**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all dependent residents received services necessary to maintain good grooming and personal hygiene when the staff failed to provide assistance with bathing to three residents (Resident #1, #2, and #3) out of a sample of thirteen residents. The facility's census was 71. Review of the facility's policy titled Daily Care Needs, dated March 2015, showed the following: -The purpose of daily care needs is to refresh the resident and provide cleanliness, comfort, and neatness; -Before beginning care, staff should check the bathing schedule. Review of the facility's policy titled Bath (Shower), dated March 2015, showed the following: -It is the policy of the facility to provide a shower to maintain skin integrity, comfort, and cleanliness; -Staff should encourage the resident to do as much of his/her own care as possible; -Supervise and assist as necessary. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 10/30/24; -Diagnoses included paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/06/24, showed the following: -Resident was cognitively intact; -Resident required supervision for oral and personal hygiene and substantial assistance from staff for toilet hygiene and showering; -Resident used a wheelchair for mobility. Review of the resident's care plan, revised 01/22/25, showed the following: -Resident required staff assistance with showering; -Resident required limited staff assistance with grooming and hygiene; -Resident required two staff assistance with mobility and transfers. Review of the resident's November 2025 Shower Sheets showed the resident received a shower on 11/21/24. Review of the resident's December shower sheets showed the resident received a shower on the following dates: -On 12/04/24, resident offered shower but refused; -On 12/16/24; -On 12/28/24. Review of the resident's January 2025 shower sheets showed the resident received a shower on 01/22/24. During interviews on 01/21/25, at 11:39 A.M., and on 01/23/25, at 9:40 A.M., the resident said the following: -The resident reported he/she had been at facility for three months and only had two showers; -The resident asked the Administrator about showers and was informed corporate would not allow the hiring of a shower aide; -Resident reported he/she liked to get two showers weekly and felt crappy not getting one; -Resident received a third shower since admission last night. 2. Review of Resident #2's face sheet showed the following information: -admission date of 09/24/24; -Diagnoses included congestive heart failure (a long-term condition in which the heart can't pump blood well enough to meet the body's needs). Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Used wheelchair for mobility; -Dependent for transfers, showers, and lower body dressing; -Substantial staff assistance with upper body dressing; -Partial to moderate staff assistance with personal hygiene; -Set up and clean up assistance with oral hygiene. Review of the resident's care plan, dated 10/17/24, showed the resident required assistance with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting). Staff assistance needed with showers including hair care. Review of the resident's shower sheets showed staff did not document a shower offered or provided in October 2024. Review of the resident's November 2024 Shower Sheets showed resident received a shower on the following dates: -On 11/01/24; -On 11/10/24; -On 11/15/24; -On 11/19/24, resident refused shower; -On 11/20/24. Review of the resident's December 2024 Shower Sheets showed resident one sheet, dated 12/05/24, which indicated resident in the hospital and no shower given. 3. Review of Resident #3's face sheet showed the following information: -admission date of 12/17/16; -Diagnoses included hemiplegia and hemiparesis affecting right dominate side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) and obesity. Review of the resident's annual MDS, dated [DATE], showed the following information: -Moderate cognitive impairment; -Used wheelchair or cane for mobility; -Independent with oral hygiene, dressing, personal hygiene, and toileting; -Moderate staff assistance with showers. Review of the resident's care plan, revised 12/13/24, showed the resident was mostly independent with ADL's, but required one staff assistance with showers and hair brushing. Review of the resident's October 2024 and November 2024 Shower Sheets showed staff did not document offering or completion of a shower for the month. Review of the resident's December 2024 Shower Sheets showed the resident received a shower on 12/15/24 and on 12/28/24. Review of the resident's January 2025 shower sheets showed resident received a shower on 01/14/25 and on 01/22/25. During an interview on 01/21/25, at 11:00 A.M., the resident said he/she had a shower once every two weeks. He/she was supposed to have one shower per week, but would like more. 4. During an interview on 01/23/25, at 2:20 P.M., Nurse Assistant (NA) A said residents should receive two showers per week. Staff should complete shower sheets upon completion of resident shower. During an interview on 01/23/25, at 2:40 P.M., Certified Medication Technician (CMT) B said he/she did not provide resident showers, but residents should be receiving two showers weekly. During an interview on 01/23/25, at 2:45 P.M., Licensed Practical Nurse (LPN) C said the following: -Residents should receive showers two to three times per week; -Staff do not get a chance to shower residents twice weekly sometimes; -Residents receive at least one shower per week; -Shower sheets should be completed after the shower and given to the Director of Nursing (DON). During an interview on 01/23/25, at 3:25 P.M., Licensed Practical Nurse (LPN) C said residents should receive showers twice per week. During an interview on 01/23/25, at 11:35 A.M., the Director of Nursing (DON) said that he/she had recently been working on a new process to improve resident showers. Staff should provide him/her with a completed shower sheet. He/she has requested staff sign shower sheets even if the resident refused. During an interview on 01/23/25, at 5:00 P.M., the Administrator said the following: -Residents should have a shower at least one time per week; -He/she would prefer residents to have showers based on preference or at least two showers per week. MO00246671, MO00246674, MO00246824

