**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper personal protective equipment (PPE) was used during transfers and catheter care for 1 of 1 resident (R7) reviewed for enhanced barrier precautions (EBP). Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE] indicated R7 was cognitively intact and had an indwelling catheter. R7's provider orders included urinary catheter 18 french with/30 cc (cubic centimeter) balloon (size of catheter) related to open wounds and decreased mobility. May irrigated with 20-60 ml (milliliters) of NS (normal saline) prn (as needed) if sluggish or suspected blockage. R7's careplan indicated R7 had an indwelling catheter due to pressure ulcer and please follow EBP when emptying catheter. During an observation and interview on 2/18/25 at 3:34 p.m., an orange sign was noted on R7's door titled EBP indicated staff must wear gown and gloves for high contact resident cares including but not limited to transfers and catheter care. During the interview, R7 confirmed they had a catheter. A catheter bag was observed hanging on the side of R7's bed inside a dignity bag. During observation and interview on 02/19/25 at 10:46 a.m., licensed practical nurse (LPN)-A and nursing assistant (NA)-A entered R7's room to perform a dressing change. LPN-A and NA-A put on gloves and disposable yellow gown. After finishing the dressing change, LPN-A removed PPE, washed hands, and left the room. NA-A removed gown and gloves, washed hands, and applied new gloves. NA-B entered R7's room with mechanical lift. NA-B put on gloves. Without a gown, NA-A and NA-B rolled R7 from side to side to place lift sling under R7. NA-A raised R7 in the air with mechanical lift. NA-B held on to sling while R7 was moved to the broda chair (specialized wheelchair). R7 was lowered into the chair. NA-A and NA-B adjusted lift sling to make R7 more comfortable. NA-A removed gloves, washed hands, and returned with a paper towel and urinal to empty R7's catheter bag. Without a gown, NA-A placed the urinal on the paper towel on the floor. NA-A wiped the catheter bag valve with an alcohol wipe before and after emptying the bag into the urinal. NA-A then emptied the urinal in the toilet, rinsed it with water, and again emptied it in the toilet. NA-A removed gloves and washed hands. When interviewed, NA-A stated gowns are worn when assisting nurses with dressing changes only. NA-B stated hands are washed when entering a resident's room. Gowns and gloves are worn when assisting the nurse with dressing changes and when emptying Foley catheters and ostomy bags (a bag used to collect stool from an opening in the abdomen). During an interview on 2/20/25 at 10:50 a.m., the director of nursing/infection preventionist (DON/IP) stated proper PPE of gown and gloves is expected during peri care, dressing changes, bathing, activities of daily living, transferring, and emptying catheter bags. DON/IP confirmed staff should have worn a gown and gloves when R7 was transferred to their broda chair and when the catheter bag was emptied. A policy titled Enhanced Barrier Precautions (EBP) dated 5/1/24 indicated EBP is implemented for the prevention of transmission of multidrug-resistant organisms. EBP will be implemented for residents with chronic wounds such as pressure ulcers and/or indwelling medical devices including urinary catheters. PPE is necessary when performing high-contact care activities. High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, devices care or use including urinary catheters, and wound care requiring a dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure comprehensive care plans were developed to implement care and services for oxygen therapy due to obstructive sleep apnea (OSA), for 1 of 1 residents (R1) reviewed for discharge. Findings include: R1's Telephone Order dated 4/8/24, identified to start nocturnal oxygen at 1 liter per nasal canula for OSA and anxiety. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's cognition to be intact and diagnoses of obstructive sleep apnea (a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway during sleep, leading to reduced or absent breathing which can result in low oxygen levels). Further identified R1 used oxygen while a resident. R1's care plan was reviewed and did not identify R1's diagnoses of sleep apnea nor did it identify the medical provider ordered intervention to receive oxygen therapy. Further did not identify interventions to to manage/treat the disorder with goals of care. During an interview on 1/29/25 at 11:57 a.m., nursing assistant (NA)-A stated R1 would use her oxygen whenever she would sleep, she thought she used 2 liters at night. During an interview on 1/29/25 at 1:38 p.m., licensed practical nurse (LPN)-A stated R1 used her oxygen while she slept, R1 would get very anxious about sleeping, and quite hard to deal with if she didn't have her oxygen. During an interview on 1/29/25 at 1:46 p.m., NA-B stated R1 would use her oxygen anytime she was laying down in the bed, she did not like to lie down without it. During an interview on 1/29/25 at 1:53 p.m., director of nursing (DON) stated R1's care plan was not updated to include R1's oxygen use, for obstructive sleep apnea after it was ordered on 4/8/24, and it should have been. During an interview on 1/29/25 at 2:26 p.m., the administrator stated It does not look like R1's care plan was updated to include her oxygen use for obstructive sleep apnea after it was ordered on 4/8/24, and it should have been. Facility policy, CARE & REHAB-[NAME] NURSING POLICY FORMULATION OF RESIDENT PLAN OF CARE, reviewed 7/2022, identified the Policy: [NAME] Care & Rehab will assess and provide guidelines for individualized resident plan of care. Rationale: The facility will establish a plan of care and create goals specified for the resident to reach and maintain the highest level of physical, mental and psychosocial function possible. Procedure: 1. Residents will be assessed upon admission and through nursing assessment the initial care plan will be developed. 2. The comprehensive care plan must be completed within 21 days of admission. 3. Care plans are updated quarterly, unless significant change is warranted. 4. Comprehensive plan of care which includes: resident-specific priority problems, short-term goals and measurable outcomes, interventions to meet the goals, Nursing summary response to interventions, nursing plan changes and recommendations, dietary, rehabilitation, discharge planning and others as applicable. 5. A care plan meeting will be held within 21 days of admission. The IDT will meet with the resident and/or advocate to discuss the formal determination of the residents plan of care as indicated by the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to provide planning and coordination of services to facilitate a safe discharge to an assisted living facility (ALF) for 1 of 1 residents (R1) reviewed for misappropriation. Findings include: R1's Telephone Order dated 4/8/24, identified to start nocturnal oxygen at 1 liter per nasal canula for obstructive sleep apnea (OSA) and anxiety. R1's care plan dated 5/3/24, identified a focus that R1 required or requested assistance arranging medical appointments. Intervention dated 5/16/24, identified to notify family of appointments, schedule and arrange for transportation to medical appointments. An additional focus revised 9/26/24 identified R1 has agreed to go to an ALF due to inability to return home. R1's county worker was involved with discharge plans as well. Interventions dated 3/27/24 identified to coordinate, facilitate and communicate all plans for follow-up and future care needs and to perform medication reconciliation of all prescribed and non-prescribed medications. R1's care plan did not identify R1's diagnoses of sleep apnea nor did it identify the medical provider ordered intervention to receive oxygen therapy. Further did not identify interventions to assess and monitor for sleep apnea. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's cognition to be intact and diagnoses of OSA (a sleep disorder characterized by repeated episodes of complete or partial blockage of the upper airway during sleep, leading to reduced or absent breathing which can result in low oxygen levels) and congestive heart failure (a chronic condition where the heart muscle weakens and cannot pump blood effectively which can lead to shortness of breath). Further identified oxygen was used. During an interview on 1/29/25 at 11:57 a.m., nursing assistant (NA)-A stated R1 would use her oxygen whenever she would sleep, she thought she used 2 liters at night. During an interview on 1/29/25 at 1:38 p.m., licensed practical nurse (LPN)-A stated R1 used her oxygen while she slept and would get very anxious about sleeping and quite hard to deal with if she didn't have her oxygen. During an interview on 1/29/25 at 1:46 p.m., NA-B stated R1 would use her oxygen anytime she was laying down in the bed, she did not like to lie down without it. R1's Discharge summary dated [DATE], identified R1 had a planned discharge to the community. The discharge plan did not identify any set up for oxygen services. During a phone interview on 1/29/25 at 3:24 p.m., assisted living registered nurse (ALRN)-A stated on 1/14/25, R1 was admitted to the facility without oxygen services. ALRN-A stated R1 went without oxygen until 1/18/25, when R1 was not feeling well, was dizzy and was having a hard time breathing so the ambulance came and got her, and she was hospitalized until 1/21/25. ALRN-A stated R1 needs the oxygen at night while she sleeps. R1's Prehospital Care Report dated 1/18/25 at 3:17 p.m., identified an ambulance was dispatched to ALF for R1 who was complaining of difficulty breathing .facility staff report that R1 was transferred on 1/18/25, from another facility and still had not received R1's oxygen. R1 reported to staff experiencing a near syncopal (fainting) episode 20 minutes prior and still having a hard time breathing. R1's emergency department (ED) Provider note dated 1/18/25, identified R1 presented with a brief episode of lightheadedness and hypoxia .R1 was supposed to be on home oxygen but has been off it since her recent move. R1 was mildly hypoxic (inadequate supply of oxygen to the body's tissues) in the ED. We are unable to obtain home oxygen tonight and R1 was unable to be admitted to ED observation because of inability to independently safely ambulate. Will admit for further care. R1's hospital admission note dated 1/18/25 identified R1 presented to the ED via EMS due to a near syncopal episode along with feeling weak and lightheaded around 2:30 p.m. and had been on 1L nasal canula (NC) oxygen since 2016 and had moved facilities this past week and has not had been on the oxygen. R1's hospital Discharge summary dated [DATE] to 1/21/25, identified R1 was supposed to be on oxygen via NC (1 L) at baseline however had not been able to obtain oxygen at her new assisted living facility, had not been using it for the past 4-5 days. R1 was evaluated by respiratory therapy (RT) colleagues for oxygen needs. R1 was found to be saturating above 88% at rest and ambulation, with no need for daytime oxygen. R1 also had nocturnal (night time) oxygen study done that revealed desaturations