**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure proper implementation of the self-administration of medication (SAM) assessments for 2 of 2 residents (R36, R1), reviewed for medication administration. Findings include: R36's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R36 was cognitively intact and diagnoses of diabetes, heart failure, and arthritis and required the assistance of one staff with activities of daily living (ADL's) for transfers and toileting. R36's physician orders dated 8/4/25, revealed the following: - Lidocaine External Patch 4%, apply to back topically two times a day for pain. Apply at bedtime (HS) and remove at morning (AM). R36's electronic medical record (eMAR) dated 7/1/25 to 8/5/25, revealed nursing staff had applied and removed the lidocaine patch daily following physician’s orders. R36's self-administration of medication (SAM) assessment dated [DATE], indicated R36 was able to self-administer medications after the nurse set-up R36’s medications. During an observation on 8/05/25 at 3:45 p.m., trained medication aid (TMA)-C stated R36 was to have a lidocaine patch applied at HS. TMA-C confirmed R36's box of lidocaine patches were sitting out on R36's dresser in R36's room. TMA-C left the room after giving R36's medications, however, did not put R36’s box of lidocaine patches away in the locked medication drawer. During an observation on 8/06/25 at 8:09 a.m., R36 continued to have an open box of lidocaine patches, containing three unopen patches, sitting on top of R36’s dresser in R36’s room. During an observation and interview on 8/06/2025 at 8:52 a.m., R36's lidocaine patches remained in the same position. R36 indicated she had a patch put on at HS and R36 removed the lidocaine patch independently in the AM. During an interview on 8/06/25 at 8:32 a.m., pharmacy consultant (PC) stated R36 was to have one lidocaine patch on at a time and nursing staff should have only leave one patch out for R36 to apply. PC further stated it was important to follow the SAM assessments to ensure residents are appropriately using medications. During an interview on 8/06/2025 at 9:01 a.m., clinical coordinator (CC)-A confirmed R36's order for lidocaine patches. CC-A indicated R36 was not able to apply them independently but could remove them independently. CC-A revealed the lidocaine patches should have been put away in R36's drawer when they were not being used. CC-A entered R36's room and put the lidocaine patches away in R36's locked medication drawer. During an interview on 8/06/25 at 9:21 a.m., director of nursing (DON) confirmed the above findings and stated it was important for medication staff to put medications away in the appropriate location for safety reasons. DON further stated it was important for medication staff to return to the residents’ room to ensure medications were taken properly. R1's significant change minimum data set (MDS) dated [DATE], revealed R1 had a mild cognitive impairment. R1 had a diagnosis of having an indwelling urinary catheter, heart failure, and hypertension. R1 needed extensive assistance for activities of daily living (ADLs). R1's signed orders dated 6/17/25, had an order for Clotrimazole ointment 1% (antifungal) for cutaneous candidiasis (skin infection), apply to the penis head twice a day, and Miconazole powder (antifungal) to affected red areas topically as needed when the current supply of nystatin powder (antifungal) is exhausted. R1's care plan revised on 6/6/25, revealed R1 is not able to self-administer medications. R1's self-administration of medication assessment dated [DATE], revealed R1 was not able to self-administer medications. During an observation and interview on 8/4/25 at 1:07 p.m., a tube of Clotrimazole cream 1% and Nystatin powder was sitting on the nightstand. R1 indicated that staff would leave the cream and powder on the nightstand for staff to apply. R1 indicated that if the medications were not left out on the nightstand, staff would not apply the cream and powder, as only one person can get out the cream and powder and apply it when they are locked up. During an interview on 8/4/25 at 1:26 p.m., licensed practical nurse (LPN)-A verified R1 did not have an order to self-administer medication. LPN-A verified there was a tube of Clotrimazole cream 1% and Nystatin powder on R1 nightstand. LPN-A locked up the medications in the medication drawer. During an interview on 8:33 a.m., pharmacy consultant indicated Clotrimazole and Nystatin are both antifungal medications and should have a self-administered assessment done to ensure the resident knows how to correctly administer the medications. During an interview on 8/6/25 at 9:23 a.m., clinical coordinator manager (CCM)-A indicated medications applied by the nurse or trained medical assistant (TMA) should be in the medication drawer. CCM-A indicated that a self-administration assessment was important to ensure the resident understands how to administer a medication correctly. CCM-A indicated that locking a medication in a medication drawer is important to ensure the safety of residents and visitors. During an interview on 08/06/2025 at 10:23 a.m., director of nursing (DON) verified that creams and powders should be in a locked drawer unless the resident has a self-administration of medications order and was assessed to ensure they were safe to have the medications at bedside. Facility policy titled Self-Administration of Medications dated 2/21, the interdisciplinary team (IDT) assesses each resident’s cognitive ability and physical abilities to determine whether self-administering of medications is safe and appropriate. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively assess the use of a low bed as a potential restraint for 1 of 1 resident (R32) reviewed for restraints.Findings include: R32's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R32 had severe cognitive impairment and diagnosis of Parkinson's, hypertension (elevated blood pressure) and arthritis. R32 required extensive assistance for activities of daily living (ADL's) which included bed mobility, transfers, and toileting. R32 had no impairment of upper or lower extremities, had a history of falls, and required a wheelchair for mobility. MDS indicated R32 did not use any restraints. R32's significant change Care Area Assessment (CAA) dated 6/24/25, identified R32 had severe cognitive impairment and was a fall risk and R32 did not use any restraints. Review of R32's quarterly fall assessment dated [DATE], identified R32 had balance problems when walking and standing and was a moderate risk for falls. Assessment did not identify the use of any restraints. Review of R32's current physician orders signed 6/17/25, did not identify an order for a restraint. R32's medical record lacked any evidence a restraint assessment had been completed. R32's care plan revised 7/25/25, identified R32 had a self - care deficit and was at risk for falls related to confusion, impaired balance and limited mobility. Identified 32 had a fall on 7/25/25 and directed staff to ensure R32's bed is in the lowest position at night for safety. Identified R32 transferred using a stand-up lift. R32's progress note dated 7/28/25 at 10:55 a.m., identified on 7/25/25 R32 was found on the floor next to her bed. Identified R32 had attempted to self-transfer from bed. Identified a new intervention after fall was to have bed in lowest position when R32 was in bed. During an observation on 8/4/25 at 6:49 p.m., R32's bed was about 1 ft. off the ground and R32 was sitting at the edge of the bed leaning forward and was yelling I can't get up come help me. Nursing assistant (NA)-A and NA-B entered R32's room and assisted R32 to lie back down in bed and boosted R32 up in the bed. During a joint interview on 8/4/25 at 6:56 p.m., nursing assistant (NA)-A stated R32 attempts to get out of bed on her own and had fallen. NA-A stated the latest intervention was to put R32's bed in the lowest position to keep R32 from getting up and falling. NA-B stated the low bed makes it really hard for R32 to stand up on her own. NA-A and NA-B stated R32 was able to stand on her own even though it was not always safe. NA-A and NA-B stated they were unsure if R32's low bed was a potential restraint. During an interview on 8/5/25 at 8:26 a.m., licensed practical nurse (LPN)-A stated R32 's bed is in lowest position because R32 has had falls trying to self transfer out of bed. LPN-A verified R32 was able to stand up on her own. LPN-A stated she did not feel putting R32's bed in lowest position was a restraint because even though R32 was able to stand on her own it was not safe for R32 to stand on her own. LPN-A verified R32's low bed was not assessed as a potential restraint. During an interview on 8/5/25 at 8:33 a.m., physical therapy assistant (PTA) stated R32 was able to stand up on her own and she should wait for help to stand up. PTA stated R32's bed is in the lowest position so that if R32 attempts to stand up on her own and falls it won't be so far to fall. PTA stated she did not think of the low bed as a potential restraint for R32 because R32 was not aware of the potential of falls when she stood on her own. During an interview on 8/5/25 at 10:08 a.m., director of nursing (DON) verified R32's care plan revealed R32 had falls attempting to self- transfer and the latest intervention was for 32's bed to be placed in the lowest position. DON verified a restraint assessment had not been completed prior to placing R32's bed in the lowest position. DON stated she had not thought of the low bed as a restraint for R32 because even though R32 was able to self transfer she was not always safe during self- transfers. DON further stated she could see how R32's low bed could be a potential restraint. DON stated her expectation was that a restraint assessment would have been completed prior to placing R32's bed in the lowest position. Review of a facility policy titled Restraint Free Environment revised 2025, identified a physical restrain refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body such as placing a resident in a chair that prevents the resident from rising independently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded to include the use of safety alarms for 1 of 1 residents (R17) reviewed for MDS. Findings include R17's significant change in status MDS dated [DATE], identified R17 had medically complex conditions, hypertension, anxiety, and depression. R17 needed extensive assistance with activities of daily living (ADLs). R17 did not use a bed alarm, chair alarm, floor mat alarm, or motion sensor alarm.R17's care plan was revised on 7/25/24, revealing R17 had audible wheelchair and silent bed and recliner alarms. R17's signed orders dated 6/17/25, revealed R17 had orders to monitor the placement and function of the bed and recliner alarm, and the audible wheelchair alarm every shift for fall intervention; the order start date was 2/6/24.During an observation on 8/4/25 at 6:48 p.m., R17 was in the living room area next to the dining room, with a chair alarm on the back of the wheelchair. During an observation on 8/5/25 at 8:05 a.m., R17 was lying down in bed, the bed was low to the floor with a floor mat and a bed alarm attached to the bed. During an observation on 8/5/25 at 12:10 p.m., R17 was not in the room, but the alarm strip was on the bed. R17 was in a wheelchair, sitting in front of the television with an alarm on the back of the wheelchair. During an observation on 8/6/25 at 7:10 a.m., R17 was in a low bed with a bed alarm attached to the bed. During an interview on 8/5/25 at 12:15 p.m., registered nurse (RN)-E, verified R17 has had a bed alarm and a chair alarm since RN-E started working at the facility about a year ago.During an interview on 8/5/25 at 2:17 p.m., MDS coordinator verified the MDS was not coded for a bed alarm or a chair alarm. The MDS coordinator viewed the Kardex and the care plan and verified R17 did have a bed alarm and chair alarm and should have been coded on the MDS. The MDS coordinator indicated the process was to review the assessments, care plan, and care conference notes when completing an MDS. The MDS coordinator indicated at times she would perform a visual assessment on a resident, but did not have a visual assessment when completing R17's MDS. During an interview on 8/5/25 at 2:52 p.m., RN-F viewed R17's care plan and Kardex and verified R17 had a bed alarm and chair alarm and should have been coded on the MDS. During an interview on 8/6/25 at 10:21 a.m., director of nursing (DON) expectation would be for the MDS coordinator to review the care plan. DON verified the bed alarm and chair alarm were located in R17's care plan. DON's expectation would be for the MDS to be coded correctly. Review of the facility policy titled Resident assessments dated October 2023, revealed information in the MDS assessment will consistently reflect information in the progress notes, plans of care, and resident observations/interviews.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure recommended splint or alternative devices were utilized to help prevent further contractures and stiffness for 1 of 1 residents (R11) reviewed for range of motion (ROM). Findings include:R11's annual Minimum Data Set (MDS) assessment dated [DATE], identified R11 had severe cognitive impairment and had diagnoses of cerebral palsy (irregular brain development that affects movement and posture), seizure disorder, and malnutrition. Indicated R11 required extensive assistance of staff for activities of daily living (ADLs) including transfers and toileting. R11's care plan revised 7/26/23, identified R11 had limited physical mobility related to the disease process. Additionally, R11 had the potential for skin impairment related to decreased mobility. R11's care planned interventions included:- Apply small towel roll in between left elbow and shoulder and small roll in left palm web space.- Left Hand Contractures: Place foam roll in palm of left hand between thumb and palm to prevent skin breakdown. Remove and check skin every two hours and as needed. R11's treatment administration record (TAR) dated 7/1/25 to 8/5/25, identified R11 was to apply a small towel roll in between left elbow and shoulder and small roll in left palm web space Monday, Wednesday, and Friday.R11's Kardex dated 8/5/25 revealed the following:- Left Hand Contractures: Place small towel/washcloth as resident will tolerate in left palm between thumb and palm every two hours and as needed.- Place small towel/ washcloth as resident will tolerate between left elbow and shoulder. Notify nurse if noted skin alternation. During an observation on 8/4/25 at 12:18 p.m., R11 was lying in bed with eyes closed. R11 left hand was tightly closed with thumb pressed against palm of hand and four fingers placed over thumb. Additionally, R11's left arm was bent up at the elbow. R11 was able to move right hand open and closed. R11 is non-verbal and unable to answer any questions. R11 did not have a washcloth or foam roll placed in R11's left hand and left elbow.During an observation on 8/4/25 3:30 p.m., R11 remained in a similar position as noted above.During an observation on 8/4/25 at 7:02 p.m., R11 was resting in bed with music playing. R11 had a gown on and was covered with a thin blanket. R11 did not have a washcloth or foam roll placed in R11's left hand and left elbow.During an observation on 8/5/25 at 8:20 a.m., R11 was resting in bed covered with a blanket. R11 was listening to music with R11's eyes closed. R11 did not have a washcloth or foam roll placed in R11's left hand and left elbow.During an observation and interview on 8/5/25 to 9:47 a.m., registered nurse (RN)-E entered R11's room to provide medications. RN-E stated R11 did not have a brace for R11's left hand. RN-E further stated staff were to be doing range of motion (ROM) on R11's upper extremities to help reduce further contractures. RN-E provided ROM on R11 after completing medication administration. RN-E completed ROM, cleaned up supplies, left R11's room, and charted ROM in R11's TAR.During an interview and observation on 8/5/25 at 11:06 a.m., rehabilitation director (RD) revealed passive range of motion (PROM) of R11's upper extremities was an order from occupational therapy (OT). RD further revealed R11's left hand was contracted when R11 was admitted to the facility and R11 could not use a brace. RD indicated OT ordered the use of a washcloth in place of a brace. RD further indicated R11 had an order to place a washcloth in the left hand and left elbow Monday, Wednesday, and Friday. RD reviewed R11's care plan and stated another intervention was listed for staff to place a foam roll in R11's left hand and monitor every two hours. RD confirmed the correct order should have been to place a washcloth in R11's hand and elbow Monday, Wednesday, and Friday. RD entered R11's room to evaluate R11's left hand to see if contractors had gotten worse. RD stated there had not been much change in R11's left hand and left arm. RD indicated R11 would still benefit from having a washcloth placed in R11's hand and elbow as tolerated Monday, Wednesday, and Friday.During an interview on 8/5/25 at 11:22 a.m., registered nurse (RN)-F and RD reviewed R11's orders and care plan. RN-F confirmed the current orders and care plan interventions for R11 and indicated RN-F was unaware what exact orders staff should have been following. RN-F indicated RN-F would contact the clinical coordinator to confirm the correct orders for R11. During a follow-up interview on 8/5/25 at 2:13 p.m., RN-F indicated the clinical coordinator stated R11 should have had the foam roll intervention removed from the care plan. RN-F further indicated the correct order was currently listed on the TAR and staff should have been following the current order.During an interview on 8/5/25 at 2:33 p.m., director of nursing (DON) confirmed the above findings and stated she expected staff to follow the plan of care to ensure residents do not have a decline in care. DON further stated it is important residents continue to keep the highest level of ROM as possible. Facility policy titled restorative nursing services revised 7/17, resident will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitation services. Restorative goals may include, but are not limited to supporting and assisting the resident in: participating in the development and implementation of his/her plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure medications were labeled appropriately to include administration directions, insulin pens were dated and not expired and failed to dispose of expired eye drops per manufacturer recommendation's for 9 of 9 residents (R47, R69, R92, R36, R40, R73, R19, R10, R13) reviewed during medication storage and administration. Finding include: R47's medication review report signed [DATE], included orders for Thera Tears (for dry eyes) solution 0.25%, install one drop in both eyes four times a day for dry eyes. During an observation and interview on [DATE] at 3:31 p.m., a bottle of Thera Tears 0.25% eye drops was in R47's medication drawer. The bottle had no name, label, or date opened. The directions on the bottle from the manufacturing company indicated to install 1-2 drops in the affected eye as needed. Registered nurse (RN)-B indicated the box the eye drops came in was thrown after it was verified with the EMAR. RN-B checked the EMAR and indicated R47 receives Thera Tears four times a day, which was different than what was written on the bottle. RN-B indicated staff would follow the orders on the MAR and not on the bottle. During an observation and interview on [DATE] at 9:10 a.m., RN-C verified there was no name or directions on the R47 Thera Tears eye drop bottle. RN-C indicated the directions are on the EMAR and would follow the directions on the EMAR. RN-C indicated the family would bring R47's eye drops; that is why there is no name or label on the eye drop bottle. R69 R69's medication review report signed [DATE], included orders for latanoprost 0.005%, install one drop in both eyes one time a day for glaucoma. During an observation and interview on [DATE] at 3:34 p.m., R69 had a bottle of latanoprost (glaucoma) 0.005% eye drops in the medication drawer. There was no date of when the medication was opened, RN-B indicated the facility has a list of medications and when they expire on the medication cart from the pharmacy. RN-B verified the eye drops were open, and the EMAR indicated the eye drops expire 5/26. During an observation and interview on [DATE] 9:12 a.m., RN-C verified R69 latanoprost 0.005% eye drops had no date of when it was opened or when it expired on the eye drop bottle. RN-C indicated the process was to write on the eye drop when it was opened. RN-C indicated latanoprost normally expires in 28-40 days after being opened. RN-C indicated staff would write in the MAR when a medication expires. RN-C looked at the EMAR and showed the EMAR had the latanoprost expiring 5/26. During an interview on [DATE] at 9:23 a.m., clinical coordinator manager (CCM)-A indicated staff should date eye drops after opening. CCM-A was under the assumption that latanoprost eye drops expire 28 days after opening. CCM-A indicated staff should throw the eye drops if not dated when opened, and to order new eye drops from the pharmacy. CCM-A indicated it is important not to administer a medication when it has expired, to ensure the medication is working at its full strength. CCM-A checked with the pharmacy and confirmed the latanoprost eye drops were filled on [DATE], which indicates the medication had not expired. CCM-A indicated she would date the medication with the correct expiration date. CCM-A also provided a list of medications and expiration dates that the facility uses, and according to the list, latanoprost was good for six weeks after opening and being unrefrigerated. CCM-A also indicated the facility had labels with the resident names and room number for medications that were brought in by family and should have been applied to R47 eye drops. R92 R92’s Medication Review Report signed undated, revealed the following: - Artificial Tears Ophthalmic Solution1.4% instill one drop in both eyes as needed for dry eyes four times a day (QID). - Artificial Tears Ophthalmic Solution 1.4% instill one drop in both eyes three times a day for cataract evaluation until [DATE]. R92’s eMAR dated [DATE] to [DATE], revealed the following: - Ketorolac Tromethamine Ophthalmic Solution 0/5% instill one drop in both eyes one time a day for cataracts for 14 days starting [DATE]. - Ketorolac Tromethamine Ophthalmic Solution 0/5% instill one drop in both eyes one time a day for cataracts for 14 days starting [DATE]. - Prednisolone Acetate Ophthalmic Suspension 1% instill one drop in both eyes one time a day for cataract surgery for 21 days starting [DATE]. - Prednisolone Acetate Ophthalmic Suspension 1% instill one drop in both eyes one time a day for cataract surgery for 21 days starting [DATE]. - Refresh Tears Ophthalmic Solution (Carboxymethylcellulose Sodium) instill one drop in right eye three times a day for dry eyes starting [DATE]. - Refresh Tears Ophthalmic Solution (Carboxymethylcellulose Sodium) instill one drop in right eye as needed for dry eyes starting [DATE]. - Moxifloxacin HCL Ophthalmic Solution 0.5% instill one drop in both eyes four times a day for cataract surgery for seven days starting [DATE]. During an observation/interview on [DATE] at 3:45 p.m., RN-B opened R92’s locked medication drawer in R92’s room. Located in a cup in R92’s drawer revealed the following: - Refresh Tears Ophthalmic Solution (Carboxymethylcellulose Sodium) with R92’s name and prescription number (Rx). Eye drops lacked boxed packaging and instructions. - Moxifloxacin Ophthalmic Solution 0.5% with R92’s name and Rx number. Eye drops lacked boxed packaging and instructions. - Prednisolone Acetate Ophthalmic Suspension and lacked R92’s name, Rx number, boxed packaging, and instructions. RN-B confirmed the above findings and stated eye drops should be in the boxed packaging labeled with resident’s name, Rx number, and directions. R36 R36's Medication Review Report signed [DATE], included orders for Lantus Solo Star Subcutaneous solution Pen-injector 100 unit/ML (insulin Glargine) inject 8 units subcutaneously once a day for diabetes. R36's electronic medical record (eMAR) dated [DATE] to [DATE], identified R36 was currently receiving 8 units of Lantus insulin injection one time a day at bedtime. During an observation/interview on [DATE] at 3:33 p.m., trained medication aid (TMA)-C reviewed insulin pen with surveyor and confirmed the pen was not dated. TMA-C indicated TMA-C was aware pens were only good for 28 days after they were opened. TMA-C took the pen to registered nurse (RN)-F who confirmed the insulin pen was undated. RN-F discarded the insulin pen in the sharp’s container. R40 R40's Medication Review Report signed [DATE], included orders for Lantus Solo Star Subcutaneous solution Pen-injector 100 unit/ML(insulin Glargine) inject 14 units subcutaneously once a day for diabetes. R40's current medication administration record (MAR) identified R40 was currently receiving 14 units of Lantus insulin injection at bedtime daily. R73 R73's Medication Review Report signed [DATE], included orders for Latanoprost Solution 0.005% one drop to each eye once per day for glaucoma. R73's MAR identified R73 was currently receiving Latanoprost Solution 0.005% one drop to each eye once per day. During an observation and interview on [DATE] at 3:33 p.m., registered nurse (RN)-D confirmed R40's insulin pen in the locked drawer was not dated and R73's Latanoprost Solution 0.005% eye drops had an expiration date of [DATE]. RN removed the insulin pen from R40's locked medication drawer and the eye drops from R73's locked medication drawer and brought them to the medication room to be destroyed. RN-D verified Lantus insulin pen was good for 28 days and stated her expectation was R40's insulin pen would have been dated when it was opened. RN-A further stated her expectation was R73's eye drops were thrown away on or before the expiration date to ensure the medications were effective. R19 R19's Medication Review Report signed [DATE], included orders for Silicon Oil (Sil-Optho) prosthetic lubricant- one drop to left prosthetic eye twice a day for lubrication as needed. Artificial tear solution- instill one drop in right eye as needed for dry eye, and one drop in right eye five times a day for dry eye. Muro 128 ointment 5%- instill one application in right eye one time a day for corneal abrasion to right eye. During observation on [DATE] at 3:33 p.m., registered nurse (RN)-A confirmed R19 had a bottle of Sil-Optho not labeled, a bottle of Eye Relief not labeled, and a tube of Muro 5% not labeled. RN-A removed the medications from R19's medication locked drawer and brought to medication room, then indicated they would be destroyed. R10 R10's Medication Review Report signed [DATE], included order for Nitrogycerin Sublingual (below tongue) 0.4 milligram (MG)- give one tablet sublingually as needed for chest pain. Give one dose every five minutes for chest pain. Do not exceed three doses in 15 minutes. During observation on [DATE] at 3:44 p.m., RN-A confirmed R10 had two bottles of nitroglycerine, one with a label which included R10's name only and one not marked. RN-A stated they both should have R10's name and instructions attached. R13 R13's Medication Review Report signed [DATE], included orders for Breztri Aerosphere Inhalation Aerosol 160-9-4.8 microgram (MCG-ACT)- two puffs inhale orally two times a day for wheezing. Muro 128 ointment 5%- instill one drop in both eyes at bedtime for dry eye 1/4 strip in both eyes. During observation on [DATE] at 3:57 p.m., trained medication aide (TMA)-A indicated R13's two Brezti inhalers were not labeled. One was in her medication drawer, and one was on her bedside table. TMA-A stated there was a box for the inhaler with the label on it at one time, but it was not in R13's drawer anymore. R13 also had a Muro 5% eye ointment with no label. TMA-A indicated the Muro had a label, but it was not on it anymore. TMA-A also stated no expiration date was found on the Muro ointment. During a phone interview on [DATE] at 8:32 a.m., consultant pharmacist (CP)-A indicated all medications should have a pharmacy label with the resident's name and instructions. CP-A indicated if the medication was too small for a full label, she would expect the medication to be labeled with the resident's name and instructions to see electronic medication administration record (EMAR) for directions. CP-A stated if the medication was received in a box, the medication should be stored in the box which would contain the pharmacy label. CP-A stated it was important for medications to be labeled correctly to assure used correctly and for correct resident. CP-A indicated Xalatan/latanoprost eye drops expired 42 days or six weeks after opened. They should be labeled with date opened, and destroyed once expired. CP-A stated insulin pens should be dated when first used, and destroyed after manufactures recommended dates of how long the pens should be used, which was usually 28 days. CP-A indicated eye drops, and insulin pens should be dated when opened, and not used after expiration date per manufactures instructions. During interview on [DATE] at 9:14 a.m., director of nursing (DON) indicated her expectation was all medications would be labeled with resident's name, expiration date and directions for use. If the medication was not large enough for the full label, it should be kept in the box it came in. DON indicated the facility had labels they could use that had the resident's name and to refer to chart for direction of use. DON stated labels on medications were important to follow the rights of medication administration and safety. DON stated the facility had a shortened expiration date form, provided by pharmacy, which indicated which eye drops had shortened expiration dates after opened. DON stated her expectation was the eye drops were labeled when opened and disposed of when expired. DON stated insulin pens should also be dated when opened and disposed of when expired. DON indicated most insulin pens were to be disposed of after 28 days. DON stated it was important to dispose of medications after expiration as the medication may not be as effective after expired. The facility policy titled Medication Labeling And Storage revised 2/23, identified medications were stored in packaging, containers or other dispensing systems they were received. The policy identified medication labels included medication name, prescribed dose, strength, expiration date when applicable, resident's name, route of administration, and appropriate instructions and precautions. If medication containers had missing, incomplete, improper or incorrect labels, contact pharmacy for instructions regarding returning or destroying those items.

Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators and freezers were labeled, dated and discarded properly. This deficient practice had the potential to affect all 89 residents who received food from the refrigerators, freezers and the kitchen.Findings include:On 8/4/25 at 9:44 a.m., during the kitchen tour with the cook the following concerns were identified.Walk in cooler-half container of sour cream without notation of an opened date and an expiration date of 6/20/25.Fridge in kitchen-1/4 container of mustard with an expiration date of 7/28/25.-1/2 bottle of barbeque sauce without notation of an opened date and no expiration date.During an interview on 8/4/25 at 10:20 a.m., cook verified the above findings during the kitchen tour. [NAME] stated her expectation was all opened food should have been dated and thrown away on or before the expiration date to prevent food-borne illness.During an interview on 8/4/25 at 10:30 a.m. dietary manager (DM) stated her expectation was all food should have been dated when it was opened and thrown away after the shelf life or the expiration date to prevent food-borne illness.Review of a facility policy titled Food Storage updated 3/23/25, identified leftover foods should be stored in covered containers or wrapped and clearly labeled, dated and monitored to assure that foods are consumed by their safe use by dates, or frozen.

Based on interview and document review, the facility failed to notify a physician timely of a change in condition for 1 of 3 residents (R1) who had an injury of unknown origin related to bruising on her inner thigh. Findings include: R1's annual Minimum Date Set (MDS) on 4/24/25, identified R1 had severely impaired cognition, inattention (difficulty focusing, easily distractible, and difficulty keeping track of what was said), and disorganized thinking. Facility Resident Accident/Incident Report dated 5/17/25, completed by floor supervisor registered nurse (RN)-A identified date of incident 5/17/25, at 8:00 a.m. Staff noted R1 had eight areas of greenish colored bruising, dime to nickel sized, on inner knee/thighs which appeared to be fingerprint in size. Area on report labeled Was it necessary to notify MD/GNP/PA? was left blank, as was then name/date/time of MD/GNP/PA notified. Administrator and director of nursing (DON) notified on 5/17/25 at 9:45 a.m. R1's progress note dated 5/17/25 at 10:27 a.m., identified she had bruising to upper/inner thighs and inner left knee. The bruises were dark green in color, fingerprint sized and did not appear to cause pain when palpated. R1 was unable to indicate if she felt safe in the facility, if anybody had hurt her or if she remembered how she got the bruises. Progress note indicated resource manager was notified and appropriate actions were in place (those actions not described in progress note). Her granddaughter was contacted and informed of the incident and had no questions/concerns at this time. Will continue to monitor and document as needed. R1's progress note dated 5/19/25 at 1:34 p.m., Complete Skin Assessment: Healing bruises in inner thigh almost gone. No new concerns to report to provider. R1's routine visit follow up visit by medical doctor/director (MD) on 5/20/25 at 9:55 a.m., lacked any mention of skin/bruising. R1's progress note dated 5/22/25 at 11:49 a.m. Type: skin/wound note medical doctor (MD) updated via fax. (5 days later) During an interview on 5/23/25 at 11:10 a.m. RN-A stated the provider should have been notified immediately when the bruises were discovered on 5/17/25 so they could have chosen to evaluate her or send her in for evaluation. The provider was notified via fax yesterday, (5/22/25). During an interview on 5/23/25 at 2:42 p.m. DON stated the staff would be expected to have notified the provider right away after R1's bruises were found to see if he wanted a further medical evaluation completed and/or other interventions necessary depending on the situation. During an interview on 5/27/25 at 8:32 a.m. MD stated he was not familiar with R1's incident that occurred on 5/17/25, regarding bruises. MD stated he did not believe it was included on the rounding form he received from the nurse when he saw her on 5/20/35, and no mention of bruises were identified on his visit notes. He would have wanted to be notified so that R1 could have been examined, especially when there was a potential for alleged abuse. MD indicated the he would have completed the examination to verify if there were concerns for abuse. Certainty there would have been a possibility of sexual abuse especially if bruises were located close to the genital area, if not, rough handling and/or transfers with bruising would have been possible.

