needle and lancet in the Sharps container in the bathroom. Staff G, LPN washed her hands in the bathroom sink. Then Staff G, LPN put the bottle of test strips in her left pocket. Staff G, LPN returned to the bathroom and washed her hands in the sink again. Then Staff G, LPN took the glucometer and headed out of the room. Staff G, LPN placed the glucometer on top of the medication cart. Then Staff G, LPN removed keys from her right pocket. After that, Staff G, LPN removed the test strips from her pocket and placed them on top of the medication cart. After unlocking the medication cart, Staff G, LPN opened the top drawer and placed the glucometer in it. Staff G, LPN closed the drawer. Staff G, LPN began pushing the medication cart down the hallway. She had not performed any hand hygiene after handling the contaminated glucometer. The surveyor asked her if she cleaned the glucometer. Staff G, LPN said she cleaned it before she used it on Resident #15. The surveyor asked if she should clean it after using it. Staff G, LPN indicated she thought she did. She proceeded to push the med cart down the hallway. The surveyor stopped her again and asked if Staff G, LPN was going to clean the glucometer. Staff G, LPN stopped and unlocked the medication cart. Staff G, LPN removed a germicidal wipe from the container in the medication cart. Staff G, LPN wiped the glucometer using her bare hands, for less than 5 seconds. Then Staff G, LPN set the glucometer back in the drawer and disposed of the wipe. Resident #33 was admitted to the facility with a diagnosis of type 2 diabetes mellitus according to the face sheet in the admission record. On 1/30/20 at 11:40 a.m. an observation was conducted with Staff A, LPN during insulin administration. Staff A, LPN paced the supplies on a foam plate, knocked on Resident #33's door, went to the bathroom and washed her hands in the sink. Next, Staff A, LPN put on a pair of gloves. After turning on the glucometer, Staff A, LPN placed a test strip in it. Then Staff A, LPN used an alcohol prep to clean Resident #33's left middle finger. Staff A, LPN poked the finger tip with the lancet and applied a droplet of blood to the test strip. The glucometer read a blood glucose of 99. Next Staff A, LPN attached the needle to the Novolog flexpen. Staff A, LPN removed the gloves and washed her hands in the bathroom sink. Then Staff A, LPN returned to the medication cart for another alcohol prep. When Staff A, LPN returned to the room, she washed her hands in the sink again. Then Staff A, LPN put on another pair of gloves. Staff A, dialed the insulin pen to 4 units. Then Staff A, LPN cleaned Resident #33's right upper abdominal area with the alcohol prep pad. Staff A, LPN pressed the insulin pen against the area she had cleaned, and pressed the button to release the insulin. Next, Staff A, LPN disposed of the needle and lancet in the sharps container in the bathroom, and the supplies in the trash can. Then Staff A, LPN removed the gloves and placed them in the trash can as well. Next, Staff A, LPN washed her hands in the bathroom sink. Staff A, LPN exited the room and looked for a germicidal wipe in the medication cart. When she couldn't find one, she asked a staff member to bring her some. Then Staff A, LPN removed a germicidal wipe from the container, and cleaned the glucometer with it. She placed the glucometer in a drawer in the medication cart. Staff A, LPN removed another germicidal wipe and cleaned the flexpen. Then Staff A, LPN placed the flexpen in a plastic bag and returned it to the drawer. Review of the manufacturer's instructions for Assure Platinum Blood Glucose Monitoring System, Page 47, Cleaning and Disinfecting Guidelines, revealed the following information: Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1 Cleaning and disinfecting can be completely by you using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid on the test strip and key code ports of the meter. Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used, use one wipe to clean and a second wipe to disinfect. A review of the policy, Obtaining a Fingerstick Glucose Level, revised October 2011, showed the following: Purpose The purpose of this procedure is to obtain a blood sample to determine the residents blood glucose level. 18. Clean and disinfect reusable equipment between uses according to the manufacturers instructions and current infection control standards of practice. A review of manufacturer's instructions, Microdot Blood Glucose Monitoring System, Protocol to disinfect Microdot Meter, undated, reflected the following information: To disinfect the Microdot Meter: Read the Microdot Bleach Wipe (EPA reg. no. 69687- 1- 88459) label and follow directions for use. Microdot Bleach Wipe is for the exterior surfaces of the blood glucose meter and is not for use on the needle or the monitor. 3. Open Microdot Bleach wipe pop-up canister. The wipes are pre-saturated with a sodium hypochlorite (bleach) hospital use solution. 