Based on observation, interview, and record review the facility failed to administer insulin according to manufacturer's instructions. This applies to 1 of 2 residents reviewed for insulin administration in the sample of 20. The findings include: R4's admission Record (Face Sheet) showed a current/recent admission date of 10/17/24. R4's face sheet showed a diagnosis of Diabetes Type II. R4's Order Summary Report as of 2/19/25 showed an order for 7 units of rapid-acting insulin (a medication to control blood sugar in diabetic patients) to be given at mealtime, if the resident eats his meal. The order showed the insulin was to be dispensed via a prefilled insulin pen. On 2/18/25 at 11:59 AM, V3 Registered Nurse (RN) began preparation of R4's insulin pen. V3 removed the pen's cap, attached a needle, dialed in 2 units, held the pen horizontally, and depressed the plunger. The needle cap remained in place and the tip of the needle was not visible through the opaque cap (a drop of insulin was not visible at the tip of the needle). V3 then dialed in 7 units of insulin, entered R4's room, wiped is abdomen with alcohol, removed the needle cap, then injected the insulin. V3 held the insulin plunger for less than 2 seconds, removed her thumb from the plunger, held the needle in his skin for less than 4 seconds, then removed the needle from his abdomen. The rapid acting insulin manufacturer's instructions (revision 2/2023) showed, after the needle is attached, small amounts of air may collect in the pen and to ensure proper dosing, Turn the dose selector to select 2 units. Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows '0' .A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin repeat steps . The instructions showed, following the priming of the pen, the desired insulin dose should be dialed in and the needle injected into the skin. The instructions continued, once the needle is injected the dose button should be pressed and when the insulin dial reads zero, the dose button should continue to be pressed and the needle left in the skin for a slow 6 count. The manufacturer instructions stated if the 6 count is not done with the dose button pressed, the full dose of insulin may not be administered. On 2/19/25 at 9:33 AM, V2 Director of Nursing stated, nursing staff should be following manufacturer's instructions. V2 said the purpose of priming the insulin pen is to ensure there are no air bubbles and the resident receives their full dose of insulin. V2 said the purpose of keeping the dose button pressed is to ensure the resident receives their full dose of insulin.

Based on observation, interview, and record review the facility failed to have a properly functioning lock for the drawer containing the residents' emergency supply of controlled substances. This failure has the potential to affect all residents in the facility. The findings include: On 2/18/25 at 10:45 AM, during medication room inspection, the drawer containing the emergency supply of controlled substances was opened without a key. The lock was not functioning as intended. On 2/18/25 at 10:45 AM, V3 Registered Nurse stated, I have not checked or accessed this drawer in a long time. The document Ekit Contents showed the drawer contained, but not limited to, fentanyl patches, morphine, and oxycontin (all Schedule II narcotic pain medications.) On 2/19/25 at 9:33 AM, V2 Director of Nursing stated controlled substance have to be double locked. V2 said the controlled substance boxes, within the locked drawer, have a keyed lock but they are not affixed to the cabinet. V2 said controlled substances are double locked because they are more likely to be diverted compared to other medications. V2 said the emergency supply of narcotics are available for all residents to be used. V2 said if a provider order a controlled substance for a resident, the emergency supply would be used until pharmacy could deliver the regular supply. The facility's policy Controlled Substances (Revision 12/6/22) showed The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications . The facility's policy does not show controlled substances must be separately locked from non-controlled medications in a permanently affixed container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was safely transferred who has a history of multiple falls. This applies to 1 of 8 residents (R13) reviewed for safety in the sample of 8. The findings include: R13's face sheet shows she is an [AGE] year old female with diagnoses including repeated falls, dementia, Alzheimer's and hypertension. On 4/22/24 at 9:28 AM, V4 (RN) said R13 is a very high fall risk and has increased weakness. On 4/22/24 at 12:55 PM, R13 was wheeled to her room. V5 and V6 (Both Certified Nursing Assistant's) lifted R13 with the gait belt and transferred her to the bed. R13 was leaning back and unable to stand upright. The back of her heels were on the floor with her feet and toes pointed upwards. A mechanical lift sling was hanging on her bathroom door. On 4/22/24 at 1:00 PM, V5 (CNA) said R13 is alert to self, confused and transfers with two person assist. On 4/22/24 at 1:28 PM, V2 (DON) said R13 is alert to person only and is high fall risk. She has had multiple falls and requires substantial assistance with transfers. She used to be able to bear weight and walk and has had a decline with increased weakness. Some days staff use the mechanical stand lift to transfer her when she is weak. Staff should ensure a resident is able to stand and bear weight when transferring. On 4/23/24 at 8:58 AM, V3 (MDS Nurse) said R13 has a history of multiple falls. She is getting weaker, and she will need to be re-assessed for her transfer status. R13's Fall Risk Evaluation dated 1/2/24 shows she is HIGH Risk for falls. The facility's Incident Accident Reports provided on 4/22/24 shows R13 had seven falls in the last four months on (1/8/24, 1/17/24, 1/18/24, 2/3/24, 2/5/24 and 3/30/24). The facility's Safe Lifting and Movements of Residents Policy dated 2022, states, In order to protect the safety and well-being of staff and residents. and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following .weight bearing ability .

