Based on record review, resident and staff interviews the facility failed to conduct quarterly care conferences and invite resident/family to attend and provide input for 1 of 12 residents reviewed (Resident #11) The facility census was 34 residents. Findings include: Review of the documentation for Resident #11 revealed an admission date to the facility of 4/12/21. Review of the most recent Minimum Data Set MDS) assessment for Resident #11 dated 4/15/22, showed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident was cognitively intact. During an interview on 7/12/22 at 10:59 am, Resident #11 stated they have been a resident here for a little over a year now and is only aware of 2 care conferences for reviewing and updating her plan of care since her admission here and states that the second one only happened because she asked the facility Social Worker why she only had one since admission to the facility. Resident #11 went on to say that she used to work in a nursing home so she knows they are to have care conferences quarterly, Resident #11 stated the Social Worker said they could do one right then, sat in her room and asked if she had any concerns, Resident #11 told the Social Worker she had no concerns at that time. Review of the EMR (Electronic Medical Record) for Resident #11 revealed Care Conference Progress Notes for documentation of care conferences since the residents admission dated 7/22/21, 10/21/21, & 11/17/21. Further review of those Care Conference Progress Notes revealed that the Care Conference held on 7/22/21 Resident #11 attended, the Care Conference held 10/21/21 documented the resident as having attended (though the resident does not recall this), and the Care Conference documented on 11/17/21 only the facility Social Worker and Resident #11 attended, no other Care Conference Progress Notes were found in the EMR since that date to the current date of 7/14/22. During an interview on 7/13/22 at 11:16 am the facility ADON verified the Resident had no other Care Conferences since admission to the facility and stated she would expect Care Conferences to be held at least quarterly (every 3 months) and that a Resident with a BIMS score of 15 would be invited to attend their Care Conference to provide input for updating the plan of care for that resident.

Based on observation, record review, and staff interviews the facility failed to follow manufacturers recommendations for use of insulin pens for 1 of 1 residents observed receiving insulin injections (Resident #4). The facility census was 34 residents. Findings include: Review of the Physicians Orders for Resident #4 revealed current orders on 7/13/22 for the resident to receive a scheduled dose of Lantus (long acting) insulin of 45 units every morning as well as an adjusted dose of Humalog (short acting) insulin based on the residents blood sugar level at that time. During observation of Medication Administration on 7/13/22 at 7:00 am, Staff A (LPN) reviewed the medication orders for Resident #4 and took out the Residents Lantus pre-filled insulin pen and placed a disposable, one-time use insulin needle on the pen then dialed the administration dose to 45 units as ordered, then removed the Residents Humalog pre-filled insulin pen and placed a disposable, one-time use insulin needle on the pen then dialed the administration dose to 4 units (based on the residents blood sugar of 254). Staff A then went into the resident room and administered both doses of insulin to Resident #4 without priming the needles to ensure no air was present and accurate insulin dose administration. During an interview on 7/13/22 at 7:05 am, after administration of the 2 doses of insulin to Resident #4, Staff A stated that they were not aware that use of insulin pens required priming of the needles with 2 units of insulin prior to dialing up the ordered dose of insulin to be administered to ensure the accurate amount of insulin is administered to the residents. Review of the manufacturers information/recommendation provided to the facility by their pharmacy for the use of Lantus insulin pens directs the users to use a new needle for each injection and to follow Step 3 of the Instructions for use. Step 3 of the Instructions for use directs the users to always perform a safety test before each injection, this ensures that you get an accurate dose by ensuring the pen and needle work properly and remove any air bubbles, then instructs the user to select a dose of 2 units, remove the cap, hold pen with needle pointing upwards, tap the insulin pen so any air bubble rise to the needle, then press the injection button all the way in and check that insulin comes out of the needle tip. Review of the manufacturers information/recommendation provided to the facility by their pharmacy for the use of Humalog insulin pens directs the users to prime the insulin pen before each use and warns that if you do not prime before each injection you may get too much or too little insulin, then directs users to prime the pen by turning the Dose Knob to 2 units, hold the pen with the needle pointing up and tap on the pen gently to collect air bubbles at the top, continuing to hold the pen with needle pointing up and push the Dose Knob until it stops at 0 and says that you should see insulin at the tip of the needle. The information then directs the users to turn the Dose Knob to the desired number of units of insulin to be administered. During an interview on 7/13/22 at 11:18 am, the facility ADON stated that they do expect nursing staff to prime insulin pens with 2 units of insulin each time before use and that she does instruct any new nurses to the facility to follow this procedure for insulin administration using insulin pens.