Based on record review, Facility Assessment review, and resident and staff interviews the facility failed to employ sufficient numbers of staff on the weekends to meet resident needs. The facility reported a census of 43 residents. Findings include: A review of the Centers for Medicare & Medicaid Services (CMS) PBJ Staffing Data Report revealed the facility triggered for excessively low weekend staffing for Quarter 3, 2024 (April 1-June 30). A review of the Edgewood Convalescent Home Shift assignment sheets from April 1st through June 30th, 2024 revealed required staff were absent for either partial or whole shifts as follows: First shift- Certified Nursing Aides (CNA) 23 days Second shift- CNA 19 days, Nurse 3 days Third shift- CNA 1 day In an interview on 10/30/24 at 9:25 AM Resident #2 expressed the facility needed more staff, especially CNA's on weekends. She noted there just didn't seem to be enough. In an interview on 10/30/24 at 9:32 AM Resident #21 verbalized they [the facility] needed more staff on the weekends. They treated her well but she has had several episodes of incontinence because she had to wait too long for them to come and help. They just run short on the weekends. In an interview on 10/30/24 at 10:13 AM Staff A, CNA reported she did not feel like they had enough staff during the weekend, and noted they can't get their normal tasks done during the day because of this. In an interview on 10/30/24 at 11:25 AM Staff B, CNA explained she did not feel they had enough staff on the weekends. When the facility was full, or even now, it was not enough. They did not have enough time to get everything done during the shift and didn't have the extra staff around like during the week. Toileting got missed the most. In an interview on 10/30/24 at 12:59 PM the Administrator explained the facility receives a sheet from Corporate that tells them how many staff they should have per resident. It is a document based off of the census, not acuity. Corporate utilizes the Facility Assessment to create the sheets that inform the staffing numbers. In an interview on 10/30/24 at 1:04 PM the Director of Nursing (DON) explained Corporate decided what staffing ratios should be, based on census, not acuity. The facility goes off of the staffing sheets sent to the Administrator. The Facility Assessment Tool, undated expressed the following: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The intent of the Facility Assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. The facility assessment is used to inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill set necessary to care for residents' needs as identified through resident assessments and plans of care. Staffing needs for each shift and each unit area adjusted as necessary based on changes to the resident population. It instructed staff ratios to be the following: First shift- 2 nurses, 5 CNA's Second shift- 2 nurses, 5 CNA's Third shift- 1 nurse, 2 CNA's

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, insulin pen competency review, Novolog highlights of prescribing information (manufacturer's directions for use), and staff interview, the facility failed to prime the insulin pen with 2 units of insulin prior to the administration of the physician ordered dose of insulin for 1 of 1 residents observed for insulin administration (Resident #5). The facility identified a census of 48 residents. Findings include: Resident #5 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status score of 14 indicating intact cognition. The MDS listed a diagnosis of diabetes mellitus and documented Resident #5 received insulin injections 7 days per week. The Care Plan revised 8/25/23 noted a diagnosis of diabetes and directed the staff to check blood sugars and administer diabetic medications as physician ordered. The October 2023 Medication Administration Record (MAR) detailed the following physician orders: a. Novolog Solution 100 Units (u) per Milliliter (ml) inject 14 units subcutaneously (under the skin) before meals related to type 2 diabetes mellitus without complications. b. Novolog Injection Solution 100 u/ml inject as per sliding scale insulin (SSI): if 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units ; 401 - 450 = 6 units. Call the medical doctor if the blood sugar is greater than 400, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. An Order Summary Report signed by the Provider on 10/03/23 listed the following physician orders: a. Novolog Solution 100 u/ml inject 14 units subcutaneously before meals related to type 2 diabetes mellitus without complications. b. Novolog Injection Solution 100 u/ml inject as per sliding scale insulin (SSI): if 151 - 200 = 1 unit; 201 - 250 = 2 units; 251 - 300 = 3 units; 301 - 350 = 4 units; 351 - 400 = 5 units; 401 - 450 = 6 units. Call the medical doctor if the blood sugar is greater than 400, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. During an observation on 10/03/23 at 11:17 AM Staff A, Registered Nurse (RN) verbalized she would administer 14 units of Novolog insulin and 1 unit of Novolog SSI for a blood sugar of 167. Staff A reviewed the MAR orders and set the Novolog insulin pen to a total of 15 units and prepared to administer the insulin. At 11:24 AM the Surveyor stopped Staff A from administering the Novolog insulin flex pen. Staff A verbalized she didn't know what she had done wrong. Staff A referred to the Director of Nursing (DON) and asked what she had done wrong. The DON stated she needed to prime the pen with 1-2 units of insulin prior to setting the dose on the insulin pen. At 11:26 AM Staff A administered the correct amount of insulin to Resident #5. On 10/04/23 at 9:04 AM Staff B RN reported she received training by the facility on administration of insulin per pen. She explained the pen should be set to 2 units to prime the pen prior to setting the dial to the amount of insulin ordered by the physician. During an interview on 10/05/23 at 8:50 AM the DON reported she expected the nurses to follow the Insulin Pen Competency for proper priming of the pen. The undated Insulin Pen Competency provided by the facility directed the nurses in the following procedure: a. Prime the pen by dialing up 2 units of insulin. Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. b. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero. c. If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and perform the test again. d. Make sure the window says 0 and then select the dose. The Novolog Highlights of Prescribing Information under priming the Novolog Flex Touch Pen instructed the following: a. Turn the pen dose selector to select 2 units. b. 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. c. Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. d. A drop of insulin should be seen at needle tip. If you do not see a drop of insulin repeat the priming steps, no more than 6 times. e. If you still do not see a drop of insulin, change the needle and repeat the priming steps. f. Turn the dose selector to select the number of units you need to inject.

Based on Continuous Quality Improvement Attendance sheets, policy review, and staff interviews the facility failed to have routine quarterly Quality Assurance and Performance Improvement (QAPI) meetings in the years of 2021 and 2022. In addition the facility failed to have the Medical Director attend 1 of 2 QAPI meetings held in 2021. The facility identified a census of 42 residents. Findings include: A review of the facility Continuous Quality Improvement (CQI) Attendance sheets completed on 6/8/22 revealed the facility held two QAPI meetings in the year 2021 on 8/31/21 and 9/30/21. The facility lacked documentation of a QAPI meeting held in the year 2022. The CQI Attendance sign-in sheet dated 8/31/21 documented that the facility held a QAPI meeting at 8:00 a.m. with the Medical Director, the Director of Nursing (DON), and two additional staff members as required. The CQI Attendance sign-in sheet for the QAPI meeting held on 9/30/21 lacked documentation of the Medical Directors signature for attendance. On 6/8/22 at 2:12 p.m. the Administrator reported that she started working at the facility in January (2022). The facility had a quality meeting in January with the Medical Director, but she didn't know that they needed to keep notes and have a sign-in sheet. The Administrator explained that they did miss the April 2022 quality meeting. She stated they developed an action plan and the Medical Director would come to the facility that week to get a quality meeting completed. The undated QAPI Plan Policy provided by the facility, documented the Administrator responsible and accountable to the board of directors and/or executive leadership for ensuring that QAPI is implemented throughout the organization. The Administrator is responsible for assuring that all QAPI activities and required documentation is provided to the governing body. All department managers, the Administrator, the Director of Nursing, infection control and prevention office, medical director, consulting pharmacist and up to three additional staff will provide QAPI leadership as the Quality Assessment and Assurance (QAA) committee. The QAA committee will meet monthly.