to 87%, requiring 2 liters/minute nasal canula. Follow up identified a prescription for overnight oxygen of 2 liters/minute nasal canula was sent with R1 for hypoxia due to chronic diastolic heart failure. During a phone interview on 1/29/25 at 10:41 a.m., emergency department social worker (EDSW)-A stated R1 was admitted to the hospital on [DATE], due to lightheadedness and hypoxia due to the facility not sending her oxygen to R1's ALF when she discharged and had been without oxygen for 4 days. During a phone interview on 1/29/25 at 11:04 a.m., R1 stated she has used her oxygen at night for years because she stopped breathing in the night. R1 stated when she was discharged from the facility on 1/14/25, to the ALF the facility never sent her oxygen with so she went without it for five nights and the one night she couldn't breathe. R1 stated she ended up in the hospital from not having her oxygen. During a phone interview on 1/29/25 at 9:10 a.m., family member (FM)-B stated R1 discharged from the facility to an ALF on 1/14/25 and her oxygen was not set up ahead of time with northwest respiratory services. FM-B stated R1 needed her oxygen at night for her sleep apnea and when R1 lays down her artificial heart valve doesn't work as well, due to that she had been on oxygen for years. FM-B identified she received a phone call from the hospital on 1/17/25, that R1 had been admitted because she had been without her oxygen for a few days because the prescription did not get written for her oxygen when she left the faciity on 1/14/25, to go to the ALF. During an interview on 1/29/25 at 10:18 a.m., medical director (MD)-A stated R1 discharged from the facility on 1/14/25, without a DME order for oxygen. MD-A further stated R1 used the oxygen at night while at the facility for sleep apnea. MD-A indicated without the use of oxygen at night, R1 had the potential for hypoxia and fatigue. . During an interview on 1/29/25 at 1:53 p.m., director of nursing (DON) stated R1 did not have R1's oxygen set up for her discharge from the facility on 1/14/25. DON indicated she received a phone call from a nurse at R1's ALF on 1/15/25, asking how to get R1's oxygen. DON indicated she had one of the providers send a prescription for oxygen to Northwest respiratory services (NRS). DON further indicated NRS had wanted her to send over R1's current nocturnal oxygen saturations levels and did not have the data for that so she did not send it as R1 was no longer a resident at their facility. DON indicated she thought R1's county case manager would set up R1's oxygen services and stated since she thought the oxygen was order was sent to NRS she didn't do any more follow up to ensure R1 would receive oxygen services. During an interview on 1/29/25 at 2:31 p.m., the administrator stated they did not have any oxygen orders for R1 sent with for discharge on [DATE]. During a phone interview on 1/29/25 at 3:56 p.m., with (NRS) intake department trainer (IDT)-A stated R1 discharged from her facility on 1/14/25, and they did not receive an order for R1's oxygen until 1/15/25. IDT-A stated we did not have the information needed to submit to R1's insurance for her nocturnal oxygen use, so we were not able to establish care at R1's new facility. IDT-A stated typically we have a contract with long-term care (LTC) facilities and prior to a residents discharge the facility would contact us to go over necessary information needed for insurance verification to see if this is a service we can provide outside of the contracted nursing facility. On 1/16/25, we asked the facility for nocturnal oxygen saturations for R1, and we never received them. IDT-A stated we needed recent documentation that supports the continued need for oxygen in a home setting for insurance purposes. IDT-A stated we finally got everything we needed from the nurse at the ALF on 1/24/25, and R1's oxygen was then set up. Facility Policy, DISCHARGE PLANNING POLICY, revised 8/2018, identified a purpose that the interdisciplinary team shall prepare a comprehensive discharge care plan with the resident and resident representative to assist the resident to reach their discharge goal .4. Discharge a. If the resident is being discharged to a lower level of care within the facility, the facility will document the discharge plan and approaches as developed via the comprehensive care planning process (See Discharge Transfer Policy). b. If the resident desires returning to the community, document any referrals to Local Contact Agencies or other appropriate entities for the purpose of discharge (if applicable). c. Update the resident's comprehensive care plan and discharge plan (if applicable) with any information received form referrals to local contact agencies or other appropriate entities .7. Information for the Receiving Provider: The facility will share relevant information with the post-discharge care provider, including a. The resident's primary care physician and other consulting practitioners as well as their respective and contact information. a. The resident representative's contact information b. The resident's Advance Directives, c. All special instructions or precautions and for ongoing care as appropriate, d. The resident's comprehensive care plan goals, e. A copy of the discharge summary, and f. Any other necessary or relevant information or documentations to facilitate safe and effective transition of care. 8. Discharge Summary: a. A discharge summary will be completed upon discharge to include: a recapitulation of the residents stay in the facility (diagnoses, course of illness/treatment, therapy, lab, radiology and consultation reports, a final summary of resident status, medication reconciliation, a post-discharge plan of care developed with the resident and resident representative: Location/Agency/Facility where resident will reside, arrangements for care, medications and services post-discharge, arrangements for follow up communication post-discharge. 9. Discharge Follow Up Process: a. Upon discharge (internally or externally), social services or designee will complete follow up calls or visits with the resident, resident representative and receiving location (insert facility and state specific information here) for an appropriate transition of care, b. If areas of additional care coordination are needed, the facility representative and applicable team members will assist in the care coordination process. (insert transition of care policy information here) and c. documentation of discharge follow up will be completed per policy. (insert transition of care policy information here).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure allegations of missing money/theft was reported to the state agency (SA) within 24 hours, in accordance with established policies and procedures, for 1 of 1 resident (R4) reviewed for personal property. Findings include: R4's face sheet printed on 11/8/23, indicated R4's diagnoses included anxiety, major depressive disorder (mood disorder), personality disorder, hoarding disorder, and insomnia (sleep disorder). R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R4 had intact cognition, required supervision of 1 staff for bed mobility and transfers, substantial/maximal assistance of 1 staff for ambulation in room and on unit, was independent of use of wheelchair in room and on unit. R4's care plan received on 11/9/23, indicated for staff to maintain R4's safety due to mood disorder. Review of facility investigation report indicated R4 informed licensed practical nurse (LPN)-A on 12/31/22 at 1:40 p.m. she was missing $200 (2- $100 bills) she had received from her mother on 12/29/22, LPN-A immediately notified director of nursing (DON) of R4's allegations of missing money, DON then notified the administrator of allegations. The DON contacted R4's family and confirmed $200 had been placed in a card within an envelope and delivered to facility. Report indicated R4's allegations of missing money was not reported per facility until 1/24/23, the DON contacted local law enforcement and filed a report with SA. Report indicated local law enforcement investigated incident, verified money had been received per R4 while at facility, unable to confirm allegation of staff theft. During an interview on 11/06/23 at 3:52 p.m., R4 indicated had $200 in cash sent to her in an envelope from her mother for Christmas, kept letter containing $200 in room, noticed money was no longer in envelope and was reported missing to staff. R4 stated she could not remember exact date money went missing and was reported to staff, reported incident occurred approximately end of 12/22. R4 indicated staff looked for missing money immediately after she reported money missing, stated staff could not locate missing money, reported she believed money was taken by a staff member, could not identify any staff when asked during interview. R4 indicated since incident, staff provided her a lockbox in room for safe keeping of money, reported only she had access to money in lockbox as she was only person aware of location for key to lockbox. While interviewed on 11/07/23 at 2:23 p.m., NA-A indicated awareness of incident with R4's $200 being reported missing. NA-A stated incident occurred approximately end of 12/22 and was reported right away to administrator and DON, indicated staff looked for R4's missing money for several weeks, money was unable to locate. NA-A reported R4 alleged a staff member took her money, stated she could not remember staff member R4 identified taking money. During an interview on 11/07/23 at 3:03 p.m., LPN-A indicated R4 initially reported to her $200 went missing from R4's room, stated when R4 reported incident to her she immediately contacted DON, staff searched R4's room and all over facility areas looking for missing money reported per R4, indicated staff looked for several weeks for missing money, unable to locate missing money. LPN-A indicated R4's report of missing money was reported to law enforcement, stated DON had reported, unaware when DON reported incident to law enforcement. LPN-A stated at time of admission, residents were offered personal trust account for money management, residents informed to not keep cash on hand to avoid losing and possible theft of, indicated following incident R4 had a lockbox implemented for securing money on hand. While interviewed on 11/07/23 at 4:48 p.m., the DON stated she was notified on 12/31/22 per LPN-A of R4's allegations of missing money, DON confirmed she had not reported allegations of missing money within 24 hours to local law enforcement, indicated allegations of missing money had not been reported to local law enforcement until 1/24/23. DON was asked why she reported allegations of missing money late, DON stated incident occurred awhile back and couldn't remember all the details, would review investigation report and follow-up with surveyor. During an interview with the DON and administrator on 11/08/23 at 8:38 a.m., the DON stated when R4 reported missing money on 12/31/22, thought to search for missing money first and forgot to report to SA. The administrator indicated R4 had a mental illness including history of fabrication (false claims), stated R4 was not always truthful and wanted evidence before filing