Based on observation, interview and record review the facility failed to ensure residents were treated in a dignified manner during dining for three of 11 residents (R11, R3, R9) reviewed for dignity in the sample of 11. The findings include: 1. On May 22, 2023, at 12:16 PM, R11 was seated in the dining room. V5 Certified Nursing Assistant (CNA) stood next to R11, feeding R11 soup. 2. On May 22, 2023, at 12:20 PM, R3 was seated in the dining room. V7 CNA stood next to R3, feeding R3 soup. 3. On May 22, 2023, at 12:37 PM, R9 was seated in the dining room. V5 CNA was standing next to R9 while she was feeding him soup and his main meal. 4. On May 23, 2023, at 12:10 PM, V9 CNA was on her cell phone in the dining room while feeding R11. At 12:25 PM, V9's cell phone was sitting next to her on top of the table while she was still feeding R11. On May 23, 2023, at 8:24 AM, V3 Registered Nurse stated, Staff are not to be standing when feeding residents. Staff are to be face-to-face with residents. It's a dignity issue. Per our policy, staff are not to be standing. On May 23, 2023, at 1:50 PM, V8 CNA said staff should be sitting down while feeding residents so that they are able to face the residents and see eye to eye. V8 said cell phones should not be used while feeding residents. The facility's Assistance with Meals policy dated December 6, 2022, shows, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure pressure injury treatments and interventions were in place for 3 of 3 (R11, R2, R9) residents reviewed for pressure injuries in the sample of 11. The findings include: 1.R11's admission Record form showed R11 was admitted to the facility on [DATE], with diagnoses including altered mental status, dementia, and Alzheimer's disease. R11's Skin/Wound note dated March 22, 2023, showed a new open wound was found to R11's sacral/coccyx area, measuring 3.0 cm (centimeters) x 0.3 cm. R11's Skin/Wound note dated May 22, 2023, showed, Skin remains fragile. Coccyx area remains with superficial open area, (Stage) 2. R11's current care plan showed, Keep skin clean and dry .Follow facility protocols for treatment of injury .Cleanse open area to sacrum, pat dry, apply Mepilex (foam) dressing, change dressing every 3 days and prn (as needed) until healed. On May 22, 2023, at 9:26 AM, R11 was asleep, seated in a recliner in a room. An odor of stool was noted in R11's room. On May 22, 2023, at 10:31 AM, R11 remained asleep in the recliner in her room. An odor of stool remained in R11's room. On May 22, 2023, at 11:13 AM, R11 remained asleep in the recliner in her room. An odor of stool remained in R11's room. On May 22, 2023, at 11:50 AM, V4 Certified Nursing Assistant (CNA) and V5 CNA entered R11's room to provide cares. V4 and V5 assisted R11 out of her wheelchair, to the toilet, via a mechanical lift. As R11 stood in front of the toilet, V5 CNA began removing R11's brief. As V5 removed the brief, a large amount of mushy, liquid stool, fell out of the brief onto the floor, Stool was noted leaking out of the brief, onto R11's inner thighs. R11's entire buttock area was covered with a large amount of stool. No dressing was noted to the circular reddened area to R11's coccyx area. No dressing was noted in R11's soiled incontinence brief. R11's buttocks were reddened. V5 CNA stated, We got (R11) up around 7:30 AM this morning. We did incontinence care at that time (4.5 hours prior). She doesn't have a dressing to her bottom. She doesn't need one. On May 23, 2023, at 8:24 AM, V3 Registered Nurse (RN) stated, (R11) has a stage 2 (pressure injury) to her coccyx .She is to have a foam dressing over her coccyx wound. It gets changed every 3 days and as needed. If the dressing is missing or has fallen off, staff are to tell the nurse so we can apply a new one. To help her wound heal, she is on a low air loss mattress, has a dressing to her coccyx, reposition her every 2 hours, and make sure her skin is kept clean and dry. No one told me yesterday that (R11) did not have a dressing over her coccyx wound. 