4. Remove a pre-saturated 6 x 6 wipe. 5. Thoroughly wipe the Microdot Meter surface to be disinfected. 6. Then allow the Microdot Meter surface to air dry. Disinfectant tip: In order to maintain five minutes of contact time with the sodium hypochlorite, wrap the MD meter in the wipe and place meter face down. 2) Resident #34 was admitted to the facility with a diagnosis of sepsis, according to the face sheet in the admission record. Upon review of Resident #34's physician's orders in the electronic medical record, the following order was discovered: 1/27/20 Contact isolation every shift for 7 days. Further review of the electronic medical record revealed a lab result for a urine culture, dated 1/23/20. The culture results indicated Resident #34 had ESBL (Escherichia coli, Extended Spectrum Betalactamase), and another isolate was found as well, Pseudomonas aeruginosa. Review of the MDS (Minimum Data Set), Bladder and Bowel, dated 1/14/20, indicated Resident #34 had an indwelling catheter. On 1/30/20 at 6:12 p.m. an observation was conducted. There was an isolation kit located outside of the door to Resident #34's room, with gloves, gowns, and masks in it. There was also a sign indicating to see nurse before entering the room. Staff C, CNA was observed in Resident #34's room wearing only a pair of gloves. Staff C, CNA was assisting Resident #34 with the dinner meal. Staff C, CNA removed the gloves, and went in the bathroom where he washed his hands in the sink. Then Staff C, CNA removed the dinner tray form the bedside table and exited the room. Staff C, CNA put the tray in the dining cart. Then Staff C, CNA went to the soiled utility room and washed his hands. At 6:15 p.m. on 1/30/20 an interview was conducted with Staff C, CNA. He said he has only worked at the facility for a week. This is the first time he has had this assignment. Staff C, CNA said Resident #34 required total care assistance. She had a Foley catheter, and she was on contact isolation. Staff C, CNA said he was told he only needed to wear gloves to feed her. Staff C, CNA said, They did tell me she was on isolation for her urine. Yes, you wear a gown if you're providing care, but I was just feeding her. If I was turning her or emptying the catheter I would wear a gown. Resident #267 was admitted to the facility with a diagnosis of enterocolitis due to C-Diff, according to the face sheet in the admission record. A review of the physician's orders in the electronic medical record revealed an order dated 1/21/20: Contact isolation precautions. On 1/30/20 at 4:45 p.m. an observation was conducted. Resident #267 was in her bed, clean, groomed, eyes closed, and no odor was present. The surveyor asked Staff J, CNA to remove the blanket from Resident #267's legs to confirm if her heels were being floated as ordered. Staff J, CNA came in the room after putting on PPE. Then Staff J, CNA removed the blanket from Resident #267's feet. Resident #267's legs were propped up with a pillow. Staff J, CNA said she was not caring for Resident #267. Staff J, CNA didn't know what kind of isolation she was on. She said it was contact, but she wasn't sure if it was urine or bowel. When Staff J, CNA exited the room she did not wash her hands or perform hand hygiene. The surveyor instructed her the resident was on isolation for C-diff and she must wash her hands with soap and water. According to Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2008) from the Centers for Disease Control and Prevention, III.B.1. Contact precautions. Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient ' s environment as described in I.B.3.a. The specific agents and circumstance for which Contact Precautions are indicated are found in Appendix A. The application of Contact Precautions for patients infected or colonized with MDROs is described in the 2006 HICPAC/CDC MDRO guideline927. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. A single-patient room is preferred for patients who require Contact Precautions. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient ' s environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, C. difficile, noroviruses and other intestinal tract pathogens; RSV)54, 72, 73, 78, 274, 275, 740 https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html 3) Resident #89 was admitted to the facility with a diagnosis of hypertension, according to the face sheet in the admission record. Review of Resident #89's physician's orders in the medical record revealed an order dated 9/18/18 for artificial tear solution instill 1 drop in each eye three times a day for dry eyes. On 1/30/20 at 8:17 a.m. an observation was conducted during medication administration. Staff F, LPN performed hand hygiene. After removing Resident #89's medication from the medication cart, including a bottle of artificial tears, Staff F, LPN brought some tissues along with Resident #89's