report. The administrator indicated awareness of 24-hour reporting time frame for allegations of possible theft, confirmed R4's allegations of missing money should have been reported immediately upon learning of incident on 12/31/22. The facility Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property policy revised 2/23; indicated each covered individual shall report to the state agency and one or more law enforcement entities, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility and each covered individual shall report immediately, but not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Examples of situations that would likely be considered crimes include, but are not limited to: -Theft/Robbery

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide a safe environment, ensuring residents who smoked had smoking products/devices used for smoking secured to prevent accidents for 1 of 2 (R15) reviewed for accidents/hazards. Findings include: R15's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R15 had intact cognition, displayed no behaviors, was independent of activities of daily living (ADLs), had impairment to left lower extremity, used a walker and wheelchair for mobility, and was a tobacco user. R15's face sheet printed on 11/8/23, included diagnoses of an unspecified brain disorder, chronic embolism and thrombosis of femoral vein (blood clot in leg), nicotine dependence, and weakness. R15's care plan printed on 11/8/23, indicated for staff to conduct smoking safety evaluation on admission and as needed (PRN) to ensure safe to smoke, educate resident/responsible party on facility's tobacco/smoking policy(s), and to orient resident to smoking times and procedures. Care plan lacked information provided to resident/staff on education for securing tobacco products/devices securely within facility. R15's smoking and safety assessment completed on 8/30/23, indicated R15 used tobacco products, had balance problems while sitting or standing, followed the facility's policy on location and time of smoking, and was deemed safe to smoke unsupervised. During an observation and interview on 11/06/23 at 1:59 p.m., R15 was noted to have a table with a lunch tray sitting on top in room. On the lunch tray observed a cigarette rolling machine, a bag of tobacco with loose tobacco spread all over tray, and cigarette filters. On a tray table next to bedside visualized a Marlboro menthol cigarette pack and a lighter. On bedside table observed a carton of Marlboro menthol cigarettes, 9 packs of unopened cigarette packs contained within carton. R15 reported was independent of smoking, denied any accidents/injuries when smoking, stated could smoke outside of facility on patio whenever he wanted to, placed extinguished cigarettes into a receptacle placed on patio. R15 reported able to keep tobacco products/devices used for smoking in room, was unaware if needed to keep tobacco products/devices secured in room, stated was never told per staff he needed to keep tobacco products/devices secured in room, indicated staff aware of tobacco products/devices left open in room. While interviewed on 11/07/23 at 3:26 p.m., LPN-A indicated residents were able to smoke while residing at facility, residents who smoked had to smoke outside of building in patio area, when finished smoking residents needed to discard cigarettes in receptacle located on patio prior to coming back into facility. LPN-A reported awareness of R15 being a smoker, unaware if R15 had a smoking safety assessment completed as DON completed all resident smoking safety assessments. LPN-A indicated awareness of R15 having tobacco products/devices used for smoking unsecured in room, reported unawareness if residents needed to keep tobacco products/devices used for smoking secured in room or secured in another area for supervision, stated she had not been informed resident's tobacco products/devices used for smoking needed to be secured. During an interview on 11/07/23 at 4:50 p.m., the director of nursing (DON) indicated was responsible to complete smoking safety assessments for all residents who smoked, stated assessments were completed upon admission, quarterly, significant change in conditions, or any time resident appeared unsafe while smoking. The DON indicated if residents were deemed independent with smoking, residents could keep tobacco products/devices used for smoking in room, stated residents needed to keep smoking products/devices in a secured location within room. The DON stated all residents independent of smoking were provided education on securing tobacco products/devices used for smoking at time of admission, education provided to residents was contained in resident admission packet, as well as in resident's care plan. The DON stated R15 was independent of smoking, was able to keep tobacco products/devices used for smoking in room, reported unawareness if R15's smoking products/devices were unsecured in room. The DON stated staff were aware of all residents who smoked, indicated staff were aware and expected to ensure residents who smoked were keeping tobacco products/devices used for smoking secured in room and if there were concerns to notify DON. While interviewed on 11/08/23 at 8:17 a.m., LPN-B indicated awareness R15 was independent with smoking and was aware R15 kept smoking products/devices unsecured in room. LPN-B reported unawareness of responsibility to ensure residents kept smoking products/devices secured in room, verified R15's care plan lacked any documentation for staff and/or residents to ensure smoking products/devices were kept secured in room. During an interview on 11/08/23 at 8:50 a.m., the DON indicated was responsible for initiating and updating care plans. The DON reviewed R15's care plan regarding securement of smoking products/devices, The DON confirmed lack of documentation provided for staff awareness. The DON verified potential risk for accidents/hazards and fire safety with not having R15's tobacco products/devices secured in room. The DON stated would update R15's care plan and educate staff to ensure all residents independent of smoking had smoking products/devices secured appropriately. The facility Rules and Regulations for [NAME] Care and Rehab procedure undated, indicated Smoking: Smoking within the facility is prohibited for visitors, employees, and residents. Residents may smoke outside. All smoking materials will be maintained at the nurse's station or concealed in your room and supervision will be provided by facility associates if deemed necessary by physician and/or nursing staff.

Based on observation and interview, the facility failed to ensure controlled substance medications were stored in a separately locked, permanently affixed compartment in refrigerator of storage room. In addition, the facility failed to ensure timely removal of expired stock medications of medication cart and storage room. Findings include: On 11/7/23 at 9:18 a.m., medications in medication cart were reviewed with licensed practical nurse (LPN)-A, noted several expired medications, including resident prescribed medications and stock medications. Expired medications included, 1. Stock over the counter (OTC) acetaminophen liquid pain relief 160mg/5ml, 473ml bottle, approximately ½ full, expiration date on bottle 10/23, medication remained in med cart for use. A tour of the medication storage room was conducted with LPN-A on 11/07/23 at 10:11 a.m. Door to medication storage room was locked upon entering, cupboards in storage room containing stock OTC medications were reviewed with LPN-A, noted several expired medications including 4 bottles of aspirin 81mg tablets, all unopened, exp. date on all bottles 10/23; 2 bottles of zinc 50mg all unopened, exp. date on all bottles 10/23; 2 bottles of melatonin 3mg, all unopened, exp. date on all bottles 10/23; 1 bottle of liquid pain relief acetaminophen 160mg/5ml- 473ml bottle unopened, exp. date on bottle 10/23. LPN-A stated stock OTC medications in cupboard of storage room were used for residents per physician standing orders/physician orders, confirmed stock OTC medications in cupboard in storage room were expired and should've been removed, stated would ensure all expired stock OTC medications were removed immediately. A portable (moveable) refrigerator, used for storing refrigerated medications was reviewed with LPN-A. LPN-A was observed to unlock portable refrigerator door, noted a small clear locked E-kit container. E-Kit container visualized and consisted of 1 small stock vial of injectable lorazepam (an anti-anxiety medication/controlled substance) on shelving rack, 3 bottles of lorazepam- 2mg/ml oral concentrate (30ml) prescribed to R14 noted in rack of portable refrigerator side door. Although, the medications were double locked, the refrigerator was not permanently affixed. During an interview, on 11/07/23 at 10:27 a.m., LPN-A indicated medication cart was gone through by any nursing staff able to administer medications daily to remove any expired stock and resident prescribed medications, stated medication storage room was gone through by nursing staff able to administer medications monthly to remove any expired stock and resident prescribed medications. LPN-A indicated any removal of controlled medications was completed with 2 licensed nursing staff. LPN-A reported awareness that controlled substance medications needed to be stored in an area providing 2 separately locked, one permanently affixed compartment, stated she was unsure why this hadn't been completed for the controlled substance medications stored in portable refrigerator. While interviewed on 11/07/23 at 11:31 a.m., the director of nursing (DON) stated staff were aware and it was her expectation for staff to check all medications in medication cart and medication storage room daily for expiration and non-use of and remove when indicated. The DON reported awareness that controlled substance medications needed to be stored in an area providing 2 separately locked compartments, stated was not aware controlled substance medications needed to be locked in a permanently affixed compartment. The DON indicated controlled substance medications to be refrigerated were kept in facility locked medication storage room, within a locked portable refrigerator, stated she thought process used for controlled medication substance storage was sufficient at time, would ensure process for controlled medication storage was corrected immediately. The facility Medication administration policy revised 5/23, indicated all medications require an order, all orders are valid for the specified number of days/doses ordered, Orders that do not specify the number of days/doses ordered are valid per physicians signed renewal of medications and treatments, Check labels for accuracy and expiration dates, All OTC medications are stored in medication carts or secured in locked cabinets, All new vials/inhalers/eye drops/nose sprays are marked with date they were opened. Safe handling, storage, & security of medication I. Schedule II-V controlled medications are to be stored in a separate area under double lock. (Does not indicate affixed compartment) M. Outdated, discontinued, contaminated, unwrapped, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of.