2.R2's Wound Progress Note dated May 10, 2023, showed R2 had an unstageable pressure injury to her left heel and a stage 2 pressure injury to her right heel. R2's left heel pressure injury measured 3.5 cm x 4 cm x 0.4 cm. R2's right heel pressure injury measured 0.7 cm x 0.4 cm x 0.2 cm. R2's physician progress note dated May 1, 2023, showed, Needs offloading boots on at all times. On May 22, 2023, at 9:36 AM, R2 was seated in a wheelchair in her room. Gauze dressings were noted to both of R2's heels. No offloading boots were noted to R2's feet. On May 22, 2023, at 10:05 AM, R2 remained seated in a wheelchair in her room. No offloading boots were noted to R2's feet. The facility's Prevention of Pressure Injuries policy dated December 6, 2022, showed, Clean promptly after episodes of incontinence. Use facility-approved protective dressings for at risk individuals, Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. 3. R9's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, hematuria, and dementia. R9's MDS (Minimum Data Set) dated March 2, 2023, shows R9 requires total assistance with bed mobility and transferring. R9's Scale for Predicting Pressure Injury Risk dated May 23, 2023, shows R9 is high risk for developing pressure injuries. R9 Order Summary Report dated May 23.2023 shows an order for low air loss mattress dated June 18,2021. R9's Care Plan shows R9 has a potential for pressure injury development related to history of skin breakdown and limited mobility. R9 has a history of pressure injuries to his buttock. Intervention for low air loss. On May 22, 2023, at 1:13 PM, R9 was transferred into his bed. R9 had an air mattress pump to the foot of his bed and the pump was shut off. On May 23, 2023, at 2:03 PM, the mattress pump was shut off again. V4 CNA stated she thought the air mattress (pump) was on.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure peri care was provided in a manner to prevent urinary tract infections and failed to maintain a urinary drainage bag below the level of the bladder for two of five residents (R9, R15) reviewed for incontinence care and catheter care in the sample of 11. The findings include: 1. R9's admission Record shows he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hematuria, and dementia. R9's MDS (Minimum Data Set) dated March 2, 2023, shows he is always incontinent of bowel and bladder. R9's Care Plan shows he is totally dependent on staff for personal hygiene and oral care. On May 22, 2023, at 1:13 PM, V4 and V5 CNAs (Certified Nursing Assistants) transferred R9 from his recliner to his bed. R9 had urine and stool in his incontinence brief. V5 CNA wiped the stool from R9's buttocks but did not clean the urine from R9's front peri area. On May 23, 2023, at 1:50 PM, V8 CNA said residents peri areas should be washed from front to back. The facility's Perineal Care policy dated December 6, 2022, shows, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Wash perineal area starting with urethra and working outward .continue to wipe the perineal area including the penis, scrotum and inner thighs. Wash and rinse the rectal area thoroughly. 2. R15's admission Record shows he was admitted to the facility on [DATE], with diagnoses including urinary retention, gross hematuria, cognitive communication deficit, and acute kidney failure. R15's Care Plan dated April 25, 2023, shows R15 has a urinary catheter and to position catheter bag and tubing below the level of the bladder and away from entrance room door. On May 22, 2023, at 1:24 PM, V4 and V5 CNAs transferred R15 from his wheelchair to the toilet. V5 lifted R15's urinary drainage bag above the level of his bladder while he was sitting in the wheelchair. There was urine in R15's urinary drainage bag and in the tubing of the urinary catheter. On May 23, 2023, at 1:50 PM, V8 CNA said the urinary drainage bag should be kept below the level of the resident's bladder, so urine doesn't flow back and cause infection. The facility's Indwelling Catheter Protocol dated October 24, 2018, shows, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide ADL (activities of daily living) assistance for residents' requiring assistance for incontinence care for 4 of 11 residents (R11, R3, R9, R8) reviewed for ADLs in the sample of 11. The findings include: 1. R11's admission Record form showed R11 was admitted to the facility on [DATE], with diagnoses including altered mental status, dementia, and Alzheimer's disease. R11's resident assessment dated [DATE], showed R11 required the extensive assistance of staff for toileting and repositioning. The assessment showed R11 was incontinent of bowel