**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility's policy titled Insulin Pen, and review of the manufacturer's instructions titled Instructions for use [Name] Pen Pen-injector (Insulin Lispro) injection, to ensure care and services were provided in accordance with accepted professional standards for one of four residents (R) (R368) observed during medication administration. Specifically, the facility failed to prime the insulin pen prior to use for R368. This deficient practice had the potential to affect the resident's blood glucose level and have a negative impact on the resident's quality of life. Findings include: Review of the facility's policy titled Insulin Pen, revised 4/16/2024, under the Policy Explanation and Compliance Guidelines revealed, 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir .11. Procedure . h. Prime the insulin pen: (i) Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Review of the manufacturer's Instructions for use [Name] Pen Pen-injector (Insulin Lispro) injection under the section titled Priming your Pen revealed, Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Review of R368's orders dated 2/25/2025 revealed, [Name] Kwik-Pen Subcutaneous Solution Pen Injector 100 unit/ml (milliliter) (Insulin Lispro), inject as per sliding scale. During observation of medication administration on 2/26/2025 at 11:32 am with Licensed Practical Nurse (LPN) AA who was observed performing a blood sugar check without concerns and subsequently administering four (4) units of insulin subcutaneously for a blood sugar level of 243. LPN AA retrieved the R368's insulin pen, attached a disposable, single-use insulin needle, and dialed the administration dose to 4 units as per doctors ordered. LPN AA then entered the R368's room and administered the insulin to R368 without priming the needle to remove air and to ensure an accurate insulin dose. During an interview on 2/26/2025 at 11:35 am with LPN AA revealed that she usually primes the insulin pen but admitted that she was nervous and forgot to do so today. During an interview on 2/26/ 2025 at 1:30 pm with the Director of Nursing (DON) revealed, there were two perspectives on whether insulin pens need to be primed-some believe priming is necessary, while others consider it unnecessary. The DON agreed to double check for it in their policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy titled Abuse Prohibition the facility failed to ensure residents were protected from verbal abuse. This affected one Resident (R#154) of four facility reported incidents reviewed. Findings include: Review of facility Abuse Prohibition policy (2020) revealed under intent; It is the intent of this center to actively preserve each patient's right to be fee from mistreatment, neglect, abuse, or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Review of R#154 medical record revealed resident was admitted to facility on 2/4/21 and discharged from the facility on 6/17/21 and had diagnoses that included sequelae of cerebral infarction, Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries, Hemiplegia affecting left nondominant side, Tachycardia, COVID-19, Difficulty in walking, lack of coordination, Dysphagia, Essential (primary) hypertension, Type 2 diabetes mellitus with hyperglycemia, pulmonary embolism without acute Candida stomatitis, Urinary tract infection, Constipation, Hypokalemia, Muscle weakness (generalized). Review of Minimum Data Set (MDS) quarterly assessment dated [DATE] for R#154 revealed Section C (Cognitive Patterns) Brief Interview of Mental Status (BIMS) score 14 indicating resident was cognitively intact and able to make needs known to staff. Continued review of MDS also revealed no indicators for mood or behaviors in sections D (Mood) and Section E (Behaviors) identified during the assessment period. Review of Facility Reported Incident Form dated 4/15/21 documented type of abuse as staff to resident. Details of incident included R#154 stated the Certified Nursing Assistant (CNA) entered her room using a loud voiced tone and spoke to her in an inappropriate manner. Documentation revealed that CNA was immediately suspended, family and physician were notified. Further review of facility documentation also revealed that after investigation of incident which included interviewing of staff and residents, the CNA that was involved in the allegation was terminated and reported to the licensure board. Interview with Administrator on 2/3/21 at 4:45 p.m. revealed the incident with R#154 was reported to her by R#154s' family after overhearing the conversation, while on the phone with resident, when the CNA entered resident's room. The CNA was immediately suspended pending investigation. Further interview also revealed that R#154 did have a history of reporting false allegations toward staff. However, after interviewing cognitive residents that resided on the A-hall and C-hall where the CNA was assigned, it was determined that there had been other incidents of the CNA speaking inappropriately to residents and it was determined that the