Based on observation, interview and document review, the facility failed to ensure dishmachine chemical sanitization solution was appropriately monitored to ensure dishes were properly sanitized. This had the potential to effect all 18 residents who resided in the facility. Findings include: During an observation and interview on 11/06/23 at 12:49 p.m., with dietary supervisor (DS)-C, observed the dishmachine in use. DS-C stated the dishmachine used low temperature heat and chemical to sanitize the dishes. While observing the dishmachine in use, dietary aide (DA)-A was asked to test the sanitizing solution. DA-A obtained a white Ecolab brand test strip from a container with expiration date of 5/1/24, and placed a strip in the water at the bottom of the dishmachine. When she removed the strip, it remained the same white color as when she inserted it into the water. DA-A tested it again with another strip and the color remained white. DS-C stated the test strip should turn dark purple to indicate the required 50 to 100 PPM (parts per million) to ensure proper disinfection of dishes. A paper log titled Dishwasher Temperature and PPM Levels had been on a clipboard hanging on the wall. The log indicated for every reading since 10/1/23 through 11/6/23, the PPM for testing the sanitizing solution was consistently 100 PPM, three times a day. DA-A admitted it was possible staff were writing the desired PPM on the log, but not actually getting those readings with the test strip. DS-C stated she would immediately contact the Ecolab representative. During an interview on 11/06/23 at 1:21 p.m., after speaking to the Ecolab representative, DS-C stated she became aware she had not primed the tubing when she replaced the 5 gallon bucket of Ecolab Ultra San (sanitizing solution) on about 10/31/23, and therefore sanitizing solution had not entered the dishmachine to sanitize dishes. With guidance over the phone from the Ecolab representative, DS-C stated after she primed the tubing, she tested the dishmachine water and the chemical strip indicated 100 PPM. DS-C presented this strip and it had been verified as reading 100 PPM. DS-C admitted that between at least 10/31/23 and 11/6/23, the PPM could not have tested at the required 50 to 100 PPM, yet the dietary staff had not informed her. DS-C admitted she had not monitored the PPM herself. DS-C acknowledged the staff were likely not testing the sanitizing solution, but yet filled in the log with the required PPM reading. During an interview and observation on 11/07/23 at 9:34 a.m., in the kitchen, DS-C was able to point out a priming button on the side of the dishmachine that was to be used to get air out of the line between the bucket of sanitizing solution and the dishmachine so that the sanitizing solution could reach the dishmachine. DS-C admitted she did not know about this button and this process until she spoke to the Ecolab representative. DS-C stated, I didn't know that .no one told me .I've been working here a year and had no clue. DS-C stated she understood the implication of improperly sanitized dishes causing illness in residents. DS-C stated she was not aware of the facility having an infectious outbreak and this was confirmed with the director of nursing (DON) who was also the infection preventionist. During a telephone interview on 11/07/23 at 11:09 a.m., the registered dietician (RD)-D stated she was at the facility once a month. RD-D stated she was unaware of the dishmachine sanitation solution being below the required PPM and thought the Ecolab representative should have been monitoring that. RD-D admitted not doing audits for regulatory compliance in the kitchen, but usually did a walk-through and could usually tell if there had been a problem, however had not observed verification of PPM for dishmachine sanitation solution. During an interview on 11/07/23 at 11:46 a.m., the administrator stated she would have expected dishmachine concerns to have been identified before now. The administrator stated the maintenance manager (MM)-A who used to be the dietary manager, told the administrator the sanitizer solution bucket needed to be changed before it ran out, then the tubing would not need to be primed. During an interview on 11/07/23 at 12:50 p.m., MM-A stated when she had been the dietary manager, she had not let a bucket of sanitizer solution go empty before adding a new bucket, then made sure to watch the solution to go up the tubing into the dishmachine. During a return call, telephone interview on 11/10/23 at 10:55 a.m., Ecolab representative (ER)-E stated when using the Ecolab Ultra San sanitizing solution in this application, the PPM should be between 50 and 100 PPM. ER-E stated there was no required dishmachine water temperature range for this product; just that it could not be a very high temperature. ER-E stated Ecolab had been at the facility quarterly for preventive maintenance checks on the dishmachine and before leaving, measured and verified the correct PPM. ER-E stated he had a scheduled inservice on the dishmachine at the facility on 11/13/23. The facility Cleaning Dishes/Dish Machine policy dated 2021, indicated prior to use, proper temperature and/or chemical concentrations and machine function should be verified. For low temperature dishwasher, 50 PPM hypochlorite.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 3, 2023), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. Findings include: During an interview on 11/07/23 at 2:50 p.m., facility PBJ Staffing Data Report for quarter 3, 2023 (April 1 - June 30), was reviewed with the administrator. The specific metric titled: failed to have licensed nursing coverage 24 hours/day had been triggered for the following infraction dates: 5/20/23, 5/21/23, 5/30/23, 6/17/23, 6/26/23, 6/27/23, 6/30/23. The administrator stated the PBJ report was not accurate; that the facility had licensed nursing staff on duty on the infraction dates. Time cards and staff schedules were requested for the infraction dates identified on the PBJ report. Documents for the infraction dates were provided by the director of nursing (DON) and administrator and included: 1) Daily Nursing Staffing forms 2) agency invoices and 3) nurse timesheets. All three documents indicated there had been licensed nursing coverage 24 hours/day for each of the infraction dates. During an interview on 11/08/23 at 10:10 a.m., the administrator stated, I know what I did .I forgot to include agency nurse hours in the data submitted for the PBJ report. The administrator acknowledged that the data submitted for the PBJ report for the infraction dates had indeed been inaccurate due to excluding agency nurse hours. Facility Assessment with review date of 8/20/23, indicated there would be one RN or LPN for day and evening shifts, with no change related to the day of the week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, facility failed to provide an opportunity for 2 of 2 residents (R10 & R12) to participate in a formal care conference to facilitate person centered care planning. Findings include: According to R10's Quarterly Minimum Data Set (MDS) assessment dated [DATE], R10 was cognitively intact and had diagnosis of diabetes mellitus, renal insufficiency post kidney transplant, anxiety and depression among other co-morbidities. When interviewed on 6/27/22, at 3:04 p.m. R10 stated he could not recall ever having been invited to a care conference (CC). He said he would go to resident council meetings, but had not been to a personal meeting regarding his care that he could recall. During the interview, R10 discussed various concerns about his medical care, his medications, the facility physician, his transplant team and coordination of care; as well as, his diet, the facility provided foods, activities, care of personal items and a wish to live in a different facility. R10 stated it was possible the facility had contacted his wife, but he had not received any notification that a CC was to be held and would like to have had. When interviewed on 6/29/22, at 10:03 a.m. the director of nursing (DON) stated she had a form that she filled out when any resident's quarterly MDS was due, and generally most of their CCs were a simple phone conversation going over that form. The DON stated the paper form was then scanned in to the resident's chart. When asked the DON was unable to locate documentation in R10's chart that a CC had occurred. DON was not able to say if R10 had been invited to a CC and did not know, without any record if a CC had been held for him since his admission approximately a year ago. DON stated this was not acceptable. According to R12's 5 day admission MDS dated [DATE] (a readmission after hospitalization), R12 was cognitively intact and included diagnosis of cancer, diabetes, heart failure, bipolar mental illness, renal issues and neuropathy. When interviewed on 6/28/22, at 11:11 a.m. R12 stated he was frustrated as he had not been feeling well. R12 said he felt like he was going backwards. R12 stated he was unsure what the facility was doing to help him with his health conditions. He expressed frustration that he was not receiving therapy, and he was unsure why that was. R12 stated he could not recall attending a care conference. When interviewed on 6/29/22, at 10:08 a.m. the DON stated she was not able to find evidence of any CC notes for R12 upon review of the chart. To prepare for CC, DON stated she gathered input from members of the interdisciplinary team (IDT), but a CC was generally completed by the DON alone. DON stated she was the social service designee for the facility. DON stated records of a CC should be accessible. A facility policy titled Care Planning, dated January 2013, indicated The Administrator is the Care Plan/ MDS Coordinator. She sets up the schedule in PCC [Point Click Care, the facility electronic health record platform] for both according to Federal Regulations. 2. The Director of Nursing shall provide a copy of the Care Planning schedule to the Dietary Manager and Activity Director and/or Social Worker (if available), who are members of the IDCT. 3. The Activity Director shall invite the resident and/or appropriate family member to the care conference via letter, phone, or in person. 4. The Activity Director will make an attempt to schedule care planning conferences at the best time of the day for residents and families. 5. At the Care Plan Conference residents and family member will be asked whether they have brought questions or concerns to the attention of facility staff. 6. The Activity Director shall maintain a record of who has been invited, who declines to attend, who fails to respond to the invitation, and who actually attends. 7.Family/resident attendance shall be documented on the Care Plan. 8. In the absence of the Activity Director, the Dietary Manager will schedule the Care Plan Conferences. And in the absence of the Dietary Manager the DON will issue the invites.