and bladder. On May 22, 2023, at 9:26 AM, R11 was asleep, seated in a recliner in a room. An odor of stool was noted in R11's room. On May 22, 2023, at 10:31 AM, R11 remained asleep in the recliner in her room. An odor of stool remained in R11's room. On May 22, 2023, at 11:13 AM, R11 remained asleep in the recliner in her room. An odor of stool remained in R11's room. On May 22, 2023, at 11:50 AM, V4 Certified Nursing Assistant (CNA) and V5 CNA entered R11's room to provide cares. V4 and V5 assisted R11 out of her wheelchair, to the toilet, via a mechanical lift. As R11 stood in front of the toilet, V5 CNA began removing R11's brief. As V5 removed the brief, a large amount of mushy, liquid stool, fell out of the brief onto the floor, Stool was noted leaking out of the brief, onto R11's inner thighs. R11's entire buttock area was covered with a large amount of stool. R11's buttocks were reddened. V5 CNA stated, We got (R11) up around 7:30 AM this morning. We did incontinence care at that time (4.5 hours prior). 2. R3's current care plan showed R3 was cognitively impaired with diagnoses of dementia, aphasia, and intracerebral (brain) hemorrhage. R3's resident assessment dated [DATE], showed R3 was totally dependent on staff for cares/ADLs. The assessment showed R3 was incontinent of bowel and bladder. On May 22, 2023, at 9:35 AM, R3 was seated in a wheelchair in the activity room. A mechanical lift, cloth sling was noted underneath R3 in the wheelchair. On May 22, 2023, at 10:30 AM, R3's family wheeled R3 out of the activity room, down to her room for a visit. On May 22, 2023, at 11:05 AM, R3's family wheeled R3 into the dining room, where facility staff were seated. On May 22, 2023, at 12:13 PM, R3 remained in the dining room as facility staff fed her lunch. On May 22, 2023, at 1:15 PM, R3 remained in the dining room, asleep in her wheelchair. On May 22, 2023, at 2:00 PM, V4 and V5 CNAs wheeled R3 into her room to provide cares. R3 was transferred to her bed by V4 and V5 CNAs. V4 removed R3's incontinence brief. R3's brief was saturated with urine and a small amount of stool. R3's buttocks were reddened with visible creases indented in the skin of her buttocks from the mechanical lift cloth sling R3 was sitting on. V4 CNA stated, I got (R3) up around 6:30 AM this morning and did incontinence then (7.5 hours prior). She was the first one I got up. I haven't done incontinence care on her since then. On May 23, 2023, at 8:24 AM, V3 Registered Nurse stated, Residents should be repositioned every 2 hours. Residents should be checked for incontinence every 2 hours and cleaned up when needed. 3. R9's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, and hematuria. R9's MDS (Minimum Data Set) dated March 2, 2023, shows he requires total assistance with toilet use, personal hygiene, bed mobility, and transferring. R9 is always incontinent of bowel and bladder. R9's Care Plan shows he has an ADL (Activities of Daily Living) self care performance deficit related to Alzheimer's, dementia. R9 is dependent on staff for repositioning, turning in bed, personal hygiene and oral care. On May 22,2023, R9 was observed sitting in a tall back recliner at various times from 9:30 AM-1:13 PM. On May 22, 2023, at 1:13 PM, V4 and V5 CNA (Certified Nursing Assistant) transferred R9 from the recliner to the bed. There was urine and stool in R9's incontinence brief. There were creases on R9's buttocks from sitting in the recliner. V4 said that R9 has been up in the recliner since 6:30 AM. 4. R8's Face Sheet shows she was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease and history of falling. R8's MDS dated [DATE] shows she requires extensive assistance with bed mobility and transferring. R8 requires total assistance for toilet use and personal hygiene. R9's Care Plan shows she has bladder incontinence related to activity intolerance, confusion, dementia, urinary tract infection, and impaired mobility. Clean peri-area with each incontinence episode. On May 22, 2023, R9 was observed sitting in her high back recliner at various times from 9:29 AM-12:55 PM. At 12:55 PM, V4 and V5 transferred R9 into bed. R9's incontinence brief was saturated with urine and creases were noted to R9's skin on her upper legs and buttocks. There was stool noted to R9's buttocks. V4 said that R9 has been up and in