medications into his bedroom after knocking on the door. Staff F, LPN opened the bottle of eye drops. Staff F, LPN did not perform hand hygiene or apply any gloves. Staff F, LPN handed Resident #89 a tissue with her bare hands. Then Staff F, LPN pulled down Resident #89's left lower eye lid, and placed a drop of the artificial tears in it. Then Staff F, LPN proceeded to Resident #89's right eye, without performing any hand hygiene, or applying gloves. Staff F, LPN used a bare hand to pull Resident #89's right lower eyelid down, and squeezed a drop of the artificial tears into it with her other hand. Resident #89 used the tissue she had handed him to wipe the excess eye drops away. Staff F, LPN returned the eye drops to the box. Then Staff F, LPN performed hand hygiene, exited the room and returned the eye drops to the medication cart. Review of the policy, Handwashing/Hand Hygiene, revised August 2015, reflected the following information: Policy statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation 1. All personnel shall be trained and regularly in-service on the importance of hand hygiene and preventing the transmission of healthcare associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: b. After contact with a resident with infectious diarrhea including, but not limited to infections caused by Norovirus, salmonella, shigella and C. Difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents. f. Before donning sterile gloves. m. After removing gloves. n. Before and after entering isolation precaution settings. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace handwashing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. On 1/31/20 at 5:39 p.m. an interview was conducted with the DON and NHA. The DON said the glucometers are shared. There are 2 per nursing cart. The NHA said it's company policy. The DON- said if one (of the meters) gets lost then you have to share anyway. They (nurses) have to follow the policy and procedure. After use, a bleach wipe is utilized on a glucometer for 3 minutes. They should wipe it, and I actually wrap it and let it set for a 3 minute duration. The surveyor asked if the nurse needed to wear gloves during eye drop administration. The DON said Yes, they should be wearing gloves to give eye drops. Yes, you don't want cross contamination. She does need to change gloves and perform hand hygiene. The surveyor asked if staff needed to wear PPE (personal protective equipment) for all resident contact if they are on contact precautions. The DON said Yes, staff must wear the PPE at all times for resident contact. The new policy states that if you're not in close contact you don't have to wear PPE. If it's close contact you need PPE. It depends if it's a closed system. With a catheter, they don't need PPE to feed the resident. The surveyor asked if staff should be handwashing prior to exiting the room when a resident has C-Diff (Clostridium Difficile). The DON said Yes, they definitely need to wash their hands prior to exiting that room. The surveyor asked if the nurse should perform hand hygiene before donning sterile gloves. The DON said, Yes, she needs to remove the gloves and do hand hygiene prior to donning sterile gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. An observation was conducted on 1/28/20 at 11:47 a.m. on the 400 hallway during the lunch meal. Staff I, CNA was observed entering room [ROOM NUMBER] without knocking. Then Staff I, CNA returned to the meal cart, removed a tray, and brought it into room [ROOM NUMBER] again, without knocking or announcing herself. Another observation was conducted on 1/28/20 at 12:05 p.m. during the lunch meal on the 500 hallway. Staff H, CNA removed a tray from the meal cart. Staff H, CNA entered room [ROOM NUMBER]. Staff H, CNA did not knock on the door or announce herself before entering the room. Then Staff H, CNA removed another tray from the cart and entered room [ROOM NUMBER] without knocking or announcing herself. Staff H, CNA exited the room. Staff H, returned to the meal cart. Staff H, CNA, removed a tray from the meal cart. Staff H, CNA took the tray into room [ROOM NUMBER]. Then Staff H, CNA, removed another tray from the meal cart, and returned to room [ROOM NUMBER]. Staff H, CNA did not knock or announce herself before entering the room. 6. Review of the policy, Resident Rights, revised December 2016, reflected the following: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and State laws guarantee certain basic rights to all residents in this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity Based on observation, interview policy, and record review, the facility failed to promote dignity and respect during the dining experience in the main dining room for ten (#s 20, 22, 23, 27, 39, 40, 43, 49, 101, and 211) of 52 sampled residents, during two (1/28 and 1/30/20) of four survey days, and in two (400 and 500) hallways and did not ensure that resident