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure resident right to personal privacy for 1 of 1 resident (R3) when staff enter residents room during provision of dressing change cares, fully exposing resident buttocks. Findings include: R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 had moderate impaired cognition and required extensive assistance from 2 staff with bed mobility, dressing, and personal hygiene. The MDS also indicated R3 had impairment of both upper and lower extremities. R3's diagnosis list included schizophrenia (a brain disorder affecting thinking and feeling), depression (mood disorder), generalized muscle weakness, morbid obesity, rhabdomyolysis (disorder causing muscle breakdown), stage 3-4 pressure ulcers to lower back and buttocks. During an observation, on 6/29/22 at 10:00 a.m., while staff were providing dressing changes to R3's lower back and buttocks; housekeeping (HSKP)-A, opened R3's door to room wide without knocking. HSKP-A asked staff present in R3's room to hand her R3's water pitcher for re-filling. At time of R3's opened room door, surveyor observed R3's neighboring resident looking towards R3's open doorway; R3 was lying on stomach in bed, buttocks fully exposed. During an interview, on 6/29/22 at 1:00 p.m., HSKP-A was asked about proper procedure when entering resident room doors, HSKP-A indicated proper procedure to include knocking on resident door and wait for response to come in. When HSKP-A was asked why she did not knock prior to entering R3's room, HSKP-A indicated she typically does knock on resident room doors prior to entering, was in a hurry to refill all resident room water-pitchers. HSKP-A did confirm that R3's privacy was compromised by opening room door wide and coming in unannounced. HSKP-A stated in future, would knock on door, wait for response to come in. When interviewed, on 6/30/22 at 11:21 a.m., licensed practical nurse (LPN)-A indicated awareness of 6/29/22 incident and R3's right to privacy being compromised. LPN-A stated while she was completing dressing changes to R3's buttocks; HSKP-A opened door to R3's room to get water-pitcher for refilling. LPN-A confirmed HSKP-A opened door wide to R3's, exposed buttocks. LPN-A stated all residents' rooms are private without privacy curtains, resident's privacy can be compromised if performing cares or procedures when opening resident doors. LPN-A indicated all staff should knock and wait for response before opening doors to enter resident rooms. During an interview, on 6/30/22 12:38 p.m., the director of nursing (DON), indicated awareness of 6/29/22 incident and R3's right to privacy being compromised. The DON indicated she was not sure of current plan in place to ensure resident privacy if resident room doors are opened and cares or procedures are being performed on resident at that time. The DON stated it was her expectation all staff should be knocking on resident room doors and waiting for response prior to entering. A facility policy, titled Combined Federal and State [NAME] of Rights, for Residents in Medicare/Medicaid Certified Skilled Nursing Facilities or Nursing Facilities; revised date 6/18/19, included a section identified as Privacy and Confidentiality and consisted of; the resident has a right to personal privacy and confidentiality, personal privacy includes personal care, facility staff shall respect the privacy of a resident's room by knocking on their door and seeking consent before entering except in an emergency or where clearly inadvisable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement and follow therapy intiated programs for 2 of 3 residents (R3, R12) who required range of motion, the use of a splint and walking programs maintain their activities of daily living. Findings include: R3's quarterly Minimum Data Set (MDS) assessment, dated 3/19/22; indicated R3 had moderately impaired cognition and functional limitations in activities of daily living (ADL). MDS also identified bilateral hand contractures, and required extensive assistance with bed mobility, transferring, dressing, personal hygiene, toileting, eating. R3 did not ambulate. The MDS further indicated diagnosis including rhabdomyolysis (breakdown of muscle tissue), repeated falls, right pelvic fracture, morbid obesity, muscle weakness. R3's Therapy Recommendations for Nursing Staff, dated 9/28/21; specified orthotic soft resting right-hand splint to be applied at night and removed in morning by nursing staff. R3's Therapy Recommendations for Nursing Staff, dated 9/30/21, updated 10/5/21; indicated nursing staff were to complete assisted AROM and PROM [active/passive range of motion] exercises to bilateral upper extremities to sites including shoulder, elbow, wrist, fingers. Nursing staff were to complete 10 repetitions to each site once daily. Therapy recommendations also indicated nursing staff were to complete PROM to BLE's to sites including ankle, knee, hips. Nursing staff were to complete 8-10 repetitions to each side once daily. Occupational therapy (OT) and physical therapy (PT) treatment encounter notes were requested and not received. On 6/27/22, at 6:34 p.m., R3 was observed sitting in her wheelchair in room. R3's bilateral fingers were visualized to appear tight, rigid, and curled inwards toward palm of hands. When R3 tried to extend her fingers of bilateral hand, fingers observed to straighten slightly, remaining mostly curled inwards to palm of hands. R3 was able to make a fist with left hand, although weak; unable to make a fist with right hand. R3 indicated she had worked in past with PT and OT, although had been several months ago. R3 stated she had not received bilateral upper/lower extremitiy (BUE or BLE) exercise therapy by staff, exercise therapy for BUE was completed independently occasionally, consisted of squeezing foam ball with bilateral fingers of hand. R3 indicated feeling contractures to right hand had worsened since last assessment by OT and PT. During an interview, on 6/30/22 at 10:04 a.m., nursing assistant (NA)-D indicated typically working night shift, was aware of R3's contractures to bilateral hands. NA-D stated R3's bilateral fingers of hand were stiffening, had weakness to bilateral hand, right hand worse than left hand. NA-D stated R3 was not receiving any restorative nursing therapy, was not aware of any exercise regimen to complete to BUE's or BLE's. NA-D indicated R3 had foam balls to use for strengthening of bilateral hand, completed strengthening exercises independently. NA-D stated was unaware of any brace or splint needing to be applied at night-time for contracture to R3's right hand. When interviewed, on 6/30/22 at 10:26 a.m., OT indicated was filling in for day, not regular staff, was not familiar with R3 or therapy needs. OT attempted to look for R3's therapy file, unable to locate. OT stated would check with PT to further assist in finding R3's therapy file. During an interview, on 6/30/22 at 11:00 a.m., licensed practical nurse (LPN)-A indicated awareness of R3's bilateral hand contracture, right side worse than left side. LPN-A stated R3 worked with PT and OT several months ago, had reached plateau and no longer needed services. LPN-A indicated since PT and OT discharge, R3 should have been receiving restorative nursing services. LPN-A stated when receiving orders from PT and OT for continued resident therapy; PT and OT staff communicate and provide resident orders directly to nursing staff, nursing staff then places resident therapy orders for all staff to review into a white binder labeled, Therapy sheets for Residents. LPN-A indicated nursing staff provides a copy of the resident's therapy order to the director of nursing (DON), DON then places the resident's therapy order into their care plan and NA assignments through the electronic medical record (EMR) system, which then triggers tasks for NAs to complete on their assignment sheet during their shift. LPN-A stated resident therapy orders are communicated to all staff during change of shift report as well. LPN-A indicated awareness of R3's exercise regimen, stated NAs were to perform range of motion (ROM) to BUE's; R3, independently, should be completing strengthening to bilateral hand by squeezing foam ball in hands. When interviewed, on 6/30/22 at 11:24 a.m., PT indicated R3 was evaluated and offered services, but never wanted to participate, just wanted to be left alone in bed in room. PT stated R3 had orders for continued AROM and PROM exercises to BUE's and BLE's, should be continued restoratively to prevent deconditioning to BUE's and BLE's. PT indicated since R3 would refuse to participate in therapy services, R3 reached plateau, discharge orders consisted of re-evaluation if deconditioning occurs or on an as needed (PRN) basis. During an interview, on 6/30/22 at 12:51 p.m., the director of nurses (DON) indicated unawareness of R3's therapy orders consisting of; soft splint to be applied at night and removed in morning, exercise regimen for AROM and PROM to be completed to BUE's and BLE's. The DON stated resident therapy orders are entered into their care plan and NA Kardex, assignments, through the EMR system by her or other nursing staff. The DON indicated when resident therapy orders are entered on NA Kardex, NAs can view tasks needing to be completed for resident during shift. The DON reviewed R3's care plan and NA assignments, confirming R3's care plan does contain AROM and PROM exercises to be completed to BUE and BLE daily, as well as soft resting right-hand splint to be applied at night and removed in morning. The DON indicated upon further review, R3's therapy order for soft resting right-hand splint application and exercise therapy to be completed to BUE's and BLE's was entered into EMR system incorrectly. The DON stated R3 should have received soft resting right-hand splint application and exercise therapy to BUE's and BLE's, and confirmed those services were not provided as ordered per therapy recommendations. On 6/30/22 at 3:59 p.m., PT re-evaluated R3's bilateral hand contractures and indicated continued stability with no new or worsening changes in condition. R12 When interviewed on 6/28/22, at 11:11 a.m. R12 stated he was frustrated as he had not been feeling well. R12 said he felt like he was going backwards. R12 stated he was unsure what the facility was doing to help him with his health conditions. He expressed frustration that he was not receiving therapy, and he was unsure why that was. Druing a follow up interview on 6/29/22, at 11:42 a.m. R12 was unable to state how frequently staff offered to walk him, but said sometimes he is in pain, or is not feeling strong enough, but he could not relate a frequency. R12 stated he was willing to go for a walk on 6/29/22, but it had not been offered. According to R12's 5 day admission MDS dated [DATE] (a readmission after hospitalization), R12 was cognitively intact, had disgnosis including cancer, diabetes, heart failure, bipolar mental illness, renal issues and neuropathy among other co-morbidities. According to a written physical therapy recommendation dated 5/18/22, R12 was to be walked at least 50 feet, 1-2 times per day with a four wheeled walker. According to R12's care plan, R12 has a focused problem area for activities of daily living dated 3/31/21 with an updated intervention added 3/15/22 that indicated R12 had a walking program and he was to be walked with a four wheeled walker 2-3 times daily by nursing for a distance of 50 feet with stand by assist. According to R12's electronic health record in the section titled tasks over the past 21 days, R12 was marked one time as being independent in ambulation, and the remainder of all entries, one per shift, documented the activity (ambulation) did not occur. When interviewed on 6/29/22, at 11:50 a.m. a licensed practical nurse (LPN)-A stated R12 was able to walk with a cane, but LPN-A did not know a frequency. LPN-A stated a belief that R12 didn't want to walk. When interviewed on 6/29/22, at 11:53 a.m. a nursing assistant (NA)-A stated R12 liked to walk but was unable to state a frequency with which R12 should be walked saying, we try to walk anyone who can walk. If we offer, and they refuse we chart that. When interviewed on 6/29/22, at 11:58 a.m. NA-B stated the only way she knew of who to walk in the facility was because she had learned it. NA-B stated R12, is not walking, he is in wheel chair. He just need some help. He can use wheel chair and can transfer himself. When interviewed on 6/30/22, at 10:03 a.m. an occupational therapist (OT) stated R12 had been receiving therapy, but had been discharged . OT stated therapy would write recommendations for the nursing staff to follow after discharge to maintain abilities. OT stated she believed the information was posted in a communication book for nursing assistants. When interviewed on 6/30/22, 11:14 a.m. a physical therapy aide (PTA) stated R12 had been receiving therapy to work on strengthening and ambulation. PTA stated recommendations had been provided to the nursing department to carry on the work after discharge from therapy services. PTA stated an expectation for nursing staff to follow the recommendations, or at least offer