CNA would be terminated from the facility. The Administrator also revealed all staff had been in-serviced on abuse and reporting of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to implement the comprehensive care plan related to catheter tubing placement for one resident (R#20) of 12 resident care plans reviewed. Findings Include: Observation of R#20 Foley catheter on 2/3/22 at 8:10 a.m. revealed catheter was noted hanging on resident side rail at the head of the bed during observation. Review of R#20 medical record revealed resident was admitted to the facility on [DATE] with diagnoses of sequelae of other cerebrovascular disease, Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, dementia without behavioral disturbance, Essential (primary) hypertension, Ventricular tachycardia, Chest pain, Urinary tract infection, site not specified, Metabolic encephalopathy, Klebsiella pneumonia, Schizophrenia, Type 2 diabetes mellitus without complications, Chronic kidney disease, stage 2. Review of Medical Data Set (MDS) admission Assessment date 11/25/21 revealed Section C (Cognitive Patterns) C0500 revealed BIM's score 99 indicating resident has cognitive deficit, Section G (Functional Abilities) revealed resident requires extensive assistance with bed mobility, transfers, dressing, and locomotion on and off the unit which includes staff assistance. Section H (Bladder and Bowel) H0100 indicated resident did have indwelling catheter present. Review of R#20 care plan dated 11/23/21 revealed under interventions: Keep catheter tubing placed below level of bladder, secure catheter tubing. Interview with Licensed Practical Nurse (LPN) AA on 2/3/22 at 8:15 a.m. confirmed R#20 Foley catheter was attached to the resident's side rail at the head of the bed without a privacy bag. Further interview also revealed that resident's catheter should be positioned below the bladder in a privacy bag, and tubing unkinked to encourage proper flow of urine. Interview with Director of Nursing (DON) on 2/3/22 at 9:00 a.m. revealed it is the expectation for all nursing staff to follow the residents plan of care, and to ensure that residents with catheters have a privacy bag and that their tubing is positioned properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the facility document titled, Foley Catheter Care, the facility failed to ensure that a Foley Catheter was placed in a privacy bag and was properly positioned for one of one resident (R#20) that had an indwelling Foley catheter. Findings include: Observation of R#20 Foley catheter on 2/1/22 at 12:05 p.m. revealed cloudy urine with sediment noted in tubing, with no privacy bag, which was visible from resident's door. Observation of R#20 Foley catheter on 2/3/22 at 8:10 a.m. revealed catheter was noted hanging on resident side rail at the head of the bed, there was no privacy bag noted during observation. Review of facility document titled Foley Catheter Care (dated 2020) revealed Intent: To promote, comfort and decrease risk of infection for patients with an indwelling catheter and is performed daily and PRN for soiling. Please see Lippincott Nursing Procedure Manual for additional information on how to complete procedure. Review of the Lippincott Nursing Procedure Manual did not provide any directives related to privacy bag usage. However, the manual stated to keep the catheter and drainage tubing free from kinks to allow the free flow of urine and keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder. Review of R#20 medical record revealed resident was admitted to the facility on [DATE] with diagnoses that included urinary retention, sequelae of other cerebrovascular disease, Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, dementia without behavioral disturbance, Essential (primary) hypertension, Ventricular tachycardia, Chest pain, Urinary tract infection, site not specified, Metabolic encephalopathy, Klebsiella pneumonia, Schizophrenia, Type 2 diabetes mellitus without complications, Chronic kidney disease, stage 2. Review of Minimum Data Set (MDS) admission Assessment date 11/25/21 revealed Section C (Cognitive Patterns) revealed Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment, Section G (Functional Abilities) revealed resident is dependent on staff related to toileting needs and requires extensive assistance with bed mobility, transfers, and dressing, and Section H (Bladder and Bowel) indicated indwelling catheter present. Interview with Licensed Practical Nurse (LPN) AA on 2/3/22 at 8:15 a.m. who confirmed R#20's Foley catheter was attached to the side rail at the head of the bed without a privacy bag. LPN AA acknowledged that R#20's catheter should be positioned below the bladder in a privacy bag, and tubing should be unkinked to encourage proper flow of urine. Interview with Director of Nursing (DON) on 2/3/22 at 9:00 a.m. revealed residents with Foley catheters should have two privacy bags one for their wheelchair and one for the bed. DON further revealed that at no time should a catheter be positioned above the resident's bladder and the