council members felt respected by staff during dining. Findings Included 1. An observation was conducted in the main hallway outside of the main dining room, on 1/28/20 at 12:04 p.m. A CNA was observed wheeling Resident #49 toward the area outside of the dining room. Four residents were observed to already be seated in wheelchairs in that area. The Director of Nursing (DON) was observed to stop Resident #49, and in front of four residents and the surveyor, ask the resident if he could come shave this stuff off your chin after lunch while pointing to the chin area of her face. Resident # 49 was observed to have visible hair growth on her chin. The resident was observed to nod yes. The DON moved away and the aide then placed Resident #49 outside of the main dining room. An interview was conducted with the DON, on 1/30/20 at 5:20 p.m. He confirmed that he did say that to the resident in the hall but stated he did not realize that he was that loud that he was overheard. He stated he did not know the name of the resident but he sees her all time time. An interview was attempted with Resident #49 on 1/30/20 at 11:30 a.m. She was asked about the conversation in the hallway with the DON however she did not recall the event. Review of the record for Resident #49 revealed that she was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, Parkinson's Disease and Major Depressive Disorder. Review of a quarterly Minimum Data Set (MDS) assessment, dated 11/18/19, revealed a score of 7 on the Brief Interview for Mental Status (BIMS) assessment which is indicative of moderate cognitive impairment and indicated that Resident #49 required extensive assistance of one person for personal hygiene tasks. 2. Review of the meal times list provided by the facility revealed that there were two scheduled meal times for the lunch meal in the main dining room- 11:30 a.m. and 12:30 p.m. Review of a seating chart for the dining room revealed that the 11:30 a.m. lunch is for independent diners and the 12:30 p.m. Helping Hand Lunch is for residents who need to be fed or need assistance to eat. An observation of the 11:30 a.m. lunch meal commenced at 11:44 a.m. on 1/28/2020 with nine residents observed to be eating independently. At 12:04 p.m. on 1/28/20, four residents were seated in wheelchairs in the hallway outside of the dining room while the nine residents in the dining room were still eating their meals. At 12:10 p.m. six residents were observed in the hallway out side of the dining room while the nine residents in the dining room were still eating their meals. The six residents included Resident's #49 and #40 who were both seated in wheelchairs right outside of the dining room and Resident's #23 and #27. Resident #40 was observed to be attempting to move himself into the dining room by propelling with his feet. His wheelchair was observed to be locked so he was unsuccessful in his attempt. An unidentified CNA came out of the dining room and was heard to tell Resident #40 that he needed to stay out here for now as it was not time for him to eat. Resident #49 was observed to be shaking her head. A brief interview was conducted with Resident #49 and she stated, they are telling us to come down here and to come in and then we sit here. She expressed that she was frustrated at having to sit outside the dining room and wait while others were eating. Resident #49 had been observed at 12:04 p.m. being wheeled to the dining room in her wheelchair by a staff member and being placed where she was observed when interviewed. Resident #49 was observed to be moved out of the area she was seated in to an area across the hall in order for staff to assist wheelchair residents out of the dining room. An observation was made of Resident #27 seated in the hallway in her chair outside of the dining room. She was observed speaking to the Director of Social Services. She was heard saying to the Director of Social Services that they are upset, they want to come in the dining room and keep being told it is not time yet. The Social Service Director was heard to say, well they can go in there if they want to but made no attempt to inform other staff to bring these two residents into the dining room or assist them, herself, into the dining room. Observation of the second seating for lunch commenced at 12:27 p.m. when the six residents and other residents were observed to be assisted into the dining room for their lunch meal. Resident #22 was observed to be seated at a table with another resident across from her. A placemat, silverware and napkin were observed on the table in front of her. An unknown dietary staff person was observed to approach Resident #22, pick up her placemat, silverware and napkin, and in a loud voice, heard by the surveyor across the room, stated to Resident #22, you don't eat here, your tray is in your room. She left Resident #22 seated at the table with no place setting. Resident #22 propelled herself up to another table which had a place setting. A lunch meal was eventually provided to Resident #22, after much conversation was heard in the dining room between the dietary aide and the CNAs. An interview was conducted with Resident #22 at 12:39 p.m., she stated she wants to eat in the dining room. Eighteen residents were observed in the dining room for the second meal time with the dietary person and three aides present. A female resident was wheeled into the dining room by a staff person and two aides, across the dining room assisting residents to eat, yelled out she already ate and the staff person wheeled the female resident back out of the room. Random observation at 12:37 p.m. on 1/28/20., revealed: Three residents seated at table 5. One resident was observed being served her soup by an aide while the other two residents had no food or soup in front of them. Three residents were observed to be seated at table one with one resident being fed soup by an aide and the other two residents with no food or soup. Three residents were observed to be seated at table 9 with one resident being fed soup and the other two residents with no food or soup. At 1:08 p.m. on 1/28/20, Staff I and Staff M were observed to be seated at a table assisting Resident's #101 and #43 to eat lunch. Staff I and Staff M were observed to be talking to each other about where staff, who used to work at the facility, were now working, while assisting the two residents to eat. During the Resident Council meeting, conducted on 1/30/20 at 2:00 p.m., three confidential residents, who have lunch during the 1st lunch serving (11:30 a.m.) in the main dining room, stated that they felt rushed eating lunch while the second seating residents are gathered outside the door of the dining room. They stated this happens every day during lunch. A second dining observation was conducted in the main dining room on 1/30/20, commencing at 11:47 a.m., with the first lunch seating and ending at 12:50 p.m. during the second seating. The following was observed: Nine Residents were observed to be eating their soup and or salad in the main dining room. At 11:50 a.m., a CNA, was observed to wheel Resident #211 into the dining room and left him in the middle of the dining room while she went to the seating chart to determine where he sat for lunch. He was placed at table 2 in front of a place setting. This aide and another staff person stated loudly that he was not the resident whose place setting he was seated at and that he was scheduled to eat during the second dining at 12:30 p.m. The aide then removed him from in front of the place setting and wheeled him out of the dining room. Review of the seating chart for the 12:30 dining revealed that Resident #211 was assigned to sit at table 9. Resident #22 was observed in her wheelchair seated at a table with a place setting in front to her on 1/30/20 at 11:47 a.m. A dietary aide and a CNA were heard saying loudly that, she is second seating and another aide wheeled her away from the table and took her out of the dining room. An unidentified aide was observed in the middle of the dining room while residents were eating lunch, speaking with Staff O, a CNA. Both were speaking in an audible tone that could be easily heard from the entrance to the dining room. They were discussing whether the unidentified aide should be helping during the meal. Staff O informed her no and explained to her how the schedule worked. As the aide was leaving the dining room, she was observed to yell out from the door to Staff O, who was still in the middle of the dining room, oh its breakfast tomorrow and Staff O was observed to yell back Yes. Resident #39 was observed seated at table 4 finishing his salad at 12:19 p.m. on 1/30/20. He then propelled himself out of the dining room and down the hall. An aide came out of the kitchen with his lunch and two staff who were in the middle of the dining room between table 5 and 6 were heard to yell out, he went to dialysis while other residents were seated in the dining room eating lunch. The Administrator in Training was observed to be assisting Resident #101 with a beverage. She was observed to call out to other staff in the dining room who were assisting residents Is she a sippy cup? to which the other staff who were assisting other residents verbally called out yes. Staff O was observed during the second dining in the main dining room, on 1/30/20 at approximately 12:50 p.m., wheeling a male resident, #20, into the room. She asked the dietary aide where the resident sat and the dietary aide responded that she would have to get the table set up first. Staff O left Resident #20 in the middle of the dining room and walked away. The dietary aide set up the table and moved him to the table, after he had sat in his wheelchair in the middle of dining room for five minutes. 3. Four of eight confidential residents in the Resident Council Meeting, on 1/30/20 at 2: 00 p.m. stated the did not feel that staff treated them with dignity and respect and felt that when they expressed concerns to the nurses and aides that nobody was listening. 4. An interview was conducted with the DON and the Administrator regarding the dignity concerns identified during dining. on Both the Administrator and the DON stated that 1st and 2nd dining was not set up to be for independent diners at one and assisted diners at the other. The Administrator stated that the intent of the two dining times was to get more residents out of their rooms and into the dining rooms by allowing the residents to choose which lunch time to go to. The Administrator stated its not supposed to be that way. Regarding the dignity, concerns they both stated that they will fix it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and policy review the facility did not ensure residents were free from significant medication errors, for 3 residents (#5, #33 and #100) of 11 residents observed during medication administration or reviewed for unnecessary medications. Findings Included: 1) Review of the record for Resident # 5 revealed that he was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus without Complications. Review of Physician orders on the Order Summary Report revealed an order dated 12/17/19 for Humulin R U-500 Kwik-Pen Solution Pen -Injector 500 Unit/ML: Inject 90 unit subcutaneously with meals related to Type II Diabetes Mellitus without complications . Resident # 5 also had a physician's order, dated 11/13/19 for Novolog Solution 100 Unit/ML (Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200. Review of Resident # 5's Medication Administration Record ( MAR) for December 2019 revealed the Novolog Solution 100 Unit/ML (Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200 was documented as administered when blood sugars (BS) were documented as under 200 on 20 of 93 occasions: 0630 am 12/1 BS 168, 12/2 BS 166, 12/6 BS 165, 12/11 BS 191, 12/12 BS 110, 12/13 BS 162, 12/14 BS 150, 12/16 BS 197, 12/18 BS 165, 12/22 BS 194, 12/25 BS 170, 12/28 BS 176, 12/30 BS 90, 12/31 BS 180 11:30 am 12/15 BS 132, 12/22 BS 107, 12/28 BS 135 16:30 pm (4:30 pm) 12/7 BS 108, 12/22 BS 124, 12/28 BS 158 Review of Resident # 5's MAR for January 2020 revealed the Novolog Solution 100 Unit/ML (Insulin Aspart): Inject 20 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications. Hold for blood sugar less than 200 was documented as administered when blood sugars were documents as under 200 on 8 of 91 occasions: 06:30 a.m. 1/1 BS 109, 1/5 BS 165, 1/6 BS 152, 1/11 BS 81, 1/12/ BS 188, 1/15 BS 110, 1/16 BS 171, 1/21 BS 134. An interview was conducted with the Director of Nursing, on 1/31/2020 at 11:20 a.m. He reviewed the Medication Administration Records and confirmed that the Novolog insulin was being administered when it was supposed to be held for blood sugars under 200 . He stated it looked like the nurses were not paying attention and clicking along too fast. A phone interview was conducted with the Consultant Pharmacist, on 1/31/20 at 4:15 pm. He stated he does look at the blood sugars and insulin when he does his reviews. He stated he does not like this type of order as it puts more on for the nurses to do. He stated it is definitely an issue. He was unable at the time of the phone interview to access his records to see if he had previously identified this issue for Resident # 5. 2) Resident #100 was admitted to the facility with a diagnosis of type 2 diabetes mellitus, according to the face sheet in the admission record. On 1/30/20 at 8:47 a.m. with Staff A, LPN. Staff A, poured Resident #100's medications. Then Staff A, LPN knocked on the door and entered the room. Next, Staff A, LPN washed her hands in the bathroom sink. Then Staff A, LPN put on a pair of gloves. Staff A, LPN placed the supplies and medications on paper towels on bed side table. She gave Resident #100 his medications whole with water. Then Staff A, LPN opened the needle for the insulin pen. Staff A, LPN attached the needle to the pen. Then Staff A, LPN dialed the Novolog insulin pen to 10 units. Staff A, LPN did not prime the needle with 2 units of insulin prior to dialing it to 10 units. Next, Staff A, LPN used an alcohol prep to clean Resident #100's left lower abdomen. She placed the insulin pen against the area she had cleaned, and pressed the top to inject the medication. Then Staff A, LPN removed her gloves and placed them in the trash can near the bed side, along with the other supplies she had used. She went into the bathroom and disposed of the insulin needle in the Sharp's container. Then Staff A, LPN washed her hands in the bathroom sink. Staff A, LPN returned to the medication cart where she cleaned the insulin pen with a germicidal wipe. A review of Resident #100's physician's orders in the electronic medial record revealed the following: 1/29/20 Novolog flexpen 10 units subcutaneously with meals 