her high back recliner since about 7:30 AM. On May 23, 2023, at 1:50 PM, V8 CNA said incontinence care and repositioning should be done at lease every two hours in order to protect residents skin. The facility's Activities of Daily Living policy dated December 6, 2022, shows, Residents will be provided with care, treatment and services as appropriated to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The facility's Perineal Care Policy dated December 6, 2022, shows, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview, interview, and record review the facility failed to ensure enhanced barrier precautions were implemented and failed to change gloves and perform hand hygiene during incontinence care in a manner to prevent cross contamination. This has the potential to affect all 15 residents residing in the facility. The findings include: 1. The facility's Resident Census and Condition Report (CMS 672) dated May 22, 2023, shows a resident census of 15. On May 23,2023 at 09:16 AM, V2 Director of Nursing (DON) said the facility has no residents on transmission based precautions (TBP) or enhanced barrier precautions (EBP). V2 said there is no specific facility policy on enhanced barrier precautions. The facility's Matrix dated May 22, 2023 shows R12, R14, and R15 have urinary indwelling catheters and R2 and R11 have pressure wounds. On May 23.2023 at 01:40 PM, V2 said the facility has not updated their transmission based precautions to include enhanced barrier precautions. V1 Administrator said they recall hearing about EBP but have not implemented the precautions at the facility. V2 said EBP would apply to residents with urinary catheters or wounds. V2 said the facility has 5 residents that have catheters and/or wounds. V2 said staff should wear gown and gloves when providing care for residents on EBP. The CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated July 12, 2022, shows: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and/or Infection or colonization with an MDRO. 2. R67's admission Record shows he was admitted to the facility on [DATE], with diagnoses including sepsis and urinary tract infections. On May 22, 2023, at 10:10 AM, V4 and V5 CNAs (Certified Nursing Assistants) transferred R67 from his wheelchair to his bed. There was a large amount of stool noted to the back of R67's pants. V5 removed R67's soiled pants and folded the soiled brief down in between R67's legs. V5 then touched R67's knees and the safe transfer belt. V4 wiped R67's front peri area then touched R67's body to help him to turn to his side. V5 then wiped R67's buttocks, there was stool noted to V5's right pointer finger glove. V5 then touched the wipes container and R67's call light. There was no glove change or hand hygiene performed by V4 or V5. 3. R8's admission Record shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and history of falling. R8's MDS (Minimum Data Set) dated March 20, 2023, shows R8 is frequently incontinent of urine and always incontinent of stool. On May 22, 2023, at 12:55 PM, V5 CNA folded R8's incontinence brief down, in between her legs. V5 wiped R8's front peri area, then turned R8 onto her side in order to wipe R8's buttocks. V5 did not change her gloves or perform hand hygiene. 4. R13's MDS dated [DATE], shows he is always incontinent of bowel and bladder. On May 22, 2023, at 10:51 AM, V4 and V5 placed R13 onto the toilet. There was stool noted in R13's incontinence brief. V5 removed the soiled incontinence brief and placed a new brief around R13's legs. V5 then touched R13 to help him to stand. V4 wiped the stool from R13's buttocks, then pulled the new clean incontinence brief up, touched R13's body, and touched R13's wheelchair. There was no glove change or hand hygiene performed by V4 or V5. On May 23, 2023, at 1:50 PM, V8 CNA said gloves should be changed before you touch clean items. The facility's Handwashing/Hand Hygiene policy dated December 6, 2022, shows, This facility consider hand hygiene the primary means to prevent the spread of infections. Use an alcohol based hand rub; or alternatively, soap and water for the following situations: before and after direct contact with residents, before and after handling an invasive device, and before handling clean or soiled dressings. Before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin.