The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to meet professional standards of quality when administering insulin (a hormone that lowers the level of glucose in the blood) with an insulin pen (an injection device used to deliver preloaded insulin). This placed the seven residents who received insulin at risk of receiving an inaccurate dose. Findings included: - On 03/11/25 at 08:00 AM, Licensed Nurse (LN) G administered Lantus and Aspart (manufacturer named) insulin subcutaneously (beneath the skin) without priming the insulin pen to Resident (R) 11. LN G verified she had not primed the insulin prior to administration of the insulin and was unaware of the manufacturer or facility policy to do so. On 03/11/25 at 09:59 AM, Administrative Nurse D stated she was unaware of the need to prime the insulin pens prior to dialing the ordered units of insulin. The facility's Insulin Administration policy, dated 09/2014, documented that the nursing staff will have access to specific instructions (from the manufacturer, if appropriate) on all forms of insulin delivery system (s) prior to their use. The policy lacked instructions regarding the need to prime insulin pens prior to giving the dose. The manufacturer's instructions of use for Lantus and Aspart insulin pens direct the user to prime the insulin pens with two units of waste insulin prior to dialing the physician ordered dose. The facility failed to ensure professional standards of quality when preparing and administering insulin, using insulin pens, which placed the residents at risk of receiving inaccurate doses of insulin.

The facility had a census of 31 residents. The sample included 12 residents, with five residents reviewed for immunizations. Residents (R) 11 and R13 lacked the pneumococcal vaccination (helps protect against serious illnesses like pneumonia). Based on record review, and interview, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) to administer a pneumococcal vaccine following written consent. This deficient practice placed the R11 and R13 at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease. Findings included: - A review of immunization records revealed R11 and R13 lacked the CDC recommended pneumococcal immunizations. On 09/03/24 R11 and 08/27/24 R13 had signed consent on the Consent Form for Flu and Pneumonia Vaccine to receive the pneumonia vaccine. Both R11 and R13 lacked documentation of having received the CDC recommended pneumococcal immunizations. Administrative Nurse D was unable to provide documentation R11 and R13 had received the appropriate pneumococcal vaccinations. On 03/12/25 at 12:19 PM, Administrative Nurse D reported the local medical clinic had obtained the consents and would have administered immunizations. The facility's Pneumococcal Vaccine policy, dated 10/2019, documented that administration of pneumococcal vaccinations or revaccination will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. This deficient practice placed the R11 and R13 at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to disinfect a glucometer (blood sugar reading machine) between resident use and sort soiled laundry in a sanitary manner. This placed the residents at risk for infectious disease processes. Findings included: - On 03/11/25 at 07:31 AM, Licensed Nurse (LN) G obtained a blood sugar reading for Resident (R) 6 by using a multiuse glucometer. LN G then placed the glucometer on top of the treatment cart. LN G then left the glucometer on the top of the cart and went on to perform other nursing tasks. On 03/11/25 at 07:52 AM, LN G returned to the treatment cart and retrieved the glucometer to obtain another resident's blood sugar level. LN G then took the unsanitized glucometer into another resident's room to obtain a blood sugar reading. LN G stated she had not sanitized the glucometer between resident use. On 03/11/25 at 10:01 AM, Administrative Nurse D verified the glucometer should be cleaned with appropriate sanitizing wipes between each resident use. The facility's Shared Glucometer Cleaning Protocol dated 03/21/22 documented that glucometers shared by multiple residents will be thoroughly wiped with Sani-Cloths and allowed to air dry for two minutes after every use and between residents. The facility failed to ensure the multiuse glucometer was sanitized between resident use, which placed the residents at risk for infectious disease processes. - On 03/11/25 at 10:27 AM, Housekeeping/Laundry Staff V reported wearing only gloves as personal protective equipment (PPE - gowns, face shields and/or eyeglasses/goggles, and gloves) while sorting soiled laundry. Housekeeping/Laundry Staff V stated he was new to the position and had not been informed he was to use a gown and gloves to sort soiled laundry. On 03/11/25 at 11:26 AM, Housekeeping/Laundry Supervisor U stated Housekeeper/Laundry Staff V should wear a gown and gloves while sorting soiled laundry. She stated she had gotten busy with other tasks and forgotten to replenish the supply of gowns for sorting of soiled laundry. The facility's undated Soiled [NAME] and Bedding policy documented that soiled laundry/bedding shall be handled, transported, and processed according to the best practice for infection prevention and control. All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting). Hand hygiene products, as well as appropriate PPE (i.e. gloves and gowns), are available and used while sorting and handling contaminated linens. The facility failed to sort soiled laundry by using appropriate PPE, which placed the residents at risk for infectious disease processes.