tubbing should be positioned in a way to promote urine flow. It is the expectation for all nursing staff to follow the resident's plan of care and ensure that residents with catheters have a privacy bag and that their tubing is positioned properly. Continued interview also revealed that there is not a written policy for catheter care, but staff should follow guidelines as directed in the Lippincott Nursing Procedure [NAME] that is located at the nursing station. Cross reference F656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and policy titled Skilled Inpatient Services Immunization of Patients, the facility failed to provide evidence that residents were offered the Pneumococcal vaccine for two residents (R#20 and R#36) of five sampled residents reviewed for immunizations. Findings include: Review of the facility Skilled Inpatient Services Immunization of Patients copyrighted 2020 revealed: It is a policy of this that all patients receive immunizations and vaccinations that aid in preventing infectious diseases unless medically contraindicated or otherwise ordered by the patient's attending physician or the facility's medical director. Upon admission to the facility, permission must be obtained from the patient (or representative) to administer pneumococcal vaccine if there is no documented history of vaccination and influenza vaccine annually (in the fall), unless contraindicated. to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. R#20 admitted to the facility on [DATE]. Review of R#20's Annual MDS assessment dated [DATE] revealed a BIMS score of 99. Section O revealed the Pneumococcal vaccine was not up to date and had not been received because it had not been offered. Review of facility Pneumonia Vaccine report printed 2/3/22 revealed there was no documented evidence that R#20 received a Pneumococcal vaccine. 2.Review of R#36 clinical records revealed she was admitted to the facility on [DATE]. Review of R#36's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated an intact cognition. Review of the admission MDS assessment dated [DATE] and Quarterly MDS assessment dated [DATE] Section O revealed the Pneumococcal vaccine was not up to date and had not been received because it had not been offered. Interview on 2/2/22 at 5:10 p.m. with R#36 who revealed she was not offered the Pneumococcal vaccine, she stated she does not want to receive the Pneumococcal vaccine. Review of facility Pneumonia Vaccine report printed 2/3/22 revealed there was no documented evidence that R#36 received a Pneumococcal vaccine. Interview with Director of Nursing (DON) on 2/3/22 at 9:45 a.m. revealed she along with the Assistant Director of Nursing (ADON) obtained consent for the Pneumococcal vaccine from R#36 on 2/2/22. DON stated they asked R#36 if she wanted to receive the Pneumococcal vaccine and she stated yes. DON stated she did not see a consent for R#36. Further interview with the DON revealed there was no consent form for R#20. DON stated the Infection Control Preventionist (ICP) called the family of R#20 on 2/3/22 to obtain consent. She stated since the ICP called the family she was responsible for signing the consent form. DON stated that ICP was out with COVID, but she came to the facility to sign the consent form. DON confirmed there was no consent forms for pneumococcal vaccine for R#20 and there was no consent form for pneumococcal vaccine for R#36. Interview with Assistant Director of Nursing (ADON) on 2/3/22 at 10:40 AM revealed she was collecting the information that was requested by the surveyors when she did not see a consent form for R#20, she stated she called the ICP to ask her where the consent form was. She stated the ICP stated she did not have a consent form for R#20, but she would call the family to obtain consent. ADON stated ICP stated family wanted Resident #20 to receive the pneumococcal vaccine. ADON confirmed that prior to 2/2/22 there was no consent form for R#20 and R#20 was not offered the pneumococcal vaccine. She stated consent forms are done on admission and they also get them yearly. ADON reported R#36 was not offered the pneumonia vaccine prior to yesterday. ADON stated she along with the DON asked R#36 if she wanted the pneumonia vaccine and she stated she did. ADON stated the pneumonia vaccine was not given because it was not available in the facility and had be ordered from the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident (R) #41 was admitted to facility on 4/18/19 with diagnosis's which include but not limited to Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, acute respiratory failure with hypoxia, -Sepsis, unspecified organism, Metabolic encephalopathy, Acidosis, -Acute kidney failure, Unspecified severe protein-calorie malnutrition, Pressure ulcer of sacral region and Pressure ulcer of left heel. Interview on 2/2/22 at 8:46 a.m. with Treatment Nurse who stated R#41 was admitted to facility with a Stage 4 sacral wound and DTI to right heel. She further stated that resident is being followed at a wound clinic. Treatment Nurse stated that the sacral wound treatment is daily, and Dakin's moistened gauze and foam dressing is applied daily. She furthered stated R#41's wound is improving and is now a Stage 2 with improved undermining. Treatment Nurse also stated that there are no signs of infection to the wound. R#41 also has a Deep Tissue Injury (DTI) to the right heel, which is painted with betadine every other day. The Treatment Nurse stated that resident has a low air loss mattress, wedges, and boots on while in bed as pressure relieving interventions. She further stated she is responsible for completing and documenting the skin assessments weekly. Treatment Nurse further stated that she does not consistently follow up with the staff at the wound care clinic to ensure a collaboration of wound care for R#41. Record review revealed R#41's wound care orders as follow: 1- clean sacral pressure ulcer to sacrum with normal saline, blot dry, use skin barrier wipes to peri wound, place fluffed moistened Dakin's gauze in wound bed and cover with foam dressing daily. Diagnosis: Promote wound healing. 2- clean right heel with normal saline, blot dry and apply povidone iodine and let air dry every other day. Diagnosis: Promote wound healing. During observation of wound treatment on 2/2/22 at 11:16 a.m. with Treatment Nurse, sacral wound dressing, soiled, and saturated with a date of 1/29/22. Treatment Nurse verified the date on the dressing and acknowledged that the daily treatment had not been done since 1/29/22. Treatment Nurse further stated that she does not work on weekends and the charge nurses are responsible for doing treatments over the weekends. She also confirmed that she worked 1/31/22 and 2/1/22 and did not do the treatment. Treatment Nurse stated R#41 treatment was not complete on 2/1/22 because resident was transferred to hospital before she had the opportunity to do the treatment. She further stated that she was not at work when he returned and that she did not communicate with the charge nurse to do treatment upon return. Further observation of feet, R#41 feet were observed to be on the bed and not offloaded with boots, pillow, or offloading device. Interview on 2/2/22 at 11: 55 a.m. with DON. DON stated that it is her expectation that wound care for all residents with wounds is done as ordered each day to promote wound healing. She further stated that the treatment nurse is responsible for doing wound treatments during the week and that the charge nurses complete wound treatments on the weekends. DON stated she was not aware that treatments were not being done. Interview 2/2/22 at 12:32 p.m. with Licensed Practical Nurse (LPN), DD stated that charge nurses are responsible for completing treatments on the weekends and during the week if the treatment nurse does not work. Typically, the treatment nurse works Monday thru Friday. She further stated that the nurses know when the treatment nurse is not working, and charge nurses complete the treatments according to the electronic treatment record. Observation 2/2/22 at 2:36 p.m. Certified Nursing Assistant (CNA) EE pulled covers back for surveyor to visualize R#41's feet. Pillow observed under calf. CNA EE verified that both of resident's heels were on the bed and not offloaded. Interview 2/2/22 at 3:42 p.m. with RN BB. He stated that he did complete the treatment on 1/29/22 but did not have the opportunity to do the treatment on 1/30/22. RN BB further stated that he was aware that the treatment is a daily treatment, but he had too much to do that day and did not get to it. Review of R#41's electronic treatment administration record (eTAR) revealed that treatment of sacral wound was not documented as complete for January 1, 2, 4, 7,10, 30, 31, and February 1. Treatment of DTI on right heel had not been documented as being done on January 1, 7, and 31. RN BB and DON viewed the eTAR and verified that treatments were not documented on record. Based on observation, record review, review of the facility Skilled Inpatient Services Assessment and Treatment of Pressure Ulcers, and staff interview, the facility failed to provide treatments as ordered by the Physician for two residents (R#10 and R#41) of three residents reviewed with pressure sores to promote healing and prevent further development of pressure sores. Findings include: Review of the facility Skilled Inpatient Services Assessment and Treatment of Pressure Ulcers copyrighted 2020, revealed (2) A resident having PU/PI will receive necessary treatment and services to promote healing, prevent infection and prevent new PU/PI from developing if consistent with overall clinical condition and individualized goals of care. 1. R#10 was admitted on [DATE] with diagnoses of Acute on chronic systolic (congestive) heart failure, Acute respiratory failure with hypoxia, infection and inflammatory reaction due to other internal prosthetic device, implants and grafts, Chronic atrial fibrillation, Acute Kidney Failure, Acidosis, Metabolic encephalopathy, Chronic systolic (congestive) heart failure, Essential (primary) hypertension. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that that she had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severely impaired cognition. Review of an electronic treatment administration record (eTAR) for R#10 revealed that she had a treatment order with a start date of 9/2/21 for custom order every five days day shift clean pressure ulcer on right heel with NS, blot dry, apply skin barrier wipe to peri-wound, apply polymem non-adhesive foam to site and cover with adhesive bandage. There was another treatment order with a start date of 11/9/21 for adhesive bandage every 5 days day shift clean pressure ulcer on right heel with normal saline, blot dry, apply skin barrier wipe to periwound, apply polymem and cover with non-adhesive foam dressing and wrap with kerlix every 5 days. On 11/4/21 there was an order for foam non-adhesive every five (5) days day shift clean arterial ischemic ulcer to her right little toe with normal saline, blot dry, apply skin barrier wipe to peri wound and cover with foam dressing every five (5) days. There was no evidence that there was a dressing change on 1/30/22 per the eTAR dated 1/30/22 through 2/2/22. Review of the Wound Report dated 1/25/22 - 2/1/22 revealed that R#10 had a 1.0 centimeter (cm) by 0.5 cm by 3 cm Stage III pressure ulcer on her right heel, and a 2.0 cm by 1.0 cm x 0 cm Arterial Ischemic Ulcer to her right little toe. Interview on 2/2/22 at 8:31 a.m. with the Treatment Nurse revealed R#10 has a pressure ulcer on her right heel stage II, facility acquired from several years ago. She stated R#10 has very poor circulation. Treatment nurse stated the wound has gotten smaller, but it has not completely healed. She stated the wound is cleaned with normal saline, pat dry, put skin barrier wrap around it and foam dressing and wrap with kerlix every five days. She stated the area to R#10 right little toe has an arterial ischemic area. She stated the area is cleaned with normal saline, skin barrier wipe, and foam dressing every five days. She stated she thinks the nurse changed the dressing on the 1/30/22 or 1/31/22. Informed treatment nurse that the dressing to R#10 right little toe had a date of 1/25/22. Treatment Nurse stated she was not aware of it. She stated there are times when R#10 refuses, but she is not sure if R#10 refused or not. Treatment Nurse also stated if R#10 refuses treatment she will attempt to go in later and see if she can change her mind. Treatment Nurse further stated that she could not honestly tell surveyor when she last changed R#10's dressing. She stated when she does not do treatments the nurses are in charge of dressing changes. She stated the resident's skin is assessed weekly. Treatment Nurse stated R#10 's treatment is effective because the area has not worsened. She stated it is slowly getting smaller, but it's been there for several years. Wound observation on 2/2/22 at 10:15 a.m.Treatment Nurse who confirmed dressing to right little toe had a date of 1/25/22. Treatment nurse stated that she will probably need to change the order to as needed (prn). When the Treatment Nurse was questioned on how the nurses would know when to change the dressing if the order was changed, she stated she would not change the order. She stated she only had the order because the toe was rubbing up against and sticking to the boot. Treatment nurse stated the Nurse Practitioner is a certified wound nurse and she comes in to look at the wounds sometimes. Interview with the Director of Nursing (DON) on 2/2/22 at 12:44 p.m. revealed the Treatment Nurse is responsible for dressing changes. She stated if the Treatment Nurse is not on the medication cart as a staff nurse, she is responsible but if she is on the cart the charge nurses are responsible for doing their wound treatments. DON stated the Treatment Nurse did not work at the facility on 1/30/22 or 1/31/22. She stated the Treatment Nurse worked on 2/1/22 in her role as the Treatment Nurse on 2/1/22. DON further reported the Treatment Nurse should have changed the dressing to R#10 right little toe. She stated the nurses know when the Treatment Nurse is not in the building, they are responsible for doing the treatment. Further interview with the DON revealed that she looks at wounds if residents have a wound on admission, and she looks at wounds weekly but on no particular day. She stated if it worsens, she looks at it again, she stated if it is improving, she looks at it periodically. DON stated she was not aware that R#10 had a dressing to her right little toe dated 1/25/22. DON stated the dressing on the toe is more likely for preventive to keep the toe from rubbing against something, she stated it is more like a comfort. DON also stated the dressing should have been changed yesterday. She stated nobody goes back and check to make sure dressings are changed every day. DON stated no one would not know if dressings were not being done unless someone goes and looks at the dressings every day. DON further stated she expected the Physician's Orders to be followed and she expected the Treatment Nurse to notify her with any changes in wounds.