Based on observations, interviews and document review the facility failed to ensure an injury of unknown source was thoroughly investigated for 1 of 3 residents (R1) reviewed for abuse. Findings include: R1's annual Minimum Date Set (MDS) on 4/24/25, identified R1 had severely impaired cognition. Her medical diagnoses included Parkinson's (a movement disorder of the nervous system with symptoms that worsen over time such as tremors, slowed movements, rigid muscles, poor posture/balance, loss of blinking/smiling movements, speech changes, writing changes, nonmotor symptoms), dementia, and anxiety. She had impaired range of motion to bilateral lower extremities, unable to stand independently or walk. She required substantial to maximal assistance with personal hygiene, repositioning in bed, all transfers and dependent upon staff for toileting and oral hygiene, shower/bathe, dressing, and mobility in wheelchair. R1's care plan dated 5/19/25, identified impairment to skin integrity, activities of daily living (ADL) self-care deficit, and impaired communication. Staff were directed to anticipate and meet needs, use caution during transfers and bed mobility to prevent striking arms/legs/hands against any sharp or hard surfaces, assist of two staff for bed mobility and transfers with assist of one and PAL (patient assisted stand lift), monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations, and document. She was a vulnerable adult and staff were directed to monitor and report any suspected abuse or neglect following policy. R1's progress note dated 5/17/25 at 10:27 a.m., identified she had bruising to upper/inner thighs and inner left knee. The bruises were dark green in color, fingerprint sized and did not appear to cause pain when palpated. R1 was unable to indicate if she felt safe in the facility, if anybody had hurt her or if she remembered how she got the bruises. Progress note indicated resource manager was notified and appropriate actions were in place (those actions not described in progress note). Her granddaughter was contacted and informed of the incident and had no questions/concerns at this time. Will continue to monitor and document as needed. R1's progress note dated 5/19/25 at 1:34 p.m., indicated skin assessment/observation of pubic area, buttocks, groin, and upper thighs: skin intact, warm, and dry. No new lesions, bruising or rashes noted. Chronic redness in groin, Nystatin applied. Healing bruises in inner thigh, almost gone. The state agency (SA) facility report dated 5/17/25, at 11:30 a.m. indicated no incident was observed related to bruises. Nurse caring for resident today observed greenish discoloration which appeared as bruising to residents inner knees and thighs. Size ranged from dime to nickel size. There were four small bruises in a straight line to the right inner thigh and four small bruises reported to left upper knees extending to upper thigh. Questionable if that may be related to required assist of one staff for ADLs (activity of daily living) including bathing, dressing, toileting, and transfers with a PAL lift, possible check and changed every two hours and R1's incontinent product. Observation of R1 identified she had very sensitive skin (abdominal folds/under breasts/inner thigh/groin/buttocks). Appeared to be at baseline with no changes in behaviors, participation, cognition, or mood. She continues to required assistance with bed mobility and repositioning. Previous skin assessments did not reflect skin discolorations or bruising. Interviews with staff and investigation was ongoing. Review of the SA investigative report dated 5/23/25 at 4:05 p.m. no changes to her psychosocial wellbeing that would indicate abuse. Summary of interviews completed with staff identified no witnesses and those that worked with her reported increased difficulty with turning and repositioning, occasionally resistive to oral cares and adjustment to her pillow. She was not typically resistive when checked and changed, tried to help but was having more difficulty. Resident was checked and changed every two hours; bruising could have been related to process of changing her brief. No previous reports of bruising to her legs reported. Review of facility incident investigation staff interviews on 5/22/25, lacked evidence staff were asked questions related to observed or suspected abuse, concerns with aggressive cares, or other suspicious behavior by staff or residents. During an interview on 5/22/25 at 2:58 p.m. TMA-A stated R1 was not interview able, She became aware of the yellow/greenish bruises on R1, in the healing stages located and located on both her inner thighs on 5/17/25. TMA-s indicated she reported the bruises to the nurse and was present in the room while the nurse assessed her skin. She also stated R1 did not often resist or hold her legs together, she did become ridged at times but was then given time and space to relax. TMA-A confirmed she had not been interviewed by anyone related to the bruising or abuse. During an interview on 5/22/25 at 3:17 p.m. TMA-B stated she first became aware of R1's bruises on 5/17/25 when the nurse and NA showed her the bruises. R1 had three or four bruises on both sides of her inner thighs, one on the outside of the right thigh, and one underneath each of her thighs, that were darker purple about the size of a penny. The nurse, another NA and her all thought they looked like fingerprints. TMA-B confirmed she had not been interviewed by anyone about this incident. During an interview on 5/23/25 at 2:42 p.m. director of nursing (DON) stated the facility investigation interviews with the staff included a total of three questions: had they noted any skin changes/alternations prior to incident, any trouble moving/repositioning her in the bed, and any difficulty with cares. The staff were not asked any questions about abuse and should have been. That would have helped identify if there was any abused that occurred. No abuse was determined with interviews and only an increase with repositioning was consistently identified. During an interview on 5/27/25 at 8:32 a.m. medical director (MD) stated the facility would have been expected to complete interviews with the staff that included questions about abuse. We would have wanted to know if she was being abused. If he would have been notified about the incident, an examination would have been completed, identified if things looked suspicious, and helped direct the investigation. Facility policy Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property dated 2/26/19, identified injuries of unknown origin was defined as the source of the injury was not observed by any person, or source of the injury could not be explained by the resident; and the injury was suspicious because of the extent or locations of the injury (e.g., the injury was in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incident of injuries over time. The investigation will consist of an interview with the person or persons reporting the incident, any witnesses to the incident, staff members having contact with the resident during the relevant periods or shifts of the alleged incident.

Based on interview and document review the facility failed to assess and monitor bruises for 1 of 3 resident (R1) reviewed for injury of unknown origin. Findings include: R1's order dated 2/3/25 at 8:00 a.m. weekly bath day skin note. Monitor for changes, bruising, open areas. Notify nurse/general nurse practitioner (GNP) as needed. Every Monday for skin monitoring. Signed off as completed on 5/5/25, 5/12/25, and 5/19/25. R1's annual Minimum Date Set (MDS) on 4/24/25, identified R1 had severely impaired cognition, inattention (difficulty focusing, easily distractible, and difficulty keeping track of what was said), and disorganized thinking. Her medical diagnoses included Parkinson's (a movement disorder of the nervous system with symptoms that worsen over time such as tremors, slowed movements, rigid muscles, poor posture/balance, loss of blinking/smiling movements, speech changes, writing changes, nonmotor symptoms), dementia, and anxiety. She had impaired range of motion to bilateral lower extremities, unable to stand independently or walk. She required substantial to maximal assistance with personal hygiene, repositioning in bed, all transfers and dependent upon staff for toileting and oral hygiene, shower/bathe, dressing, and mobility in wheelchair. She was frequently incontinent of bladder and occasionally incontinent of bowel. Facility Resident Accident/Incident Report dated 5/17/25, completed by floor supervisor registered nurse (RN)-A identified date of incident 5/17/25 at 8:00 a.m. staff noted R1 had eight areas on greenish colored bruising, dime to nickel sized, on inner knee/thighs and appeared to be fingerprint in size. Notification to MD/GNP/PA and MD/GNP/PA was left blank and administrator and director of nursing (DON) were notified on 5/17/25. R1's progress note dated 5/17/25 at 10:27 a.m. identified she had bruising to upper/inner thighs and inner left knee. They were dark green in color. Bruises were fingerprint sized and did not appear to have cased pain when palpated. She was unable to answer when asked if she felt safe in facility, if anybody had hurt her or if she remembered how she got the bruises. Resource manager was notified. Appropriate actions were in place (actions not identified). Her granddaughter was contacted and informed of incident and had no questions/concerns at that time. Will continue to monitor and document as needed. R1's order dated 5/18/25, monitor bruising to inner bilateral thighs for healing. Discontinue when healed. No directions specified for order. No progress notes noted on 5/18/25. R1's progress note dated 5/19/25 at 1:34 p.m., identified skin assessment/observation of pubic area, buttocks, groin, and upper thighs: skin intact, warm, and dry. No new lesions, bruising or rashes noted. Chronic redness in groin, Nystatin applied. Healing bruises in inner thigh, almost gone. R1's progress note dated 5/20/25 at 10:42 a.m. Type: appointment return/physician visit/medication change. No changes to plan. Updated family member. R1's progress note date 5/22/25 at 11:49 a.m. Type: Skin/wound note. MD updated via fax. R1's progress note date 5/22/25 at 4:55 p.m. received a fax order from MD concerning the bruising found on the resident. Continue to monitor. R1's record lacked monitoring of bruises on 5/18/25, 5/20/25-5/22/25, or until resolved. During an interview on 5/23/25 at 11:00 a.m. registered nurse (RN)-A stated R1's progress notes written on 5/17/25, indicated appropriate actions were in place. The nurse providing cares and assigned to that unit would have been expected to monitor the bruising and document in the medical record/progress notes every shift. There was a nursing order to monitor the bruises but was unable to identify it had been placed in the TAR in electronic medical record. During an interview on 5/23/25 at 2:00 p.m., trained medication aide (TMA)-C stated he skin assessments usually would be identified and assigned through the resident's TAR (Treatment Administration Record) and he had not aware of anything for R1. During an interview on 5/23/25 at 2:10 p.m. RN-B stated she was not aware of R1's bruises were to be monitored and would confirmed that would have been important to monitor for any changes from the initial assessment on 5/17/25, such as more bruises, and whether they were healing or had a change in skin integrity. RN-B stated the order should have been to assess the bruises every shift, but the schedule (frequency) was not indicated in the order. She also verified the order was not located on the TAR and/or completed. Unless the nurse looked on every order they would have not known about the assessment and planned on adding it to the TAR. During an interview on 5/23/25 at 2:42 p.m. DON stated she would have expected the nurse to have placed the order into the TAR to ensure R1's bruises were getting monitored through healing. DON added, the nursing order was missing the routine/frequency was not entered and therefore had not shown up on the TAR. The monitoring of the R1's bruises were not signed off as completed and would have needed to follow up with staff if they were assessed every shift. During an interview on 5/27/25 at 8:32 a.m. with medical doctor/director (MD) stated had not been notified of R1's incident on 5/17/25 but would have directed the nurses as to how often they should have monitored the bruise, adding bruises do not really change every shift and most likely daily would have been sufficient. Monitoring is important to watch how the bruises evolve, look different from one day to another, if new bruises popped up, which may have triggered continued concern and/or a possible hematoma (a closed wound bleeding outside the blood vessels that resulted in a collection of blood) that may have required more medical care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide adequate supervision when a resident was brought outside onto the patio area and left there without supervision, and later became unresponsive for 1 of 1 resident (R1) reviewed for safety. Findings include: R1's St. Louis University Mental Status (SLUMS, screening test for dementia) examination dated 1/6/23, identified R1 had a mild neurocognitive disorder. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had verbal behaviors one to three times a week, and rejection of care. She was dependent upon staff for toileting hygiene, personal hygiene, sit to stand, chair/bed to chair transfers, toilet transfers, and was unable to ambulate. R1 was frequently incontinent of bladder and occasionally continent of bowel. Medical diagnoses included arthritis, depression, psychotic disorder, macular degeneration, and epilepsy (seizure disorder). R1's care plan dated 3/18/25, identified R1 had impaired balance, limited mobility, and behaviors, and directed staff to provide total assistance of two for transfers with a lift, and encourage the use of bell to call for assistance. R1 did not ambulate. R1 required staff assist with wheelchair for longs distances, and she was independent with short distances. She had dementia with ineffective coping skills and delusional disorder (a serious mental health illness where a person cannot tell what is real and from what is imaginary, paranoid). She had impaired cognitive function/thought process and decision making. Staff were directed to cue, reorient, and supervise as needed. She required supervision with all decision making. She was at risk for falls related to gait/balance problems, and the care plan directed staff to provide call light within each, encourage her to use it when assistance was needed. She needed prompt response to all requests for assistance. R1's Nursing assessment dated [DATE], identified she had periods of delusions and hallucinations, unsteady gait, poor balance, can stand and pivot only with help, and had moderate agitation (called out and used threatening language). R1's progress note dated 5/11/25 through 5/13/25 identified: - On 5/11/25 at 5:21 p.m. R1 was found outside at 4:30 p.m. unresponsive. R1 was assisted into the unit. Vital signs were as follows: blood pressure (BP) 168/89, pulse 116, respiration 22, temperature 99.8 degrees Fahrenheit (F), oxygen saturation (SaO2) 95% on room air. A cold washcloth was applied on her forehead and then she started mumbling. Placed call to 911 and requested for emergency medical service (EMS), family notified through her brother. Registered nurse (RN) charge nurse and RN care coordinator were notified as well. -On 5/11/25 at 9:43 p.m. R1 returned from the emergency department (ED). -On 5/12/25 at 4:28 p.m. Follow-up with staff working Sunday afternoon. R1 was assisted outside about 1:45 p.m. onto the short stay patio. Staff followed-up with resident two times from that time until 2:30 p.m. and offered her water. They also asked if she would like to come back inside, which she declined. Two staff offered to bring her in again about 4:00 p.m. and she declined at that time as well. She told them she did not want to come back in at that time. -On 5/13/25 at 1:30 p.m. R1 required intravenous (IV) fluids (in the ED): sodium chloride 0.9% bolus on 5/11/25 for additional fluids intake for hydration needs. The need for fluids was determined by physical exam and/or diagnostic testing which had indicated: abnormal fluid loss, unstable vital signs (increased temperature) and