ambulation or exercise to the resident. PTA stated R12 may suffer a decline because he does not always like to do the exercise, but stated the nursing staff should offer regardless. PTA also stated any complaints from R12 about getting weaker should be reported to therapy so that he could be screened again to see if he might need therapy to be reinstated. PTA expressed concern that if R12 did not walk twice daily as recommended he would lose strength and would not be safe when he would next try to walk. PTA said the facility had a weekly meeting to go over caseloads and concerns, but could not recall anyone saying R12 was refusing to walk or that his condition had changed. When interviewed on 6/29/22, 12:16 p.m. director of nursing (DON) stated nursing staff should be able to access information about a resident's mobility on their electronic health record. DON stated an expectation for staff to follow therapy recommendations and if R12's chart said he was to be walked 1-2 times per day, they were to offer to walk him 1-2 times per day. DON said if documentation on the health record task list indicated activity did not occur it meant the staff had not walked the resident or had not completed the designated task. DON stated if a resident indicated they thought they were getting weaker, this should be reported to the charge nurse who should then try to figure out what was going on, including the involvement of the therapy department. DON also stated a resident's care plan should be updated as to why a resident is not walking or how they should be walked if that had changed. Facility policy and procedure titled, Range of Motion Screening, Voluntary Movement ROM Assessment, revised 10/17 and reviewed 3/14/19, consisted of; program description and rationale: to promote each resident's ability to maintain or regain the highest degree of independence as safely as possible, to promote wellness and debilitation, includes, but is not limited to programs in range of motion, splint or brace assistance. Policy: each resident will be screened for restorative nursing upon admission, annually, and with any significant change in function, appropriateness for a restorative program will be determined by the interdisciplinary team as needed and/or may be determined as a continuation of care following a course of physical, occupational, or speech therapy, licensed personnel supervise the restorative nursing programs, documentation of the interventions and the resident's response will be completed with each implementation, each resident's progress will be evaluated quarterly and with any change of condition, monthly nursing documentation should address resident functional status in relation to the plan of care. A facility policy for contractures was requested, but was not received. A facility policy last revised August of 2017 and titled Ambulation and Transfers policy, indicated Ambulation will be a part of every resident ' s daily routine as allowed by their status. Furthermore, the policy indicated nursing was to follow restorative programs that had been developed for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow intervention in place to prevent potential for injury for 1 of 1 resident's (R8) when the care plan was not followed when transferring a resident off the floor. In addition,, the facility failed to identify a potential hazard for 1 of 1 resident (R10) who was observed with a hot glue gun. Findings include: R8 According to R8's quarterly Minimum Data Set (MDS) assessment dated [DATE], R8 had severe cognitive impairment. R8 had a diagnosis of non-traumatic brain dysfunction and Alzheimer's disease, history of stroke and osteoporosis (brittle/porous bones related to aging). The MDS indicated R8 required the extensive assistance of two persons to transfer, did not have steady balance and walking did not occur. Furthermore, the MDS indicated R8 had limited range of motion of both lower extremities. R8's care plan had a focused problem area dated 7/13/20 that indicated a problem with self-care and an intervention last updated 11/26/20 was listed as, TRANSFER: The resident requires assistance with transfer with 2 of care team members for assistance with transfers. May need to use EZ stand (mechanical lift) prn (as needed), Provide direction by using short, simple instructions. Provide resident with step-by-step guidance during transfer process, encouraging their participation as much as possible. On 6/27/22, at 4:32 p.m. R8 was observed crawling on the fall, coming out of the door to her room. R8 stated, I'm okay, I just want to talk to (my neighbor). R8's bed was noted to be lowered all the way to the floor, and a thick cushion was placed next to the bed. A tab alarm system was in place, but the alarm had been somewhat disassembled. When staff came to attend to R8, the director of nursing (DON) and a nursing assistant applied a gait belt, but had difficulty getting R8 to her feet and into a wheelchair. The DON said, (R8) is known to do this, she will turn off her fall alarm and get out of bed, that is why her bed in down to the floor with a fall mat next to it. R8 was not put back to bed at that time. On 6/29/22, 11:58 a.m. R8 had been sitting in a recliner in the living area of the facility watching television. Two nursing assistants, (NAs)-A&B approached R8 and informed her that it was time for lunch. The NAs placed a gait belt loosely around R8's waist. It drooped down near her buttocks as she was scooted to the edge of the chair. R8's wheelchair had been placed about three feet away. NA-A and NA-B leaned over R8, and each of them hooked an arms under her armpit area, grabbed the gait belt and prompted her to stand while they pulled under her arms and on the belt. The gait belt slid up R8s back and up into her armpit region as well. R8 did not bear any weight on her legs, but buckled at the knees and sagged, hanging by the belt and arms. R8's arms went up at the shoulder and her legs were bent under her. NA-A tried to reach the wheelchair, but could not quite reach it, and instructed NA-B to grab it. NA-B let go of the gait belt and grabbed at the chair and was able to drag it closer. R8 continued to sag and hang from their hooked arms and the gait belt under her arms, and NA-A and NA-B dragged her the last few feet to the wheelchair and turned to set her on the seat. NA-A then took R8 to the dining area. When interviewed immediately following the transfer, NA-B stated the only way she knew of how to transfer a resident was because she had learned it. NA-B stated the transfer had been done correctly because two persons and a gait belt had been used. NA-B did not think a mechanical lift had ever been used for R8. When interviewed on 6/29/22, 12:16 p.m. the DON stated the facility completed assessments to determine the best way to safely transfer any of the residents. DON stated, in general, a two person assist should be accomplished by, snuggly applying a gait belt, allowing only two finger widths of space between the belt at the resident's waist. The staff should then assist the resident to stand by grasping the gait belt in the back and pull on the belt and prompting the resident to stand. If the resident started to sag or the belt slip, DON stated they should be allowed to sit back down, and then the gait belt should be reapplied. DON also stated that if the resident was unable to safely support their weight with a two person assist and gait belt, the staff should get an EZ stand. DON stated underarm hooking and lifting a resident was not appropriate and stated the following concerns, dislocation could occur, the muscles could get over stretched; we don't chicken wing them. The DON stated all residents had a care sheet describing what type of cares to give and all nursing staff could access the information. When interviewed on 6/30/22, 11:14 a.m. a physical therapy aide (PTA) stated concerns when a gait belt is not sufficiently snug, and lifting under the arms was not safe transfer technique. PTA also stated, if a resident is slipping or sagging it would be easy for the resident or the staff to get their feet tangled and for a fall or injury to occur. PTA stated a person who does not bear weight when approached for a transfer could be left, and reapproached a bit later, or staff could offer the use of the EZ Stand. A policy titled Ambulation and Transfers and last updated August, 2017 indicated the procedure for transfers was to consult the care plan; to apply the gait belt around the resident's waist snugly to eliminate the possibility of sliding up on the ribs and to bring the resident to a standing position by grasping the belt with both hands while remaining upright, and creating a broad base of support by spreading feet. Finally, the procedure indicated to return the resident to a comfortable position in the wheelchair; however, did not provide information on how best to perform this. The procedure did not indicate what to do if the resident was unable to follow instructions. R12 According to R12's 5 day admission MDS dated [DATE] (a readmission after hospitalization), R12 was cognitively intact, newly diagnosed cancer, diabetes, heart failure, renal issues and neuropathy. The MDS also indicated the use of oxygen. According to R12's care plan, R12 has a focused problem area for acute/chronic pain related to diabetic neuropathy, last updated 5/11/22; however, the care plan did not address safety issues that might arise in relation to his neuropathy. Hazards related to oxygen use were not included in R12's care plan. When interviewed on 6/28/22, 11:11 a.m. R12 stated he was frustrated as he had not been feeling well. R12 said he felt like he was going backwards. R12 stated he was unsure what the facility was doing to help him with his health conditions. R12 was observed to rub his left arm, and stated he had problems with pain and sensation in that limb. R12's room was observed to have a large table with craft items scattered about including paints, stickers, papers (flammable items), and a hot glue gun that was laying on its side on the vinyl table cloth, but was not plugged in. R12 was observed to utilize oxygen via nasal cannula at all times. During an observation and interview on 6/30/22, 8:51 a.m. R12 was observed seated at his craft table working on a project decorating garden trolls. His oxygen was in place and infusing. At that time, R12 expressed frustration that he was not able to use his hands as well as he used to due to his neuropathy. R12 stated he was not as adept at handling things, and in fact, had dropped one of the gnomes the other day. The hot glue gun was within a few inches of where he was working, and laying on the flammable vinyl table cloth and near combustible items, but was not plugged in. R12 was unsure of when he had last used the hot glue gun. When interviewed on 6/30/22, 10:03 a.m. an occupational therapist (OT) stated R12 had received therapy services, and they had worked on strengthening, endurance and pain control. OT stated R12 was somewhat limited in his ability to use his left arm because of pain. OT was aware that R12 enjoyed doing craftwork, but was not aware he has been using a hot glue gun. OT expressed concern that R12 might drop the glue gun, or should he touch it and/or hot glue would land on his skin, with neuropathy he might not be able to feel the heat and respond appropriately. When interviewed on 6/30/22, 12:01 p.m. DON stated she was aware that R12 had a hot glue gun in his room, but was not sure when it was last used. DON stated R12 has been known to use the hot glue gun, and he had decorated his cell phone with glued on gems. DON expressed concern that the hot glue gun was a potential source of heat that might be a fire hazard and when using oxygen, R12 would be at a higher risk for injury should a fire occur. DON also stated R12 had recently had increased problems with holding things, and had in fact, dropped his phone and broken it due to his neuropathy. DON stated the facility did not have a policy for the use of hot glue guns, but planned to develop one.