3) Resident #33 was admitted to the facility with a diagnosis of type 2 diabetes mellitus according to the face sheet in the admission record. On 1/30/20 at 11:40 a.m. an observation was conducted with Staff A, LPN during insulin administration. Staff A, LPN removed a glucometer, test strips, lancet, alcohol prep pad, Novolog flexpen, and a needle from the medication cart and placed the supplies on a foam plate. Then Staff A, LPN knocked on Resident #33's door. Staff A, LPN went to the bathroom and washed her hands in the sink. Next, Staff A, LPN put on a pair of gloves. After turning on the glucometer, Staff A, LPN placed a test strip in it. Then Staff A, LPN used an alcohol prep to clean Resident #33's left middle finger. Staff A, LPN poked the finger tip with the lancet and applied a droplet of blood to the test strip. The glucometer read a blood glucose of 99. Next Staff A, LPN attached the needle to the Novolog flexpen. Staff A, LPN removed the gloves and washed her hands in the bathroom sink. Then Staff A, LPN returned to the medication cart for another alcohol prep. When Staff A, LPN returned to the room, she washed her hands in the sink again. Then Staff A, LPN put on another pair of gloves. Staff A, dialed the insulin pen to 4 units. Staff A, LPN did not prime the insulin pen. Then Staff A, LPN cleaned Resident #33's right upper abdominal area with the alcohol prep pad. Staff A, LPN pressed the insulin pen against the area she had cleaned, and pressed the button to release the insulin. Next, Staff A. LPN disposed of the needle and lancet in the sharps container in the bathroom, and the supplies in the trash can. The Staff A, LPN removed the gloves and placed the in the trash can as well. Then Staff A, LPN washed her hands in the bathroom sink. Staff A, LPN exited the room and looked for a germicidal wipe in the medication cart. When she couldn't find one, she asked a staff member to bring her some. Then Staff A, LPN removed a germicidal wipe from the container, and cleaned the glucometer with it. She placed the glucometer in a drawer in the medication cart. Staff A, LPN removed another germicidal wipe and cleaned the flexpen. Then Staff A, LPN placed the flexpen in a plastic bag and returned it to the drawer. On 1/30/20 at 11:54 a.m. in an interview with Staff A, LPN she said she did not know she had to prime the insulin pen. She said she did not know what priming was. A review of the physician's orders in the electronic medical record reflected an order dated 8/20/19 for Novolog flexpen solution 4 units subcutaneously before meals A review of the manufacturer's instructions for Novolog Flexpen reflected the following information: Getting started on Novolog Flexpen A Guide to Using Your Novolog FlexPen Prepare you pen Remove the cap Pull off the pen cap and wipe the rubber stopper with an alcohol swab. Attach a needle Pull off the paper tab. Push and twist the needle on until it is tight. Pull off both needle caps. Prime your pen Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears. Select your dose Turn the dose selector to select the number of units you need to inject. Give your injection Insert the needle. Press and hold the dose button. After the dose counter reaches 0, slowly count to 6. On 1/31/20 at 4:04 p.m. an telephone interview was conducted with the Consultant Pharmacist. The surveyor asked if the insulin pen wasn't primed, if that would be a significant medication error. He said I think it would be a med error. I don't think it would qualify as a significant med error since it's only 2 units. The surveyor asked about use of the Symbicort inhaler. The Consultant Pharmacist said, You want to wait a minute between puffs, absolutely. When the surveyor asked about the Allegra error, he said I don't like pseudophed for that population, but the only possible outcome would be a runny nose. If the order called for Allegra D they should give Allegra D. Then the surveyor asked what the outcome would be if the Miralax wasn't mixed in 6-8 ounces (oz) of water. The Consultant Pharmacist said, A small amount of water won't dissolve the miralax, so then you're not getting the full dose. On 1/31/20 at 5:39 p.m. an interview was conducted with the DON. The DON said, what do you mean prime it? What's an air shot? He was not aware the insulin pens needed to be primed. The surveyor shared the Allegra error with him, and the DON said they called the physician and got the one time order for the Allegra. He said It should be available, yes, of course. When the surveyor shared the concern with the inhaler, the DON said The resident shouldn't be doing his own inhaler. There should be some wait time between. The nurse should have administered the medication. Review of the policy, Administering Medications, revised December 2012, revealed the following information: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 7. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.