abnormal labs such as BUN/creatinine, glucose, and potassium. R1 also received treatment for abnormal fluid loss, heat exposure, head exhaustion and hyperkalemia. Rehydration was reasonable and necessary. R1's ED provider notes dated 5/11/25 at 6:34 p.m. indicated clinical impression: heat exposure, hyperkalemia (high potassium levels), heat exhaustion. She was found by staff at the nursing facility confused outside and quite confused upon EMS arrival. She was alert and oriented, though seemed to have some limited recall of recent events and may have some underlying dementia or other cognitive disorder. Her temperature was 100.1 orally, very warm to the touch with evidence of sunburn, suspected she was quite warmer earlier. Cooling measures were initiated prior to EMS arrival to facility, and mental status improved. She was given cool intravenous fluids and cooling packs were applied to the groin and axilla (under arms). Despite prolonged exposure she did not appear at this time to have suffered any untoward effects. Stable and discharged back to the nursing facility. During an interview/observation on 5/15/25 at 2:03 p.m. R1 sat in her wheelchair in her room well groomed, fully dressed in t-shirt, zip-up long-sleeved jacket, shorts, socks, and tennis shoes. She stated unsure how long she had lived at the facility, and stated she had been there since fall to winter to spring and now it's summer, I think. She went outside every day and activities staff took her out. She stated she was tired today. During an interview on 5/15/25 at 4:00 p.m. RN-A stated R1 pushed herself around the unit in the wheelchair with her feet. The resident patio area was fenced in, and staff entered a code on the pad located off to the left of the inside door. He had seen R1 outside both in front of the building, and in the patio area. R1's care planned did not identify interventions for her to go outside with or without anyone. Her cognition was affected at times, and she would not have been safe outside by herself when she was confused. She was unable to stand, walk, and/or transfer herself independently, and did not attempt to self-transfer. On 5/11/25, he administered medications to R1 between 8:00 a.m. and 9:00 a.m. while she was in her room. She ate breakfast in the dining room, and then went back to her room. At 12:00 p.m. until 12:45 p.m. she sat in dining room and ate lunch. He had gotten busy after that, took a break before 2:00 p.m. and returned to the floor. Nursing assistant (NA)-A had already given report to the oncoming NA-C. NA-B was scheduled for evening shift at 3:15 p.m. At 4:30 p.m. R1 was not in her room and was found out on the patio area by herself. He asked her, Should we go inside? She shook her head no. She was not responding appropriately and mumbled. When cued, she was unable to lift her feet. Foot pedals were placed on her wheelchair and she was pushed inside the building. Vital signs were taken at the nurse's station: blood pressure 165/89, heart rate was 115, temperature 99.8 degrees F., respirations 22, and SaO2 91%, and she was unable to respond. 911 was called. He placed a wet washcloth on her face and she started to wake up and talked a bit. EMS arrived, and once she was transferred to the gurney she woke up and became her normal self. He followed up with staff, and NA-C told him she had taken R1 out to the patio just before 2:00 p.m. and passed the information onto the evening shift NA-A. He expected staff to inform the nurse, and he was not told about R1 being outside. NA-B hadn't informed him until 3:20 p.m. NA-A requested assistance to get R1 back into the building and R1 had refused. R1 was unable to identify how to get back into the building, she sat outside in the patio area from 3:20 p.m. until 4:30 p.m. unsupervised, in 90-degree weather, without access to water, and was not safe by herself. During an observation on 5/15/25 at 4:20 p.m. the resident patio was in the short stay wing. A code pad was located inside on the left side of the door on the wall, at approximately eye level. The door had a large glass window with NO EXIT stamped on it. The door was unable to be opened without a code placed into the pad. There were four lawn chairs and a table against the inside of the metal white fencing, and a long wooden bench located up against the outside building wall. The patio could be visually seen from the main parking lot of the facility and from inside the building was a large window. No overhead protection from the sun was noted. During an interview on 5/16/25 at 10:00 a.m. NA-A stated R1 refused to come back into building on 5/11/25. Staff were expected to check on residents inside the building every two hours, and if they were outside, they should be checked on every 30 minutes to one hour. NA-D brought R1 outside in the patio area around 1:45 p.m., she checked on her before 2:00 p.m. to see if she wanted to come back in and offered water, and R1 declined. The temperature outside was at least 80 degrees out and partly cloudy. R1 wore shorts, and a t-shirt. R1 did not have on sunscreen, a hat or sunglasses. She also had no access to water. She was unsure why they didn't leave something for her to drink. At 2:00 p.m. NA-C was informed R1 was outside on the patio, and how long she had been there. Staff were expected to check on her, they could have seen her through the window from inside the building. There was not way for R1 to alert us if she needed anything other than pound on the glass window, wave her arms or knock on the door. A code was needed to open the door from the outside to get back into the building. She would be unable to have pushed the door open, was heavy. There was a buzzer outside on the wall, but she would have most likely been unable to reach it from her wheelchair. During an interview on 5/16/25 at 10:26 a.m. NA-C stated she had received report from NA-A and was made aware R1 was outside on the patio, but was not informed how long it had been. Usually upstairs in the dementia unit a resident was brought outside to the patio area and staff were expected to stay with them, and 15 minutes later the resident was brought back into the facility, and not left alone. R1 was forgetful and confused at times. She had been informed staff attempted earlier to her back into the building, and R1 did not want to go back inside. At 4:00 p.m. she checked on R1 and asked her to come into the building and she refused. The temperature outside was hot, 90 degrees and sunny, and R1 had no protection from the sun. She should have not been placed outside by herself. NA-A stated NA-B planned on updating the nurse about R1's refusal to come inside, but was unable to locate him, it was an extremely busy day with many visitors. At about 4:30 p.m., R1 was in the hallway in her wheelchair unable to talk. They placed ice towels on her prior to EMS arrival. None of this should have happened and could have been worse. During an interview on 5/16/25 at 12:00 p.m. RN-B stated staff would be expected to check with the nurse on duty prior to a taking a resident outside and left by themselves. R1 was confused at times, especially one day last week, and may have not been able to let herself back into the building. During an interview on 5/16/25 at 2:26 p.m. the director of nursing (DON) stated staff brought R1 out to the patio, checked back and offered water, and offered to bring her back inside. She refused to come back into the building. Staff would have been expected to have notified RN-A, and they did not follow the facility process. RN-A should have been informed R1 was taken outside especially at shift change. R1 had a mental health diagnoses and an altered through process related to delusions. Staff would have expected to check on R1 at least every 15 to 30 minutes and under the circumstances, felt they checked on her appropriately. During an interview on 5/19/25 at 12:22 p.m. NA-B stated he did not receive report when he arrived at work on 5/11/25 at 3:05 p.m. He passed ice water, and R1 was not located in her room. He was unaware of her being out on the patio. She should have not been left alone outside. After 4:00 p.m., NA-C approached him and requested assistance with R1. He put in the code and opened the patio door, and held the door open while NA-C informed R1 it was time to come in for supper. R1 replied no, she was ok, and refused to go in. She wanted to sit outside longer. He told her they would come back in a while. He was unaware how long she had been outside. She was left out on the patio, and they planned on checking back with her later, before supper. R1 sat alone in the wheelchair, with shorts and a t-shirt on, and without anything to drink. RN-A was unable to find R1 to administer medications, and then requested assistance with getting her into the building from the patio. A code was required to unlock the door to get back into facility, and he was unsure if R1 would have been able to reach the code pad since she was unable to stand up independently. The facility policy Safety and Supervision of Residents dated 7/2017, directed resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessment needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. Resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure nebulizer medication was administered safely for 1 of 1 resident (R28) who was observed to self administer a nebulizer and had not been assessed as safe to self administer medications. Findings Include: R28's admission Minimum Data Set (MDS) dated [DATE], identified R28 was cognitively intact and had diagnoses which included: chronic obstructive pulmonary disease (COPD) (chronic inflammatory lung disease that causes obstructed airflow from the lungs), heart failure and anxiety disorder. Indicated R28 required partial/moderate assistance with upper body dressing, transfers, and hygiene. R28's care plan revised 6/27/24, identified R28 had activities of daily living (ADL) self-care performance deficit and required assistance for dressing, personal hygiene and transfers. R28 had potential for respiratory status/difficulty breathing related to COPD and interventions included administer medication/puffers as ordered. R28's care plan lacked self administration of medication interventions. R28's Medication Review Report signed 7/8/24, included orders for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams (MG)/3 milliliters (ML) (a bronchodiator medication that helps relax muscles in airway to increase air flow) one unit inhale orally four times a day for COPD. R28's Medication Review Report lacked an order to self-administer medication. R28's medical record lacked documentation of a self-administration medication (SAM) assessment completed. During an observation and interview on 7/23/24 at 8:36 a.m., trained medication aide (TMA)-A indicated R28 was probably done with her nebulizer medication, entered R28's room, unhooked the nebulizer mask and cup from the nebulizer machine, rinsed it in the sink and set it on a paper towel to dry. At 8:41 a.m., TMA-A indicated he planned to set up R28's nebulizer around lunch time and R28 would administer it herself after set up. During an observation and interview on 7/23/24 at 11:30 a.m., TMA-A entered R28's room, removed a vial of R28's Ipratropium-Albuterol Inhalation Solution from a locked medication drawer, opened the vial and poured it into the nebulizer cup. TMA attached the mask to the tubing on the nebulizer machine and handed the nebulizer to R28. TMA-A turned on the nebulizer machine, sanitized hands and exited R28's room. At 11:33 a.m., TMA-A was at the nursing desk. TMA-A indicated he thought R28 had been assessed to be safe to self administer medications. TMA-A reviewed R28's electronic medical record and verified it lacked a SAM for R28 to self-administer medications. TMA-A stated his usual practice was to set up R28's nebulizer, leave the room and R28 would administer the medication and shut it off when done. At 11:35 a.m., R28 continued to be self-administering her nebulizer in her room while no other staff member was present. During an interview on 7/23/24 at 3:34 p.m., unit manager registered nurse (RN)-A confirmed R28 did not have a SAM assessment, or an order for self administration of medications, which included the nebulizer. RN-A indicated the usual process was to complete a SAM assessment and if it was determined the resident was appropriate to self-administer medications, it should have been added to care plan. In addition, an order should have been obtained and it should have been identified on the resident's electronic health record banner. RN-A stated it was important to complete the SAM and obtain orders to assure medications were administered appropriately and would not cause harm. During an interview on 7/23/24 at 4:11 p.m., director of nursing (DON) indicated the facility's usual process was for licensed staff to complete a SAM and obtain an order for self-administration if the SAM determined the resident was safe to self- administer meds. DON expected staff to re-evaluate quarterly and when a significant change occurred. DON verified an order for self-administration of meds should have been obtained and should have been documented in the resident's care plan and electronic record banner. DON indicated it was important to complete the process to assure the resident received the medications as prescribed by their provider. During an interview on 7/23/24 at 5:03 p.m., R28 confirmed all nursing staff set up her nebulizer medications and did not remain with her while she self-administered the nebulized medication. R28 stated no one had discussed self-administering her nebulizer medication with her and she just automatically completed the task. During a telephone interview on 7/23/24 at 5:19 p.m., pharmacy consultant (PC)-A indicated it was her expectation the facility would have completed a SAM assessment and obtained an order for R28 to self administer her nebulizer medication. PC-A indicated for nebulized medication, the facility needed to assure the resident would keep the nebulizer mask in place and not remove it before the medication administration was completed. The facility policy titled Self-Administration Of Medications revised 2/21, identified residents had the right to self-administer medications if the interdisciplinary (IDT) team had determined that it was clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the IDT team assessed each resident's cognitive and physical abilities to determine whether self-administration medications was safe and clinically appropriate for that resident. If deemed safe and appropriate for a resident to self-administer medications, this would have been documented in the medical record and the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure facial hair was removed for 1 of 2 residents (R75) who required assistance with hygiene, and was reviewed for activities of daily living (ADL). Findings Include: R75's quarterly Minimum Data Set (MDS) dated [DATE], identified R75 was severely cognitively impaired, with diagnoses which included dementia, coronary artery disease (CAD), and hypertension. Indicated R75 required substantial/maximal assistance with shower/bathing, and partial/moderate assistance with upper and lower body dressing. Identified R75 was independent with personal hygiene. R75's care plan revised 6/28/24, identified R75 had an ADL self-care performance deficit related to confusion, fatigue and impaired balance. R75 required assistance of one staff for dressing, bathing, and personal hygiene. R75's interventions identified R75 preferred no facial hair. During an observation and interview on 7/22/24 at 9:48 a.m., R75 was dressed in street clothes and seated in her recliner chair in her room. R75 had multiple white facial hairs approximately one quarter inch long across both cheeks, chin and around her mouth. R75 had a couple of approximately half inch long white facial hairs on her chin. R75 rubbed her chin and indicated she was unable to take them off by rubbing them. During an observation on 7/23/24 at 9:16 a.m., R75 was seated in her chair in her room and dressed in street clothes. R75 was looking for a pen to complete her word search puzzle book. R75 continued to have multiple white facial hairs approximately one quarter inch long across both cheeks, chin and around her mouth. R75 had a couple of approximately half inch long white facial hairs on her chin. During an interview on 7/23/24 at 9:18 a.m., nursing assistant (NA)-B stated she had not assisted R75 that morning with cares however, had noticed R75 had a large amount of facial hair present. NA-B indicated her usual practice when she observed R75 with facial hair, was to ask her if she could remove the hair and then remove it. NA-B stated it was important to assist R75 to remove facial hair to maintain her dignity. During an interview on 7/23/24 at 9:32 a.m., NA-C confirmed assisting R75 with ADL cares that morning and another day earlier that week. NA-C indicated the usual practice was to assist residents to remove facial hair when observed. NA-C had not looked closely at R75 that morning to check for facial hair however, should have done so. NA-C indicated it was important to assist residents with facial hair removal, as most of the female residents did not want any facial hair present. During an interview on 7/23/24 at 10:32 a.m., clinical manager registered nurse (RN)-A indicated the facility's usual practice was to ask residents or family members if the resident wished to have facial hair removed. RN-A stated if a resident wished to have facial hair removed, it was her expectation that staff checked for the presence of facial hair and asked them daily if they want it removed, as it was important to maintain dignity. During an interview on 7/23/24 at 10:39 a.m., director of nursing (DON) stated the facility's usual practice was for staff to offer to remove the resident's facial hair daily when present with morning cares. If a resident refused the offer, DON expected staff to document it. DON stated the resident's facial hair preference would have been identified on the resident's care plan. DON indicated it was important to assist residents to remove facial hair if they were unable to complete the task themselves to maintain dignity, to promote confidence and to have pride in their appearance. During a telephone interview on 7/23/24 at 10:48 a.m., family member (FM)-A stated R75 did not want to have any facial hair present and expected it to be removed. The facility policy titled Shaving The Resident revised 2/18, identified the purpose was to promote cleanliness and to provide skin care. The policy instructed to review the resident's care plan to assess for any special needs of the resident. The policy instructed to notify the supervisor if the resident refused the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively assess, monitor, develop and implement interventions to promote healing for 1 of 3 residents (R38) reviewed for a current, facility acquired, stage two pressure ulcer. Stage two pressure ulcer; partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Findings include: R38's significant change of status assessment (SCSA) Minimum Data Set (MDS) dated [DATE], identified R38 had diagnoses which included dementia, aphasia (loss or impairment to use or comprehend language), cerebral infarction (brain lesion in which a cluster of brain cells die when they don't get enough blood), congestive heart failure, chronic respiratory failure and dependence on supplemental oxygen. Indicated R38 had severe cognitive impairment and required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, toileting, dressing, personal hygiene and bathing. Identified R38 was at risk for developing pressure ulcers. The MDS lacked documentation of R38 having a pressure ulcer. R38's SCSA care area assessment worksheet (CAA) dated 7/9/24, identified R38 required extensive assistance with bed mobility, had a pressure reducing mattress on his bed and no noted skin issues. Identified R38 demonstrated a steady decline over the past several months and spent more time in bed. R38's care plan revised 2/3/24, identified R38 had potential impairment of skin integrity. R38's care plan lacked documentation of a current pressure ulcer. Furthermore, R38's care plan indicated R38 had shortness of breath related to diagnosis of chronic respiratory failure and received oxygen via nasal cannula continuously. R38's care plan lacked documentation of interventions to prevent pressure ulcers related to oxygen tubing. R38's Braden scale (tool used to determine risk for pressure ulcer development) dated 7/16/24, identified R38 was at moderate risk for pressure ulcer development due to the following risk factors; slightly limited sensory perception, very moist skin, was chairfast, slightly limited mobility and very poor nutrition. In addition, friction and shearing were a potential problem for R38 who required moderate to maximum assistance with moving. R38's nursing respiratory assessment dated [DATE], identified R38 had oxygen continuously via nasal cannula and would not experience discomfort or altered quality of life related to respiratory status. R38's nursing assessment dated [DATE], identified R38 had no skin concerns. Skin remained intact. Cushion applicators present behind ears. R38's progress note weekly skin assessment dated [DATE], identified R38 continued to have skin breakdown behind left ear from nasal cannula tubing. Skin protector applicator was placed on nasal cannula tubing and a treatment to monitor R38's ear until healed was setup by nursing. The note lacked a description of the breakdown and the type of treatment initiated by nursing staff. R38's progress note weekly skin assessment dated [DATE], identified R38 had no skin alterations. R38's progress note weekly skin assessment dated [DATE], identified R38 had no skin alterations. R38's progress notes lacked assessment of the pressure ulcer including measurements, interventions implemented to promote healing and prevent further breakdown and weekly monitoring of the ulcer to determine if it was healing or worsening. R38's nursing assistant (NA) care guide/[NAME] printed 7/24/24, indicated R38 had oxygen via nasal cannula continuously. The [NAME] lacked documentation of the presence of a pressure ulcer. During an observation on 7/23/24 at 3:04 p.m., R38 was laying in bed with the nasal cannula on and foam protectors on oxygen tubing behind bilateral ears. A Band-Aid was observed to be on the back of R38's left ear. During an observation and interview on 7/23/24 at 3:25 p.m., registered nurse (RN)-B stated she was unaware R38 had a Band-Aid to the back of his ear and was unaware that R38 had a pressure ulcer present on the back of the left ear. RN-B removed the Band-Aid and stated the Band-Aid did not look new. RN-B stated the Band-Aid had dried blood on it, no odor, and no drainage noted to the area on back of the left ear. RN-B confirmed there had been no initial assessment of the pressure ulcer on the back of R38's left ear or any measurements of the pressure ulcer documented in the electronic medical record (EMR). At 4:04 p.m., RN-B measured the pressure ulcer of R38's left ear at 0.5 centimeters (cm) long by 0.5 cm wide and was round. RN-B verified the pressure ulcer was located in the middle of the back of R38's left ear and stated the first layer of the skin was gone. The wound bed was red and no drainage was observed. RN-B confirmed it was important to assess and measure a pressure ulcer to determine if the pressure ulcer was improving or worsening and to implement interventions to assist with healing. RN-B stated there was a wound checklist at the nurses' station for nurses to complete when a new pressure ulcer was identified on a resident. During an interview on 7/24/24 at 12:31 p.m., licensed practical nurse (LPN)-A verified the progress note on 7/23/24. LPN-A stated she did not observe a Band-Aid behind R38's left ear during the weekly skin assessment documented on 7/23/24 at 1:51 p.m. LPN-A stated R38 had some redness behind both ears however there were no open areas present. During an interview on 7/24/24 at 12:35 p.m., RN-A stated she was unaware of a skin concern behind R38's left ear prior to last evening on 7/23/24. RN-A confirmed R38 had developed a stage two pressure ulcer to the back of his left ear from the oxygen tubing. RN-A stated the expectation of nursing staff was to complete a wound checklist when a new pressure ulcer was identified and verified the following steps of the wound checklist: -measure wound and describe. -start initial treatment (barrier cream, dressing, monitoring schedule). -notify the following; resident, resident representative, dietary, therapy, doctor, care coordinator. -implement new interventions (start tissue tolerance, air mattress, heel boots, etc.). -update care plan. -document. -once completed turn wound assessment into care coordinator. RN-A confirmed the progress note on 7/9/24, should have had a wound checklist completed. RN-A verified it was important to complete the wound checklist sheet to determine objectively if the pressure ulcer on the back of R38's ear was healing or worsening and if the right treatment had been implemented. During an interview on 7/24/24 at 1:15 p.m., RN-C verified the progress note on 7/9/24. RN-C stated R38 had a scabbed area to the back of his left ear and RN-C stated the scab was not a new concern. During an interview on 7/24/24 at 12:46 p.m., R38's doctor verified he was not aware of R38 having a pressure ulcer prior to last evening on 7/23/24. R38's doctor confirmed he would expect the facility to update him timely when a pressure ulcer developed and stated it was important to provide the resident with treatment, prevent infection and promote proper healing. During an interview on 7/24/24 at 1:23 p.m., the director of nursing (DON) verified she was not aware R38 had a pressure ulcer prior to last evening on 7/23/24. The DON confirmed R38's care plan lacked documentation about the development of the pressure ulcer to his left ear. The DON stated the expectation of nursing staff was for them to complete a wound checklist whenever a pressure ulcer developed, complete weekly monitoring, updating the care plan, the doctor and provide interventions. The DON verified it was important to complete the wound checklist to ensure a resident's pressure ulcer was healing and not worsening and ensure the interventions in place were effective. Review of the facility policy titled Skin Assessment, undated, identified it was the policy of the facility to complete weekly skin checks and quarterly skin assessments. Indicated it was the facility's procedure once a pressure injury was identified, that assessment and treatments, which included pressure relieving and nutritional interventions, would be implemented, care planned and monitored to promote healing. Review of the facility policy titled Documentation of Wound Treatments, undated, identified a pressure ulcer would be assessed including response to treatment, change in condition and changes in treatment. Pressure ulcers would be monitored for progression of wound healing and care plans would be reviewed and modified as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure residents were free of significant medication errors for 3 of 3 residents (R1, R2, R3) who had diagnosis of Diabetes and received long, and short acting insulin used for the treatment of elevated blood sugars. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had serve cognitive impairment with disorganized thinking. R1's medical diagnoses included diabetes mellitus (DM), hypertension (HTN) (high blood pressure), malnutrition, and renal failure. R1 received insulin daily. R1's hospital Discharge summary dated [DATE], identified R1 had marked elevation of blood sugars initially primarily secondary to steroid use. R1's blood sugars improved and came back to normal with some supplemental insulin. R1's renal failure has progressed. R1's blood sugars would need to be monitored closely. Insulin orders included: -NovoLog (Aspart) insulin 2 units subcutaneous (SQ) (injection between skin and muscle to allow medication to absorb slowly over long period of time) three times a day before meals if BS (blood sugar) > 400. -Detemir insulin 38 units SQ daily. R1's physician orders dated 12/19/23, identified: -2g Na (Sodium) diet regular texture. -BS TID (three times a day) related to type two diabetes mellitus. -Check blood glucose (BG) (history of low BG in AM's) one time a day for monitoring. Started on 11/29/23. -Offer bedtime snack to prevent low BS. Needs protein rich foods to stabilize sugars throughout the night, one time a day for diabetes. -Glucose oral gel 40% (dextrose/diabetic use). Give one application by mouth as needed for low BS. -Levemir (long-acting insulin used to lower BS over a 24-hour period) flex pen SQ solution pen injector 100 unit/ml (milliliter). Inject 38 units SQ one time a day for diabetes. Order started 11/22/23 and changed on 12/4/23. -Levemir flex pen SQ solution pen injector 100 unit/ml. Inject 34 units SQ one time a day for diabetes. Order started on 12/4/23. - NovoLog (fast acting insulin starts to work in 15 minutes, peaks in one hour, and works for up to two to four hours to lower blood sugars) flex pen SQ solution pen injector 100 unit/ml. Inject 2 units SQ three times a day for diabetes Hold if BS > 400. Order started on day of admission [DATE], and changed on 12/4/23, due transcription error. -NovoLog flex pen SQ solution pen injector 100 unit/ml. Inject as per sliding scale: if BS 0 to 400 =0 units; 401+ = 2 units, SQ three times a day for diabetes. For BS > 400. Order changed on 12/4/23, and current. R1's physician standing orders dated 11/22/23, and signed by primary physician identified: -Glucose 15g orally for BS levels below 50. Recheck BS in 15 minutes. May repeat Glucose times two. If BS stabilizes doctor maybe notified the next day. If the BS remains below 50 give Glucagon 1 mg (milligram) SQ or IM (intramuscularly) and notify doctor immediately. -Accu checks (blood sugar) as indicated for diabetic residents and symptoms of acute confusion, decreased alertness, diaphoresis, pallor, and/or meal refusal. Notify medical doctor (MD) of unconscious resident with BS lower than 50. For BS > 500, licensed nurse is to check BS level in two hours then notify MD if BS remains >500. -May hold medications times 24 hours as determined by RN (registered nurse). Medications refused or held after 24 hours required MD notification. R1's care plan dated 12/19/23, indicated R1 had diagnosis of diabetes mellitus and directed staff to administer diabetes medication as ordered by doctor and monitor/document for side effects and effectiveness. The care plan did not direct staff how to care for R1 if the blood sugars were critically high or low. R1's progress notes and electronic medication administration record (EMAR) confirmation from 11/28/23, through 12/18/23 identified: -11/28/23 at 2:02 p.m. Care conference summary: R1 felt confused this morning, noted low blood sugar today, did eat all breakfast, shaking hands, concerned he still had low BS and resident reported no one rechecked BS after the first time this morning. -12/1/23 7:00 a.m. Glucose oral gel 40% administered by mouth for low blood sugar. At 7:58 a.m. administration was effective. -12/2/23 at 7:55 a.m. BS 58 orange juice provided asymptomatic. At 8:14 a.m. BS 58, asymptomatic, glucose oral tablet chewable 4 gm given by mouth for low BS. At 11:59 a.m. (over three hours later) BS 150, administration was effective. -12/4/23 at 3:24 a.m. Glucose oral gel 40% administered by mouth for low blood sugar (documented under vitals in medical record at 3:23 a.m. BS 37 and at 3:58 a.m. BS 76). At 4:08 a.m. administration was effective. At 8:25 a.m. (documented under vitals in medical record at 8:25 a.m. BS 43). Glucose oral tablet chewable 4 gm given by mouth for low blood sugar. At 8:26 a.m. BS was 129, effective. (BS recorded to increase 86 mg/dl in one minute.) -12/4/23 at 8:42 p.m. Received phone call from a nurse indicated R1's daughter inquired about insulin parameters. Reviewed by primary physician and adjusted to hold NovoLog insulin if BS less than 250. Decreased Levemir insulin form 38 units to 34 units once daily. -12/5/23 at 2:02 p.m. Medication regimen review completed by consultant pharmacist (CP) no recommendations at this time. Very complex medical condition and medication regimen. Wide fluctuations in fasting blood sugars noted prior to admit to facility. Levemir insulin dose recently decreased and parameter of NovoLog insulin updated. Will continue to follow closely. (Pharmacist Review lacked evidence to identify concern related to held medications, physician notification or delayed follow up on low blood sugars.) -12/7/23 at 8:15 a.m. Administered Glucose oral gel 40% for low