Based on observation, interview, and document review, the facility failed to ensure appropriate catheter care was provided to prevent potential for urinary tract infection (UTI) for 1 of 1 resident (R3) reviewed for catheter cares. Findings include: R3's quarterly Minimum Data Set (MDS) assessment, dated 3/19/22; indicated R3 had moderately impaired cognition and functional limitations in activities of daily living (ADL). R3's MDS identified bilateral hand contractures, required extensive assistance of 2 staff with toileting and personal hygiene. The MDS further indicated diagnosis included pressure ulcers to buttocks, rhabdomyolysis (breakdown of muscle), and muscle weakness, requiring indwelling foley catheter. R3's face sheet, indicated diagnosis of pressure ulcer of right lower back-stage 4, colostomy, pressure ulcer of right hip-stage 3, morbid obesity, and physical debility. R3's care plan, identified placement of indwelling catheter due to pressure ulcer to buttock area, also indicated to perform catheter care twice daily. R3's provider note, dated 6/15/22, indicated chronic indwelling catheter due to decubitus ulcers of buttocks and lower back. Provider's note did not mention any recent urinary infection. During an observation, on 6/29/22 at 10:18 a.m., while NA-A was visualized performing peri and catheter cares to R3, NA-A was observed to wear gloves while washing left upper inner thigh with plain water and clean washcloth. NA-A folded washcloth over to new portion of rag x4, washing only left upper inner thigh region, then dried with a clean towel. NA-A grabbed a new clean washcloth and began to cleanse right upper inner thigh. NA-A folded washcloth over to new portion of rag x4, washing only right upper inner thigh region, then dried with a clean towel. NA-A indicated during procedure, R3 does not like to be cleansed with soap while in bed, only will use soap when taken to shower or bath. When NA-A was asked why cleansing of labia, urethral meatus, and catheter had not been completed, only cleansing of bilateral upper inner thighs during cares; NA-A responded that she had cleansed sites. NA-A was observed to remove her gloves and changed into a new pair of clean gloves to perform urinary catheter drainage bag cares. With drainage bag attached to side of bed, NA-A cleansed end tip of drainage bag tubing with an alcohol wipe, released clamp for urine to drain into center of a graduated cylinder that another NA was holding for NA-A. R3's urine observed at time to appear amber in color with lots of sediment. NA-A was then visualized to re-clamp end tip of drainage bag, cleansed end tip of drainage bag with a new alcohol wipe, placed end tip into plastic holder of drainage bag. When interviewed, on 6/30/22 at 12:59 p.m., the director of nursing (DON) indicated all NAs had to complete a competency checklist upon hire, which included peri and catheter cares. The DON stated before an NA can perform resident cares independently, they had to have skills checked off by a veteran NA and DON to ensure competency. The DON indicated NAs were rechecked on their care competency skills in 3-6 months post hire to determine if any additional education was needed. The DON stated unawareness of concerns with NAs providing inappropriate peri and catheter cares, indicated all NAs working independently had been deemed competent in providing peri and catheter cares. The DON was informed while NA-A was observed per surveyor performing peri and catheter cares, NA-A was visualized to cleanse bilateral upper inner thigh, had not cleansed peri area or indwelling foley catheter. The DON stated NA-A was a newer employer, had only worked at facility for a few months. The DON confirmed cleansing of resident's bilateral upper inner thigh was not appropriate peri and catheter care. The DON indicated it was her expectation for all nursing staff to cleanse peri and catheter sites per standards of care taught, if questions or concerns about procedure, should seek further clarification from competent nursing staff or DON. A facility policy for peri care and catheter care were requested but was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, facility failed to evaluate sleep, mood and behavior to justify the use of a psychoactive medication and did not provide a routine for monitoring the effectiveness of new psychotropic medications or provide non-pharmacological interventions for 1 of 4 residents (R10) reviewed for unnecessary medication. Findings include: During an interview on 6/27/22, at 2:52 p.m. R10 stated my mood affects my sleep, and I pick at my skin when I'm sleep. R10 had an old scar from his kidney transplant with areas of irritation where he had picked at it. R10 did not complain of his current mood and said he had plenty to keep him busy as he had all his electronic gadgets and had worked with computers for a living his entire life. His affect was pleasant, and animated. According to R10's Minimum Data Set (MDS) quarterly assessment dated [DATE], R10 was cognitively intact but suffering from multiple significant physical and emotional disabilities. The MDS did not indicate any episodes of delirium, hallucination, delusions or other behavioral manifestations including depression. R10's diagnosis list indicated R1's primary diagnoses for admission was type 2 diabetes mellitus . The list indicated R10 had multiple mental health diagnosis including anxiety, depression, post-traumatic stress disorder and a diagnosis for Asperger's syndrome. The list also indicated R10 suffered from insomnia. The list did not specify any associated problems of psychosis such as delusions or hallucinations. According to R10's sleep evaluation dated 5/17/22, R10 had indicated a satisfaction with his sleep, getting up only 1-2 times per night to urinate. The assessment indicated he did not feel fatigued during the day. No other information related to sleep was included in the sleep evaluation. A prior sleep evaluation dated 11/14/21 included the same information for R10 related to his sleep; however, it also indicated he had been taking 8 mg of Melatonin for sleep at that time. According to R10's physician orders R10 had orders for the following psychotropic medications: Effexor XL (an antidepressant) 37.5mg for depression (discontinued 6/7/22), Sertraline (an antidepressant) 200mg daily, Trazodone (an antidepressant) 50mg at bedtime for sleep, Olanzapine (an antipsychotic) 2.5 mg for sleep/depression, started 6/8/22. In addition, R10 had an order for Melatonin (hormone for sleep regulation) 6mg for sleep, (increased to 9mg for sleep on 6/27/22) A review of R10's care plan indicated a focus problem area dated 7/9/21 for impaired coping. An associated intervention to evaluate sleep pattern was added on 7/9/21 without any further explanation. An additional focus problem area dated 9/2/21 indicated R10 was at risk for depression. This problem area included two interventions, one to assist with making appointments and to talk with R10 about his electronic devices because he enjoys that. No focus problem area was found addressing the use of an antipsychotic. Outside of the listed coping and depression, no other target behaviors were listed. Identification of any behavioral symptoms requiring the use of an antipsychotic were not uncovered in R10's facility medical record, and on-going monitoring of the effectiveness of an antipsychotic for sleep was not found in R10's facility medical record. Documentation of non-pharmacological interventions for sleep or other behavioral manifestations were not found in R10's record. When interviewed on 6/30/22, at 3:49 p.m. director of nursing (DON) stated R10 had a psychological history and had been to the psychiatrist. DON described R10 as having a diagnosis of anxiety and depression, and also of PTSD and Asperger's, describing behaviors of problems with social relationships at times. DON described occasions of unrealistic ideation such as becoming fixated on problems with the facility heating system, the internet or his medical care. DON described R10 as streaming everything all at once in his room with multiple electronic devices streaming television shows, videos, music etc. DON stated R10 had disliked the amount of internet available and had hacked in to the internet used for running their medical records, but had not accessed the records. The DON stated R10 had told her his psychiatrist was going to put him on sertraline and olanzapine, and this had actually occurred when he last had a visit approximately a month prior to this interview. DON stated the psychiatrist had listed the olanzapine for sleep, but DON said this was not a medication usually given for sleep. DON had reached out to the psychiatrist, but stated the return call was made by a colleague. When the psychiatrist eventually called back, DON stated the reason given by the psychiatrist for choosing olanzapine was R10 had said he had used it in the past and it had been effective. DON was unable to locate documentation in the facility records indicating the medication had been effective in treating sleep or other psychiatric concerns since the medication was originally started on 6/8/22. DON stated non-pharmacological interventions should be used prior to the use or in conjunction with the use of psychotropic medication, but was unable to locate any documentation to indicate such interventions had been attempted for R10. A facility policy titled Psychotropic Drug Assessment last reviewed on September, 2013 did not apply to the use of psychotropics beyond indicating an assessment for abnormal involuntary movement assessments must be completed with the use of such medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure expired food were identified and removed, date opened containers of food stored in walk-in refrigerator and standup freezer, follow proper food handling practices to promote food safety. This had the potential to affect all 15 residents who were served food and beverages from the facility kitchen. Findings include: During interview and observation of kitchen on 6/27/22 at 2:35 p.m., with cook (C)-A, observed food items on shelves, in the walk-in refrigerator and standup freezer that were not dated or marked and/or were expired. C-A indicated all kitchen staff were responsible for checking food for opened dates and expiration dates, all refrigerators and freezers should be gone through daily to check for expired or damaged food. C-A indicated if any food or drink is not dated when opened, it should be removed immediately. C-A stated all left-over prepared food should be discarded in 3-4 days and beverages when marked are good for 7 days from date opened. The following items were observed during tour: Shelves: 1. 1 bag of hot dog buns; opened and dated 6/25/22; exp date on bag 6/6/22 2. 3 bags of hot dog buns; unopened; exp date 6/6/22 3. 3 loaves of bread; unopened; dated on bag 6/13/22 Walk-in refrigerator: 1. 100% apple juice- 1.36L; approx. ¼ full; not marked/dated; exp date on container 1/20/23 2. 100% grape juice- 1.36L; approx. ¾ full; not marked/dated; exp date on container 2/15/23 3. 100% pineapple juice- 1.36 L; approx. ½ full; not marked/dated; exp date on container 11/19/22 4. sliced honey ham in facility zip lock bag; opened 6/17/22; use by date on by 6/27/22 5. Ensure clear- apple flavor- 8 oz. bottles (32 bottles remaining); unopened; expiration date on each bottle 4/1/22 6. Boost breeze- berry wild flavor- 8 oz. bottles (11 bottles remaining); unopened; expiration date on each bottle 11/1/21 7. Boost- chocolate rich- 8 oz. bottles (9 bottles remaining); unopened; expiration date on each bottle 3/30/22 8. Miracle whip light dressing- single packets; unopened; received in original box dated 11/30/20; no expiration date 9. cut-up radishes in facility zip lock back from facility garden; not marked/dated 10. celery- leaves on stalks observed to be dried and turning brown; original box date 6/6/22 11. La [NAME] thick and chunky salsa 8.5 lb; ¼ left; opened date 4/20; unable to read expiration date on container 12. Broccoli in facility zip lock bag; observed to be brown in appearance; opened date on bag 5/11/22 13. Shredded lettuce; ¼ left; not marked/dated; observed to have increased moisture and brown in discoloration Stand-up freezer: 1. 1 bag of freezer burned hot dog buns; unopened; exp date on bag 4/29/22 When interviewed during brief kitchen tour, on 6/27/22 at 3:00 p.m., C-A indicated when food and beverage items are delivered to facility, staff rearranged food items in kitchen storage areas, moved newer food items to back and older food items to front to be used up first. C-A stated when food items were opened, staff would write an open date on top, to indicate to staff when needed to discard items. C-A indicated that she and staff try to go through food inventory and remove anything unmarked/undated or expired frequently, did admit to having some food items that should have been removed due to being unmarked/undated and expired. During observation and interview of dinner meal on 6/29/22 at 12:18 p.m., dietary aide (DA)-A was visualized wearing hair net, walked over to employee sink, washed hands with soap/water, dried with paper towels, then applied clean gloves. DA-A walked over to counter in kitchen across from where steam table was set up, picked up resident meal tickets, placed on clean push-cart next to resident clean dishware. DA-A picked up resident meal ticket with gloved hands to read resident meal preference, set meal ticket on countertop across from steam table with gloved left hand, grabbed resident clean plate with gloved right hand, switched plate to glove left hand, picked up tongs with gloved right hand to place chicken [NAME] on plate, set plate back down on clean push-cart with left hand, grabbed a cutting knife with gloved right hand, while holding onto chicken [NAME] with left hand, would cut apart chicken [NAME] into pieces, set knife back down on clean push-cart with gloved right hand, picked apart chicken into smaller bite pieces with both gloved hands, picked plate back up with left hand, walked over to steam table, picked up spoon with gloved right hand and placed stuffing on plate, grabbed spoon for gravy with gloved right hand and poured gravy over stuffing, picked up spoon for green beans with gloved right hand and placed beans on plate, placed plate on resident tray and covered plate with covered top. DA-A was interviewed about process of food safety and cross-contamination with touching resident meal tickets, placing meal tickets on counter-top, touching meat when breaking it into smaller pieces. DA-A did not have a response other than she needed each resident meal ticket right in front of her to see what the resident's preferences and needs were, and still needed to be able to dish up, prepare meal accordingly. During an observation and interview, on 6/29/22 at 12:26 p.m., C-A took R9's dinner meal and placed on tray. C-A grabbed a thermometer from her scrub top pocket and placed thermometer on R9's napkin, covering slightly over silverware (knife), next to meal, on tray. Once entering R9's room, C-A set meal tray down in front of R9, took cover off meal plate, picked thermometer up off his meal tray, alcohol wiped end of thermometer, then temped R9's pork chop with gravy. Once exited from R9's room, C-A was asked about food safety and process of cross-contamination with placing thermometer from her pocket onto R9's meal tray/silverware. C-A indicated she shouldn't have taken thermometer from her scrub top pocket and place on resident meal tray/silverware, confirmed potential risk for foodborne illness due to unhygienic practice. Facility policy for food storage, food safety, and prevention of cross-contamination and foodborne illness were requested. Facility policy and procedure manual: Director of Food and Nutrition Services Responsibilities, dated 2021, consisted of; the director of food and nutrition services will be familiar with all local, state, and federal regulatory requirements related to food, food safety and sanitation, and assure all requirements are met; employees will be trained, assisted, and encouraged as needed; food will be prepared in a manner that prevents foodborne illness; staff will follow proper sanitation and food handling practices. Facility policy, Food Safety for Vegetable Gardens- Tips for Schools, Child Care and Long-Term Care Facilities, undated, indicated; poor personal hygiene is the cause of many foodborne outbreaks, surfaces used to prepare produce should be clean and sanitized. Facility policy, Long-Term Care Facility Garden Policy 2019, dated 11/28/17, consisted of; the facility should be following safe food handling practices once foods are harvested and brought to the kitchen for preparation, food safety requirements: the facility must procure food from sources approved or considered satisfactory by federal, state, or local authorities; nursing homes that have their own gardens such as, vegetable, fruit or herbs may be compliant with the food procurement requirements as long as the facility has and follows policies and procedures for maintaining and harvesting the gardens, including ensuring manufacturer's instructions are followed if any pesticides, fertilizer, or other topical or root-based plant preparations are applied.

Based on observation, interview and document review the facility failed to ensure that medication was administered according to standard of practice when using an insulin pen for 3 of 3 administrations observed for 2 of 6 residents (R1 and R10) receiving insulin at the facility. This resulted in a greater than 5% error rate at 11% for the facility. Findings include: During an observation on 6/29/22, 7:20 a.m. a licensed practical nurse (LPN)-A checked the medication administration record (MAR) for R10 to determine the insulin he was to receive. LPN-A removed an insulin administration pen (a container pre-filled with insulin that can be used to directly administer insulin without having to draw the medication into another syringe) that matched the MAR. The MAR and the label on the pen indicated the medication belonged to R10 and contained NPH insulin and R10 was to receive 18 units subcutaneously. LPN-A was observed to clean the tip of the pen with an alcohol swab and apply a disposable needle under a cap. LPN-A then turned the dial on the pen to match the ordered dose of 18 units without removing the cap over the needle. LPN-A then went directly to R10's room where she applied a pair of gloves and notified R10 that she was going to administer his insulin. The two of them identified an appropriate site, LPN-A cleansed the area with alcohol, removed the cap from the insulin pen, pushed the needle into the fatty abdominal tissue, quickly injected the 18 units, held the pen in place for about 3 seconds and then removed it. LPN-A disposed of the needle and went to the MAR to document the insulin as having been given. During an observation on 6/29/22, 7:31 a.m. LPN-A checked the MAR for R1 and removed two insulin pens from the medication cart. LPN-A checked the labels against the MAR and determined that R1 was to receive 16 units of Lantus insulin and 12 units of Humalog insulin. LPN-A cleaned the tip of each pen, applied the needle and checking the MAR again, dialed the dose on the pen to match the ordered dose on the MAR. Using appropriate hand hygiene and gloves, LPN-A went to R1 in a private area, cleansed his skin on a site of his left abdomen. LPN-A removed the cap from the needle to the Lantus insulin, inserted the needle in the clean site, rapidly administered the insulin into the fatty tissue and after a few seconds removed the needle. LPN-A then cleaned a site on R1's right abdomen and repeated these steps with the Humalog. LPN-A then returned to the medication cart, disposed of the needles and returned both insulin pens to the cart, then documented the administrations as having been given. When interviewed on 6/29/22, 11:17 a.m. LPN-A stated the proper procedure for using an insulin pen was to alcohol the pen, attach a needle and then express two units, then dial up the dose. LPN-A stated she did not recall having removed the cap from the needle and did not recall that she had expressed two units to prime the needle. LPN-A stated the needle should be primed prior to giving the dose so the resident receives the correct dosage. When interviewed 6/30/22, 12:22 p.m. the facility director of nursing (DON) stated the proper procedure for the use of an insulin pen what to do the initial label check against the MAR, clean the pen with alcohol and apply the needle. Following the application of the needle, DON stated the needle should be primed with 2 units of insulin and then the dose dialed. Following this, the nurse should go to the resident, explain the procedure, locate and clean the site and administer the insulin into fatty tissue, holding the pen in place for a few seconds so all of the insulin goes into the tissue. DON was not able to state an action to take if no insulin was seen coming from the needle when primed, I don't know, as long as you use 2 units, you are pretty safe. The DON stated the needle must be primed to ensure the resident receives an accurate dose. DON stated not priming the needle could result in inaccurate dosing and blood sugar instability. A facility policy titled Use of Insulin Pens last revised June, 2022, indicated the proper procedure for the device was as follows: Attach a safety pen needle to the pen device. A 2-4-unit prime is performed before every insulin injection to ensure a small amount of fluid flows through then end of the needle. If necessary, repeat until this occurs. Correct insulin dosage should be dialed and rechecked against resident ' s prescription prior to administration. Maintain a 10 second wait following delivery of insulin before removing the needle from the skin to ensure full dose delivery and leakage from the site.