BS 56. At 9:42 a.m. (over one hour later) BS 369, effective. -12/7/23 at 2:09 p.m. received orders from nurse practitioner (NP), changed NovoLog two units three times a day for BS >400. To continue with Levemir insulin 34 unit daily upon discharge. -12/9/23 at 7:19 a.m. BS 57, glucose tab and orange juice provided. R1 asymptomatic. (Documentation in progress notes lacked evidence Levemir 34 units was held, or physician was notified. R1's EMAR identified Levemir insulin 34 units was held). At 7:26 a.m. BS remained at 57 orange juice and Glucose tab given. At 9:39 a.m. BS rechecked 396 (over two hours later), documented as effective. -12/14/23 at 3:41 a.m. Gave R1 orange juice with sugars and a boost for more stable carbohydrates (BS charted under vitals 66 and rechecked one hour later 148). -12/15/23 at 8:16 a.m. BS 62 this a.m. Levemir was held. At 12:32 p.m. R1 had taken medications without difficulty. Lunch BS 402; R1 reported he ate a good breakfast and a piece of cake at morning activity. (Record lacked evidence Provider was not notified.) -12/16/23 at 4:51 p.m. R1 was given 2 units of NovoLog insulin, blood glucose monitor read HI per manufactures, was above 600 (R1's vitals in medical record additional BS taken three more times indicated on 12/16/23 at 8:04 p.m., 12/17/23 at 2:22 a.m., and 6:02 a.m. BS remained above 600 four consecutive times and lacked evidence provider was notified). -12/17/23 at 8:52 a.m. Levemir insulin 34 units SQ was held due to resident feeling weak and state vision was blurry. BS 126. History of BS dropping quick, vital signs within normal limits, will continue to monitor and drinking orange juice presently. (Record lacked evidence physician was notified of resident experiencing possible diabetic symptoms or for holding medication.) -12/18/23 at 6:02 a.m. BS had been over 600 since 4:00 p.m. yesterday. No signs/symptoms of hyperglycemia. MD will be updated this morning. -12/18/23 at 12:59 p.m. R1 discharged back to Mill Street (assisted living). -12/18/23 at 5:35 p.m. R1 was discharged from facility. R1's E[DATE]/28/23, through 11/29/23, identified: -11/28/23, R1 received NovoLog insulin 2 units midday BS 144 and supper BS 268 (order transcribed/entered wrong, R1 should have not received NovoLog 2 units midday or supper unless BS was above 400). R1 also received Levemir insulin 38 units at bedtime (HS). R1's BS on 11/29/23 at 7:59 a.m. was 54. -11/29/23, R1 received Levemir insulin 38 units at HS and NovoLog insulin 2 units midday and p.m. (order transcribed wrong. R1 should not have received NovoLog midday with BS of 336). R1's E[DATE]/1/23, through 12/17/23, identified: -12/1/23, R1 received Levemir insulin 38 units at HS and NovoLog insulin 2 units midday and p.m. (order transcribed wrong. R1 should not have received NovoLog midday with BS of 219 and p.m. with BS of 393). On 12/2/23, at 7:00 a.m. and 7:18 a.m. BS was 50 and Glucose oral gel 40 % dextrose was given by mouth. R1's BS was not rechecked again until 11:49 a.m. BS of 219 (almost 4 hours later). -12/3/23, R1 received Levemir insulin 38 units and NovoLog 2 units at supper (order transcribed wrong. R1 should not have received NovoLog at supper time with BS of 375). On 12/4/23 at 3:23 a.m. BS was 37. R1 received Glucose oral gel 40% dextrose by mouth. R1's BS was rechecked at 3:58 a.m. BS 76. -12/4/23, R1 did not receive Levemir 38 units at 7:30 a.m. or NovoLog at supper as ordered. BS was 444 at 9:31 p.m. R1's blood sugar was rechecked at 2:16 a.m. and high at 366 (over 4 ½ hours later). -12/9/23, R1 did not receive Levemir 34 units dose as ordered (order change on 12/5/23, decreased Levemir from 38 units to 34 units). R1's BS at 7:17 a.m., 7:22 a.m., and 7:26 a.m. 57. R1's BS rechecked at 11:40 a.m. read high at 342. -12/15/23, R1 did not receive Levemir 34 units dose as ordered. R1's BS at 8:17 a.m. 62. R1's blood sugar re-checked at 11:12 a.m. read high at 402. 12/17/23, R1 did not receive Levemir 34 units dose as ordered. R1's BS at 8:34 a.m. was 126. R1's blood sugar re-checked at 11:54 a.m. read high at 435. R1's BS continued to rise on 12/17/23 at 4:35 p.m. over 600, at 8:04 p.m. over 600, then on 12/18/23 at 2:22 a.m. over 600 and 6:02 a.m. Provider was not notified and R1 was discharged on 12/18/23 at 5:34 p.m. R1's healthcare visit completed by nurse practitioner (NP)-A on 11/30/23, identified R1 had DM with stage four chronic kidney disease with long term current use of insulin, peripheral neuropathy (nerve damage usually hands and feet) and diabetic retinopathy (complications of diabetes that can damage or destroy blood vessels in the retina) of both eyes both associated with DM. R1 has had a history of quite drastic blood sugar fluctuations and R1's blood sugars continued to fluctuate. R2's significant change MDS dated [DATE], identified R2 had severe impaired cognition and occasional behaviors directed towards others. R1's medical diagnoses included DM, HTN, peripheral vascular disease (PVD) (narrowed arteries with reduced blood flow to the arms or legs related to diabetes), cerebrovascular accident (CVA) (stroke), malnutrition, and dementia. R2's physician orders dated 1/10/24, identified: -Diabetic diet regular texture. -BG testing four times a day for diabetes management. -Check BG before breakfast one time a day. -Check BG at 2:00 a.m. (hypoglycemic episodes since increase of Lantus) one time a day for monitoring. -Offer/give HS snack before bed to prevent hypoglycemic over night at bedtime. -Glargine SQ solution pen-injector 100 unit/ml inject 24 units SQ one time a day for diabetes. -Metformin oral tablet 500 mg give two tabs by mouth two times a day for diabetes. -NovoLog insulin injection solution inject as per sliding scale: if 100-149 =1 unit; 150-200 = 2 units; 201-250= 4 units; 251 -300 = 6 units; 301-350 = 8 units; 351- 400 = 10 units; 401 plus = 12 units. If above 401, recheck BS in one hour. If still elevated contact physician. R2's standing orders signed and dated 11/1/23, identified: -Glucose 15 g orally for blood sugar levels below 50. Recheck BS 15 minutes. May repeat Glucose times two. If BS stabilizes doctor may be notified the next day. If the BS remains below 50 give Glucagon 1 mg SQ or IM (intermuscular) and notify doctor immediately. -Accu checks as indicated for diabetic residents and symptoms of acute confusion, decreased alertness diaphoresis, pallor and/or meal refusal. Notify MD of unconscious resident with BS lower than 50. For BS <500, licensed nurse is to check BS level in two hours and then notify MD if BS remains > 500. R2's hospital Discharge summary dated [DATE], identified principal problem was diabetic ketoacidosis (DKA) (a serious complication of diabetes when the body cannot produce enough insulin caused by hyperglycemia (high blood sugars) associated with type 2 diabetes. Has had multiple episodes of DKA. Discharge instructions included: monitor blood sugars as patient has had episodes of hyperglycemia during hospital course. Blood sugar should be regularly monitored, and medications adjusted as necessary once discharged . R2's care plan dated 11/14/23, indicated a diagnosis of diabetes mellitus and staff were directed to monitor skin, administer diabetic medications as ordered by doctor and monitor for side effects. Monitor/document/report any signs and symptoms of hyperglycemia (high BS) and hypoglycemia (low BS). R2's progress notes and EMAR for 11/7/23, through 12/12/23 identified: -11/8/23 at 7:48 a.m. (EMAR) BS 578 rechecked at 10:23 a.m. BS 378 (over 2 1/2 hours later). -11/7/23 at 1:44 p.m. consultant pharmacist note identified medication regimen review complete. Fasting blood sugars and insulin dosing followed closely. -11/10/23 at 3:16 p.m. physician here and provided an order: increase Lantus to 28 units SQ daily. -11/11/23 at 12:40 p.m. (EMAR) BS 458, rechecked at 3:30 p.m. BS 113 (almost 3 hours later). -11/13/23, Metformin 500 mg give two tablets by mouth two times a day. (Dose was not administered at breakfast according to EMAR). At 8:54 p.m. Glargine insulin SQ inject 28 units one time a day for diabetes. Gave 26 units due to low blood sugars in the morning. -11/14/23 at 7:27 a.m. (EMAR) BS 487, rechecked at 11:00 a.m. BS 198 (3 ½ hours later). At 3:57 p.m. BS 480, rechecked BS 207 at 2:08 a.m. on 11/15/23 (over 10 hours later). -11/14/23 at 3:14 p.m. Fax received back form physician with orders to decrease Lantus to 24 units daily. -11/16/23 at 2:33 a.m. snack administered for low BS. Will recheck and monitor. Record lacked evidence recheck was completed. -11/18/23 at 3:18 p.m. (EMAR) BS 474, rechecked at 7:34 p.m. BS 132 (over 4 hours later). Metformin tablet 500 mg give two tablets by mouth two times a day, dose held on 11/13/23, during breakfast. -11/19/23 at 2:15 a.m. (EMAR) check BS level at 2:00 a.m. snacks provided. -11/20/23 at 7:27 a.m. (EMAR) BS 409, rechecked at 11:59 a.m. BS 261 (4 ½ hours later). -11/22/23 at 4:10 p.m. (EMAR) BS 498, rechecked at 7:28 p.m. BS 164 (over 3 hours later). -Glargine Insulin inject 28 units SQ was held on 11/28/23 (EMAR). -11/28/23 at 4:58 p.m. (EMAR) BS 521, rechecked at 8:32 p.m. BS 170 (3 ½ hours later). -11/29/23 at 4:48 p.m. (EMAR) BS 438, rechecked at 9:10 p.m. BS 68 (over 4 hours later). -11/29/23 at 9:11 p.m. Glargine insulin was not administered according to EMAR. BS was 86. -12/4/23 at 5:17 p.m. (EMAR) BS 487, rechecked at 8:18 p.m. BS 322 (3 hours later). -12/6/23 at 6:00 p.m. consultant pharmacist note: medication regime completed. Fasting blood sugars followed closely. Glargine dosing recently adjusted. (Pharmacist Review lacked evidence to identify concern related to held medications, physician notification or delayed follow up on low blood sugars.) -12/7/23 at 2:14 a.m. administered orange juice, boost, peanut and butter jelly toast and banana. Will continue to monitor. -12/12/23 at 5:20 a.m. checked BS before breakfast 334. R2's EMAR dated 12/12/23, through 1/8/24, identified: -12/12/23 at 11:50 a.m. BS 472, rechecked at 4:40 p.m. BS 411 and another 12 unites of NovoLog was administered SQ. Rechecked at 7:57 p.m. (over 3 hours later). -12/15/23 at 3:45 p.m. BS 405, rechecked at 7:22 p.m. BS 174 (3 ½ hours later). -12/19/23 at 4:24 p.m. BS 434, rechecked at 8:16 p.m. BS 471 (over 3 ½ hours later BS remained above 400). -12/20/23 at 8:25 a.m. BS 422, rechecked at 11:50 a.m. BS 98 (over 3 hours later). -12/29/23 at 8:10 a.m. BS 512, rechecked at 11:54 a.m. BS 81 (over 3 ½ hours later). -1/4/24 at 5:28 a.m. BS 499, rechecked at 7:43 a.m. BS 270 (over 2 hours later). -1/5/24 at 7:32 a.m. BS 405, rechecked at 11:49 a.m. BS 73 (over 4 hours later). At 4:54 p.m. BS was 405, rechecked at 7:47 p.m. BS 235 (over 2 ½ hours later). R2's record lacked evidence low or elevated blood sugars were rechecked within one hour per order. MD was not notified when diabetic medication was held. R3's significant change MDS dated [DATE], identified R3 had moderately impaired cognition and occasional disorganized thinking. R1's medical diagnoses included HTN, heart failure, and DM. R3's physician orders dated 1/10/24, identified: -Assess blood sugar prior to receiving short acting insulin one time a day. -Assess blood sugars four times a day, times one week then continue to assess blood sugars twice a day. -Offer snack before bedtime to prevent low blood sugars one time a day for DM. -Insulin Aspart (NovoLog) SQ solution pen-injector 100 unit/ml inject 22 units SQ two times a day for diabetes. -Insulin Aspart (NovoLog) SQ solution pen-injector 100 unit/ml inject 24 units SQ one time a day for diabetes. -Insulin Glargine SQ solution pen-injector 300 units/ml inject 70 units SQ two times a day for diabetes. -Metformin ER (extended release) 24 hour 500 milligrams (mg) one tablet by mouth one time a day for diabetes. -Liraglutide SQ solution 18 mg/3 ml. Inject 1.8 mg SQ one time a day for diabetes. R3's standing orders dated and signed on 8/11/23, identified: -Glucose 15 g orally for blood sugar levels below 50. Recheck BS 15 minutes. May repeat Glucose times two. If BS stabilizes doctor may be notified the next day. If the BS remains below 50 give Glucagon 1 mg SQ or IM and notify doctor immediately. -Accu checks as indicated for diabetic residents and symptoms of acute confusion, decreased alertness diaphoresis, pallor and/or meal refusal. Notify MD of unconscious resident with BS lower than 50. For BS <500, licensed nurse is to check BS level in two hours and then notify MD if BS remains > 500. R3's care plan dated 12/20/23, identified R1 had diabetes and directed staff to monitor for signs and symptoms of hypoglycemia (low blood sugars), infection, and compliance with diet. R3's E[DATE]/24/23, through 11/27/23, identified: -11/24/23, 11/26/23, and 11/27/23, at HS (hour of sleep) Liraglutide SQ 1.8 mg one time a day for diabetes was held all three days. -11/23/23, at supper time Aspart insulin SQ 22 units two times a day for diabetes was held. -11/24/23 at 12:00 p.m. Insulin Aspart inject 24 units SQ one time a day was held. -11/24/23, at HS Glargine insulin 70 units SQ two times a day for diabetes was held. -11/26/23, Aspart insulin SQ 22 units two times a day for diabetes was held at breakfast time. Additionally, a.m. and HS doses of Glargine insulin 70 units were held. -11/27/23, at HS Glargine insulin 70 units was held. R3's E[DATE]/1/23, through 12/17/23, identified: -12/4/23, and 12/10/23 at HS Liraglutide 1.8. mg SQ one time a day was held. -12/13/23, and 12/16/23, at 12:00 p.m. Aspart insulin 24 units SQ was held. -12/1/23, 12/3/23, 12/5/23, 12/14/23, 12/15/23, 12/17/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23, and 12/31/23, Aspart insulin 22 units SQ ordered two times a day was held in the a.m. and 12/4/23, 12/15/23, 12/21/23, and 12/29/23, supper doses were held. On 12/8/23, supper time and 12/22/23, a.m. R3 refused both times. -On 12/4/23 at HS and 12/17/23 a.m. Glargine 70 units SQ. R3's E[DATE]/1/24 through 1/7/24, identified: -On 1/1/24, 1/2/24, 1/3/24,1/4/24, 1/5/24, breakfast time Aspart insulin 22 units SQ was held. On 1/4/24, drug refused and 1/6/24, not given. -On 1/4/24, 1/5/24, 1/6/24, 1/7/24, a.m. Glargine insulin 70 SQ and 1/5/24 HS dose were all held. Provider was not notified when insulin and/or diabetic medications were held or declined by R3. R3's progress notes and EMAR from 12/4/23 through 1/8/24 identified: -12/4/23 at a.m. EMAR indicated Glargine 70 units was held. No documentation noted in the progress notes. -12/8/23 at 5:41 p.m. Resident declined insulin. BS 187. Record lacked evidence physician was not notified when Aspart insulin was held. - 12/10/23 at 8:46 p.m. R3's BS was 83. Glargine 70 units. Insulin dose was held. Record lacked evidence physician not notified. - 12/17/23 at 10:23 a.m. and 10:25 a.m. R3's BS 111, BS drops low, had big breakfast, and drank orange juice. EMAR lacked evidence insulins (Glargine and Aspart) were administered and progress note lacked evidence physician was notified. -12/26/23 at 11:58 a.m. BS 77, writer notified R3 of low reading. Insulin still given per resident request at the same time started eating lunch. -12/26/23 at 5:08 p.m. R3 had been running hypoglycemic today at lunch and supper and now symptomatic at supper stated she was not feeling well and husband stated she was not acting right. Resident appeared slightly lethargic but was awake, alert, oriented. Held supper dose of insulin. BS was 80 at original check, drank glass of orange juice, now 106. However, R3's BS was 77 at lunch, insulin was given and recheck was 158 about 1 hour and 30 minutes after lunch and back down to 80 for supper. Record lacked evidence Physician was notified of insulin being held. Onsite NP visit dated 1/2/24 identified blood sugars look good, asymptomatic. Continue current diabetic medications. Having increased neuropath/burning in feet. -1/4/24, 1/5/24, 1/6/24, noted on EMAR R3's Glargine 70 units were held every a.m. and at HS on 1/5/24. No additional documentation noted in progress notes. No evidence Physician was not notified. -1/7/24 at 7:50 a.m. R3 received scheduled NovoLog this a.m. Had history of dropping. Glargine insulin 70 units Held at this time. Record lacked physician was notified. -1/7/24, at 11:59 p.m. note left for NP in communication book regarding R3's Glargine being held 1/6/24, and 1/7/24. -1/8/24, at 2:53 p.m. consultant pharmacist note indicated medication regimen was reviewed and completed. No mention of insulin being held or recommendations. (Pharmacist Review lacked evidence to identify concern related to held medications, physician notification or delayed follow up on low blood sugars.) During an interview on 1/8/24 at 2:34 p.m., trained medical aide (TMA)-A stated she was responsible to process the admission orders when a resident was admitted to the facility. TMA-A also stated she had entered the insulin orders for R1 when he was admitted from the hospital on [DATE] and assumed the clinical coordinator had double checked them. TMA-A verified she was notified on 12/5/23, the insulin orders entered were incorrect and she had made a mistake and misunderstood the greater and less than sign (< and >), hit the wrong key, they were next to each other on the keyboard. TMA-A stated she had entered the order staff were to administer NovoLog insulin 2 units SQ three times a day if BS was below 400 and should have read above 400 which resulted in a medication errors. TMA-A confirmed she had been immediately retrained upon facility's recognition of this error and a new system was not in place for a second check upon transposition of orders. During an interview on 1/8/24 at 3:00 p.m., director of nursing (DON) stated standing orders for residents in facility indicated under registered nurse discretion any medication could have been held up to 24 hours without notification to physician. RN verified the standing orders did not identify which medications could be held. During a follow up interview on 1/9/24 at 4:00 p.m., DON verified R1's orders were reviewed and unable to identify any other orders from physician to be notified if BS were too high or too low other than the standing orders. DON stated the standing orders needed to be reviewed with the medical director and she was unaware insulin was being held without notification to physician. DON stated staff were expected to notify the physician when high risk medications were held such as insulin. DON also expected staff to monitor BS and if too low or two high, recheck the BS per standing order and if remained abnormal staff were expected to contact the physician for further orders. DON added, when long-acting insulin was held the resident's BS could become unstable and the resident could possibly end up with hypoglycemia/hyperglycemia which can have long standing effects on the entire body/multiple organs. Residents could end up with possible kidney issues, vision problems, increased falls, and much more. DON also stated those complications required to be addressed in a timely manner. DON indicated on 12/16/23, through 12/17/23, R1's blood sugars were extremely high over 600 multiple times, standing orders were not followed, and provider was not notified in a timely manner. During an interview on 1/9/24 at 10:30 a.m., RN-A stated licensed nurses are expected to recheck an elevated BS over 500 within a couple of hours and if remained elevated contact the provider for further direction. RN-A stated staff are also expected to recheck a low blood sugar especially after administration of glucagon within 15 minutes after the resident received it and if remained low further action would be required by following provider orders. RN-A verified standing orders allowed licensed staff to hold insulin without notification to provider up to 24 hours. RN-A indicated there was confusion with the standing orders and believed they had changed them recently. RN-A indicated she was told critical medications such as insulin, coumadin and considered night alert medications should not be held without notification to the provider. RN-A stated she would have notified the provider when a BS remained extremely high such as over 400 because it could have caused complications such as DKA. During an interview on 1/9/24 at 11:26 a.m., RN-B stated she had held long-acting insulin twice and standing orders indicted if more than 24 hours the provider needed to be contacted. RN-B verified a BS on the glucometer that read 600 usually indicated it was most likely over 600 and the provider should have been notified. RN-B stated the supervisor was informed on 1/18/24, when R1's BS was discovered to be over 600 consistently four times. RN-B indicated R1 informed her he had eaten a piece of cake and the BS had gone way up. RN-B stated the provider should have been contacted because R1 could have gone into DKA and was too long for a BS to be consistently extremely high. During a telephone interview on 1/9/24 at 1:12 p.m., pharmacist consultant (PC) stated R1 presented with a wide fluctuation in fasting blood sugars prior to admission to facility. PC stated long-acting insulin regulated R1's BS not necessarily the short acting. PC stated the NovoLog insulin order for R1 was unusual with such a brittle diabetic: give two units of NovoLog 2 units if BS was over 400. PC stated they had reviewed R1's BS prior to admission and he was one of those that had BS all over the board. PC indicated facility nursing staff lacked documentation especially on 12/15/23 when BS was 62 and Levemir was held. PC indicted nursing staff would most likely benefit from a refresher course and more education on how insulin worked. PC indicated she would have expected staff to have provided more documentation on that one. PC stated on 12/17/23 R1 was symptomatic, complained of blurry vision and felt weak. PC stated nursing judgement was indicated and error on side of precaution and could have the lack of the long-acting insulin that potentially increased his blood sugars the next day. PC also stated insulin was a high-risk medication, and the physician should have been notified when BS were over 500. PC stated long term management of diabetes and abnormal BS can result in many complications such as kidney issues and retinopathy (damage to blood vessels to the eye caused by diabetes). PC indicated R1 was not considered long term and there were many people that had not realized they had diabetes yet. PC stated on 11/29/23, R2's Glargine insulin (long acting) was held with BS 86 and as a rule that type of insulin should have not been held. PC stated R2 should have been offered a snack and insulin administered. PC R2's medical record lacked nursing documentation when that decision was made, should have identified why the medication was held and if symptomatic. PC stated on 1/7/24, R3's Glargine insulin 70 units was held when BS was 125. PC indicated the standing orders were very vague and therefore relied on nursing judgment call and they would have made the decision. During an interview on 1/9/24 at 3:05 p.m., clinical coordinator (RN)-C stated she had completed R1's admission on [DATE] and thought another nurse had checked the orders and it got missed. RN-C stated a new process was in place for two licensed staff to check off new admission orders and sign off. RN-C stated the standing orders were not clear and not sure staff would have known which medications could have been held. RN-C stated long-acting insulins should always be given otherwise BS levels would become unstable and uncontrolled. RN-C verified the long-acting insulin helped stabilize BS levels. RN-C stated BS could have gone high or low and concerned the resident would become hyperglycemic/hypoglycemic, become confused and increased risk for falls. RN-C stated the nursing staff would be expected to contact the provider for further orders. RN-C stated when R1's BS was over 500 or below 50 staff were expected to follow up and recheck in two hours and provider notified if BS remained high or low. RN-C stated between 12/16/23 and 12/17/23, when R1's BS read consistently 600 on the glucose machine most likely was over 600, R1 required more insulin, and a provider should have been notified. RN-C stated diabetes was a hard thing to manager and blood sugars go up and down, this could have referred R1's recovery time from his infection. RN-A stated the standing orders were not appropriate for R1 due to BS were difficult to control and he was a brittle diabetic. RN-C stated a licensed nurse did not have the authority to hold a critical medication without provider order and should have contacted the provider. RN-C stated on 12/17/23, R1 had blurry vision, was weak, low BS provider was not notified and should have been. RN-C also stated nursing staff were expected to recheck a low BS level below 50 within 15 minutes and contact provider if needed. During a telephone interview on 1/9/24 at 3:50 p.m., MD stated he expected to be made aware when long-acting insulin was being held and the reason why. MD indicated with resident's who are considered brittle diabetics it is very important to monitor them and update provider when they had a BS consistently over 600 and determine where to go from there. MD verified a standing order for insulin with a brittle diabetic would have not been appropriate, the BS required closer monitoring and management to help prevent complications such as hyperglycemia and DKA. Facility policy titled Insulin Administration dated 2014, identified guidelines provided for the safe administration of insulin to residents with diabetes. The insulin dosage requirements must be verified prior to administration to assure it corresponds with the order on the medication sheet and the physician's order. Nursing staff were expected to notify the supervisor if

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure residents were assessed for the ability to self administer medications for 2 of 2 residents (R57, R34) observed for medication administration. Findings include: R57 R57's Diagnosis Report dated 9/13/23, indicated R57 had diagnoses which included hemiplegia and hemiparesis (paralysis and/or weakness on one side of the body) following cerebral infarction (stroke) of right dominant side, low back pain, and depression. R57's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R57 was cognitively intact. R57's Active Orders as of 9/13/23, included: -acetaminophen 650 milligrams (mg) two times a day for pain. -cyclobenzaprine five mg every eight hours as needed for pain related to muscle spasms. R57's electronic health record (EHR) lacked a medication self-administration assessment. During an observation on 9/11/23 at 6:40 p.m., registered nurse (RN)-A provided R57 with the two medications listed above and R57 stated she did not want to take the medication yet. RN-A stated R57 was approved for self-administration of medications and left the medications at R57's bedside in a paper medication cup for R57 to take at a later time independently. -at 7:25 p.m., the medications remained at the resident's bedside in the medication cup. During an interview on 9/12/23 at 11:51 a.m., clinical manager (CM)-A reviewed R57's EHR and was unable to find an assessment for self-administration of medications or a physician order for self-administration of medications. CM-A stated the medications should not have been left at R57's bedside. R34 R34's Diagnosis Report dated 9/13/23, indicated R34 had diagnoses which included bilateral primary open-angle glaucoma (chronic, progressive, and irreversible optic neuropathy with progressive loss of peripheral vision), depression, anxiety, and dependence on supplemental oxygen. R34's significant change MDS assessment dated [DATE], indicated R34 was cognitively intact. R34's Active Orders as of 9/13/23, included: -albuterol sulfate HFA aerosol solution 108 (90 Base) micrograms (mcg) per inhalation, one puff inhale every four hours as needed for shortness of breath, wheezing, or cough related to asthma -artificial tears one percent instill two drops in both eyes two times a day for dry eyes and as needed -Atrovent HFA aerosol solution 17 mcg per inhalation, two puffs inhale orally four times a day for shortness of breath related to asthma -ProAir HFA aerosol solution 108 (90 Base) mcg per inhalation, one puff every four hours as needed for shortness of breath -Symbicort aerosol 80-4.5 mcg per inhalation, two puffs two times a day for shortness of breath related to asthma. R34's EHR lacked a medication self-administration assessment. During an observation and interview on 9/11/23 at 2:24 p.m., in R34's room, her inhalers and eye drops were located in a box in her room. R34 said they were there so she could use them independently as needed. During an interview on 9/12/23 at 3:51 p.m., the director of nursing (DON) stated residents were able to self administer medications after they had been assessed to safely self administer their medications and a physician's order had been obtained. During an interview on 9/13/23 at 10:12 a.m., the consultant pharmacist stated the facility should follow their protocol/procedure to ensure the resident was safe to self-administer medications. When a resident was determined to be safe to administer medications, the facility should have obtained an order from the physician as well. The facility policy titled Self-Administration of Medications dated 2/2021, indicated the interdisciplinary team (IDT)would assess each resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate for the resident. If the IDT determined it was safe and appropriate for the resident to self-administer their medications, it would be documented in the medical record and in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide a summary of the baseline care plan to the resident representative, for 1 of 1 (R3) resident reviewed for care planning. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and had diagnosis which included anxiety disorder, depression, and seizure disorder. Indicated R23 required extensive assistance with bed mobility and toileting. Identified R23 required limited assistance from staff with transfers and personal hygiene. R23's base line care plan dated 5/31/23, identified R23 required staff assistance with personal hygiene and ambulation and was independent with eating after setup. Identified R23 was at risk for falls and directed staff to ensure R23 was wearing proper footwear, and was signed by the clinical manager (CM)-B. R 23's face sheet indicated he had been admitted to the facility on [DATE]. During an interview on 9/11/23 at 11:46 a.m., family member (FM)-A stated he had not received a summary of R23's baseline care plan. During an interview on 9/13/23 at 11:50 a.m., clinical manager (CM)-B stated she completed R23's baseline care plan and was not able to recall providing R23's representative a summary of the baseline care plan. During an interview on 9/13/23 at 12:06 p.m., director of nursing (DON) stated she was unsure why a summary of the baseline care plan was not provided to R23's representative. DON indicated her expectation was a summary of the baseline care plan would have been provided to R23's representative. A facility policy titled Care Plan - Baseline dated 2001, revised 3/22, indicated the baseline care plan includes instructions needed to provide effective, person- centered care of the resident. Identified the resident and/ or representative were provided a written summary of the baseline care plan. ·

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to conduct a care planning meeting for 1 of 1 residents (R23) reviewed for care plan. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and had diagnosis which included anxiety disorder, depression, and seizure disorder. R 23's face sheet indicated he had been admitted to the facility on [DATE]. During an interview on 9/11/23 at 11:46 a.m., family member (FM)-A verified he was the representative for R23. FM-A stated he had not been invited to a care planning conference since R23 had been admitted to the facility. FM-A stated he would have considered attending if he had been invited. R23's electronic health record (EHR) identified an admission MDS was completed on 6/6/23, and a quarterly MDS was completed on 8/29/23. The EHR lacked documentation a care conference occurred which included R23 or his responsible representative. During an interview on 9/13/23 at 8:59 a.m., health information management (HIM) stated she was responsible for scheduling the care conferences. HIM confirmed R23's EHR lacked documentation care conferences had been completed. HIM was unsure why a care conference had not been scheduled for R23. During an interview on 9/13/23 at 9:17 a.m., social services designee (SSD) stated HIM scheduled the care conferences. SSD stated she could not recall having a care conference for R23. SSD confirmed R23's EHR lacked documentation of a care conference being held. SSD stated she was unsure why a care conference had not been completed for R23. SSD indicated care conferences were important to collaborate with R23 and his family in managing R23's care. During an interview on 9/13/23 at 11:46 a.m., clinical manager (CM)-A stated she did not recall having a care conference for R23 and verified the record lacked documentation of a care conference being held for R23. CM-A stated she was unsure why a care conference had not been held. CM indicated it was important to have care conferences, to invite R23 and his family to collaborate on R23's care. During an interview on 9/13/23 at 12:06 p.m., director of nursing (DON) confirmed R23's EHR lacked evidence of a care conference being held. DON stated she was unsure why a care conference had not been held. Indicated it was important to have care conferences to establish and to collaborate about resident's care. DON stated her expectation was all residents would have care conferences and all residents and family representatives would be invited to the care conferences. A facility policy titled Care Planning-Resident Participation undated. Indicated the facility supported the resident's right to be informed of, and participate in, his or her care planning treatment. Indicated the facility would encourage and assist the resident and/ or resident representative to participate in choosing care and treatment options.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R63 R63's recent significant Minimum Data Set (MDS) dated [DATE], identified R63 had moderate cognitive impairment and had diagnosis which included cancer, dementia, and heart failure. Indicated R63 required total assistance of staff for all ADL's. R63's care plan, revised 9/11/23, indicated R63 had deficits with ADL's and required total staff assistance with all cares. R63's comprehensive Care Area Assessment (CAA) dated 7/20/23, identified R63 required total assistance from staff with all ADL's. Indicated R63 was on hospice and unable to perform ADL cares independently. During an observation on 9/13/23, at 7:05 a.m R63 was laying in bed on her back with her head slightly elevated, glasses on and blanket pulled up to her chest. Room lights were shut off and television was shut off. Resident yelled out from her room. - 9/13/23, 7:25 a.m. R63 was awake and looking around the room. R63 remained on her back with head slightly elevated. Glasses were on and call light was within reach. - 9/13/23, 7:51 a.m. R63 continued the same as above. - 9/13/23 8:03 a.m. NA-D and NA-E entered R63's room to provide daily ADL's for R63. NA-D asked R63 if her and NA-E could get her ready for the day. NA-D asked R63 to change her shirt and provided two shirt options. R63 chose a shirt, NA-D and NA-E removed R63's shirt and placed the new shirt on. NA-D placed gloves on and pulled R63's blankets down. NA-D provided directions to R63 to turn and roll and removed soiled brief. NA-D used contents from tube in drawer, placed on wipe and wiped R63's peri area and bottom. NA-D removed gloves and applied new brief under R63. NA-D applied new gloves and instructed R63 to roll to side to get brief pulled up and secured. NA-D removed gloves, pulled blankets up and applied hand sanitizer. NA-D applied gloves, obtained wet wash cloth from the bathroom sink, brought to R63's bedside and washed R63's face with the wet washcloth. NA-D removed gloves. NA-D asked if R63 would like her whiskers removed and R63 replied yes. NA-D stated she would find something to remove whiskers and then asked R63 what she would like for breakfast. NA-D then stated she would get R63 something to eat and drink, sanitized hands and left the room. NA-D or NA-E were not observed to provide oral cares. During an interview on 9/13/23, at 9:48 a.m. NA-D stated R63 required full assistance from staff with ADL's. NA-D confirmed R63 had not received oral cares during am cares. During an interview on 9/13/23, at 11:56 a.m. RN-B indicated R63 required full assistance from staff with ADL's. RN-B indicated his expectations were for staff to provide R63 with assistance of all ADL's which included oral cares. During an interview on 9/13/23, at 1:05 p.m. director of nursing (DON) stated R63 required staff assistance from staff with ADL's and was incontinent of both bladder and bowel. DON indicated the expectations were each resident receive ADL cares daily including oral cares. DON stated if R63 refused her expectations would be staff would attempt to provide cares at a later time. If R63 continued to refuse, DON would expect staff to inform the RN and the refusal would be documented. Review of a facility policy titled Activities of Daily Living (ADL's) Supporting dated 2001, revised 3/2018, revealed appropriate care and services would be provided for residents who were unable to carry out ADL's independently including: hygiene ( bathing, dressing, grooming, and oral care). Based on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 2 of 5 residents (R23 and R 63) reviewed for activities of daily living (ADL)'s. Findings include: R23 R23's quarterly Minimum Data Set (MDS) dated [DATE], identified R23 had moderate cognitive impairment and had diagnosis which included anxiety disorder, depression, and seizure disorder. Indicated R23 required extensive assistance with bed mobility and toileting. Identified R23 required limited assistance from staff with transfers and personal hygiene. R23's current care plan dated 5/31/23, indicated R23 had deficits with ADL's related to activity intolerance. R23 required staff assistance with personal hygiene. R23's comprehensive Care Area Assessment (CAA) dated 6/11/23, identified R23 required assistance with ADL's. Indicated R23 had an activity intolerance. During an observation on 9/11/23 at 10:59 a.m., R23 was seated in a recliner in his room and had several dark long facial hair present on his chin, above his lips and on his cheeks which were approximately 1/4 inch or longer. During an interview on 9/11/23, at 1:45 p.m., family member (FM)-A stated R23 preferred to be shaved daily. During an observation on 9/11/23 at 6:06 p.m., R23 was seated on the edge of his bed and continued to have several long facial hair 1/4 inch or longer on his chin, above his lips and on his cheeks. During an observation on 9/12/23 at 8:43 a.m., R23 was seated at the dining room table eating breakfast and continued to have several facial hair 1/4 inch or longer on his chin, above his lips and on his cheeks. During an interview on 9/12/23 at 10:00 a.m., nursing assistant (NA)-A stated R23 required set up assistance from staff to shave. NA-A stated she had not assisted him with shaving recently. NA-A indicated she was unsure of when the last time R23 had been shaved and indicated the long dark facial hair on R23's face appeared to be more than a few days growth. During an interview on 9/12/23 at 10:05 a.m., NA-B stated staff were required to assist with set up for R23 to shave when facial hair became visible. NA-B stated he had not assisted NA-B with shaving recently. NA-B indicated the long facial hair on R23's face appeared to be more than a few days growth. During an interview on 9/12/23 at 11:34 a.m., licensed practical nurse (LPN-A) stated R23 required set up assistance from staff to shave. LPN-A verified R23 had long facial hair and was uncertain when the last time R23 had been shaved. LPN-A stated her expectation was R23 would have been shaved daily. During an interview on 9/12/23 at 3:55 p.m., director of nursing (DON) indicated R23 required staff assistance with shaving. DON stated her expectation was R23 would have been shaved daily or when facial hair was present. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure 1 of 1 residents(R78) received appropriate ongoing catheter cares reviewed for urinary catheter care. Findings include: R78's Diagnosis Report dated 9/13/23, indicated R78 had diagnoses which included malignant neoplasm of prostate. R78's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R78 was cognitively intact and had an indwelling foley (urinary) catheter. R78's significant change Care Area Assessment (CAA) dated 6/30/23, indicated R78 had a foley catheter in place related to a diagnosis of prostate cancer. The CAA identified proceed to care plan to avoid risk and complications related to the indwelling foley catheter. R78's care plan dated 6/21/23, indicated R78 had a self-care deficit, had a foley catheter and had a goal to remain free from catheter-related trauma. Interventions included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door, monitor and document intake and output, monitor for pain and discomfort due to catheter, and monitor for signs and symptoms of infection (pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color and increased pulse and temperature). The care plan lacked information on how to care for the indwelling foley catheter. R78's Order Summary Report current as of 9/13/23, directed staff to obtain urinary output (foley catheter) every shift. The report lacked information about catheter cares. During an observation on 9/12/23 at 10:47 a.m., nursing assistant (NA)-C entered R78's room to assist him out of bed and to get ready for the day. NA-C performed hand hygiene, donned gloves, placed a gait belt on R78 and walked with him into the bathroom. NA-C assisted R78 to sit on the toilet and removed his brief. NA-C reminded R78 to use the call light when he was done. -at 10:56 a.m., R78 put on his call light, NA-C answered the call light, performed hand hygiene, put on gloves, threaded R78's foley catheter bag through his brief, assisted him to stand, pulled up his brief after wiping his rectal area, walked him to the sink and stood by while R78 washed his hands at the sink. NA-C assisted R78 to walk to his recliner, settled him into his chair, placed a blanket on his lap and exited the room with the garbage. During an interview on 9/11/23 at 10:36 a.m., R78 said he believed he had the catheter in place for about two months. R78 stated staff did not cleanse around the catheter tube daily. During an interview on 9/12/23 at 11:03 a.m., NA-C stated she did not complete catheter cares and believed the nurses performed R78's catheter cares. NA-C confirmed she had never completed any catheter cares for R78. During an interview on 9/12/23 at 11:07 a.m., trained medication aide (TMA)-A stated R78 received catheter cares at bedtime and he would get a bath on Tuesdays and occasionally on Saturdays. TMA-A stated catheter cares had not been completed by her on 9/12/23. TMA-A reviewed R78's electronic health record (EHR) and was not able to locate where catheter cares had been documented as completed. During a follow-up interview on 9/12/23 at 11:14 a.m., R78 stated staff had never washed around his catheter or his perineal area. R78 stated he received a tub bath twice a week. During an interview on 9/12/23 at 11:45 a.m., clinical manager (CM)-A stated the standard of care for an indwelling foley catheter would be for staff to complete catheter and perineal cares at least once daily and to document the cares. CM-A stated catheter care was expected to be completed by the NAs. CM-A reviewed R78's care plan and verified the care plan lacked interventions for catheter cares. During an interview on 9/13/23 at 11:38 a.m., the director on nursing (DON) stated the standard of care for residents who had catheters would be for staff to complete catheter care twice daily and as needed to prevent infections. The policy Catheter Care, Urinary dated 8/2022, indicated the purpose of catheter care was to prevent urinary catheter-associated complications, including urinary tract infections. The policy indicated perineal care should have been completed daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure oxygen tubing and nasal cannula ( a device that delivers extra oxygen through a tube and into the nose) were stored in a manner to prevent the potential contamination during the use of oxygen for 1 of 1 resident (R5) who utilized oxygen therapy. Finding include: R5's Diagnosis Report dated 9/13/23, indicated R5 had diagnoses which included heart failure (a disease in which the heart does not pump as well as it should), dementia, chronic respiratory failure with hypoxia (low oxygen levels in the blood stream), and cognitive communication deficit. R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R5 was severely cognitively impaired and used oxygen. Identified R5 was dependent on staff for activities of daily living. R5's care plan dated 8/16/23, indicated R5 had a potential for altered respiratory status related to heart failure with hypoxia. R5's interventions included to keep R5's oxygen saturations greater than 88% by applying oxygen. R5's Order Summary current as of 9/13/23, indicated R5 had an order for oxygen at two liters per nasal cannula at all times three times a day for hypoxemia with chronic respiratory failure. During an observation on 9/11/23 at 12:01 p.m., R5 was lying in bed and she did not have her oxygen on. R5's nasal cannula was on the floor under the bed, no date identified on the tubing and oxygen was running at two liters per minute. During an observation on 9/12/23 at 2:03 p.m., R5 was observed lying in bed her and oxygen tubing was draped over the dresser in her room with the nasal cannula resting on the floor behind the dresser. During an observation on 9/12/23 at 3:57 p.m., R5 rested in bed while receiving oxygen at two liters per nasal cannula. During an interview on 9/12/23 at 3:59 p.m., registered nurse (RN)-A stated she had applied oxygen to R5 as she had checked R5's oxygen saturations and they were noted to be 87%. RN-A verified she used the nasal cannula that had been draped over the dresser. RN-A stated she had not noticed the nasal cannula was on the floor however verified it should have been changed prior to applying it to R5. During an interview on 9/13/23 at 11:46 a.m., the director of nursing (DON) stated she believed oxygen tubing was changed monthly and the tubing should have been dated. The DON verified she would expect staff to retrieve new oxygen tubing if the nasal cannula had been left on the floor to prevent the potential spread or development of infection. The policy Oxygen Administration dated 2023, indicated oxygen tubing and mask/cannula should have been changed weekly and as needed when it had been soiled or contaminated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 3 of 5 residents (R7, R37, R41) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the Pneumococcal Vaccine Timing for Adults, dated 3/15/23, from the CDC identified adults [AGE] years of age or older who had previously received the Pneumococcal 13-valent Conjugate Vaccine (PCV13) and the Pneumococcal Polysaccharide Vaccine 23 (PPSV23) should receive one dose of the 20-valent Pneumococcal Conjugate Vaccine (PCV20). Review of R7's Minnesota Immunization Information Connection (MIIC) identified R7 had received the PCV-13 vaccination on 4/23/15, and the PPSV23 vaccination on 10/04/07. R7's medical record lacked documentation R7 had been offered or received the PCV20 vaccination. Review of R37's MIIC identified R37 had received the PCV-13 vaccination on 12/12/16, and the PPSV23 vaccination on 11/23/04. R37's medical record lacked documentation R37 had been offered or received the PCV20 vaccination. Review of R41's MIIC identified R41 had received the PCV-13 vaccination on 5/9/16, and the PPSV23 vaccination on 11/06/00. R41's medical record lacked documentation R41 had been offered or received the PCV20 vaccination. During an interview on 9/13/23 at 1:02 p.m., the director of nursing (DON confirmed the updated pneumococcal guidelines issued by the CDC on 3/15/23. DON reviewed residents' immunization records and confirmed the medical records lacked documentation of the PVC20 vaccination. The DON stated her expectation were residents would be offered or receive pneumococcal vaccinations according to CDC guidelines upon admission and thereafter in accordance to the CDC recommendations. Review of facility policy titled, Pneumococcal Vaccine updated 3/22, identified all residents would be offered pneumococcal vaccinations to aid in prevention of pneumococcal infections. Upon admission, residents would be provided information on the pneumococcal vaccinations and would be offered pneumococcal vaccinations after reviewing the residents pneumococcal vaccination history. Administration of pneumococcal vaccinations or revaccination would be made in accordance to CDC recommendations at the time of the vaccination.