Based upon record review and interviews, the facility failed to perform a complete admission assessment, including a skin assessment, and did not identify and provide timely treatment for a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one resident (Resident #1). The facility census was 71. Review of a facility policy titled admission Nurse's Note, dated March 2015, showed the following: -The purpose of the policy is to ensure information is documented for the resident upon admission; -Upon admission of a resident, the nurse will document a body audit which includes site and size of the scars, rashes, bruises or abrasions, pressure sores (injury to skin and underlying tissue resulting from prolonged pressure on the skin) or stasis ulcer (wound to the leg or ankle caused by abnormal or damaged veins), and general overall appearance and cleanliness. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admission date of 10/30/24; -Diagnoses included paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), diabetes mellitus (disease that results in too much sugar in the blood), and pressure ulcer of the sacral (area located above the tailbone) region, stage 3 (wound that extends through the entire thickness of skin and damages the underlying tissue). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/06/24, showed the following: -Resident was cognitively intact; -Resident required supervision for oral and personal hygiene and substantial assistance from staff for toilet hygiene and showering; -Resident had a stage 3 pressure ulcer; -Resident used a wheelchair for mobility. Review of the resident's care plan, revised 01/22/25, showed the following: -Required two staff assistance with mobility and transfers; -Nursing should check skin routinely, treat and perform all preventative cares (turning, propping, repositioning) to prevent pressure injury; -Had skin breakdown to coccyx (tailbone) that the wound nurse and wound care provider will monitor and treat. Review of the resident's admission clinical assessment, dated 10/30/24, showed the resident had the following risk factors for skin breakdown: a history of pressure sores, poor skin turgor, and predisposing diseases. The nurse documented he/she was unable to do a skin assessment as the resident was up in a power chair and arranging new room. Review of the resident's progress notes, dated 10/31/24 to 11/01/24, showed staff did not document regarding skin, or attempts to assess skin. Review of the resident's progress note, dated 11/02/24, showed staff notified the nurse that the resident had a brown adhesive foam dressing on. The nurse observed a brown adhesive dressing to the coccyx upon assessment. Resident noted to have open area to coccyx and a piece of calcium alginate (highly absorptive dressing) to area beneath dressing. Area cleansed and new dressing applied. Air mattress ordered and wound care nurse notified. Review of the resident's physician order report showed an order, dated 11/02/24, to cleanse area to coccyx with hypochlorous acid (fights bacteria), apply sure prep (skin protectant) to peri wound area, apply calcium alginate to wound bed, and cover with adhesive foam border gauze as needed for loose or soiled dressing (three days after the resident admitted to the facility with the wound). Review of the resident;s progress notes, dated 11/03/24, showed staff did not document regarding the resident's coccyx wound. Review of the resident's progress note, dated 11/04/24, showed the Wound Care Nurse assessed wound to coccyx and noted wound bed was pink with small amount of bloody drainage noted with firm scar tissue noted to peri wound. Order updated and outside wound provider notified (five days after the resident admitted to the facility with the wound). Review of the resident's weekly skin assessment, dated 11/04/24, showed the resident had an open area to the coccyx and resident had effective treatment in place. During an interview on 01/23/25, at 1:31 P.M., Licensed Practical Nurse (LPN) E said the following: -He/she was the facility wound care nurse; -The admission nurse was responsible for skin assessments, but if he/she was at the facility during admission they will assist; -The initial skin assessment should not be completed after resident has been in facility two or three days; -admission skin assessment should occur within two hours of admission to the facility. During an interview on 01/23/25, at 2:45 P.M. LPN C said the following: -Skin assessments should be completed within two hours of admission; -The nurse should try again if the resident refuses first attempt at skin assessment and it should be completed within the first 24 hours. During an interview on 01/23/25, at 3:25 P.M. LPN D said the following: -The nurse on duty when the resident was admitted was responsible for the admission assessment; -He/she would document any refusal of assessment and notify the oncoming shift to have it completed; -A skin assessment should be completed with two hours of admission so the facility can assume responsibility for any wounds. During an interview on 01/23/25, at 5:00 P.M. the Director of Nursing (DON) said the following: -The nurse should complete a skin assessment within two hours of admission; -The nurse should notify the wound care nurse if a resident refuses a skin assessment so he/she can follow up the next day;d-The nurse should notify physician and family if resident continues to refuse a skin assessment. During an interview on 01/23/25, at 5:00 P.M. the Administrator said a resident should not go three days without a skin assessment. The nurse should notify the Administrator, the physician, and the resident's family of refusals. MO00246671

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - mandated federal assessment completed by facility staff) assessment was accurate and complete for one resident (Resident #24) of 22 residents whose MDS were reviewed. Review of the Resident Assessment Instrument manual, version 1.19.1, dated October 2023, showed the following: -The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status; -In addition, an accurate assessment required collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, and/or other legally authorized representative, or significant other as appropriate or acceptable. 1. Review of Resident #24's Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), showed the following: -admission date of 02/15/24; -Diagnoses included heart failure, kidney disease, and a stroke. Review of the resident's quarterly MDS, located in the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 05/21/24, showed staff did not assess the resident in the following care areas: -Section C: Cognitive Patterns; -Section D: Mood; -Section E: Behaviors. During an interview on 08/22/24, at 10:36 A.M., the Social Services Director (SSD) said he/she was responsible for coding Sections C, D, and E on the MDS assessments. The SSD said she was unsure why those areas were no coded and thought maybe he/she had been out that week. During an interview on 08/23/24, at 10:26 A.M., the MDS Coordinator (MDSC) said he/she did not know why he/she did not code the missing sections. He/she did sign off on the assessment as complete.

Based on interview and record review, the facility failed to provide care per standards of practice when staff failed to document and follow physician's orders related to blood sugar tests for one of one resident (Resident #23) reviewed for insulin use out of a total sample of 22. 1. Review of Resident #23's Face Sheet,' located in the 'Face Sheet tab of the EMR, showed the following: -admission date of 07/05/24; -Diagnoses included diabetes and bilateral (both sides) shoulder fractures. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), located in the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 07/11/24, showed the following: -Cognitively intact for daily decision-making' -Administered insulin on six out seven days during the observation period. Review of the resident's Physician Orders, located under the Orders tab of the EMR, showed an order for the resident's blood sugar level to be checked before meals. Review of the resident's nursing Progress Notes, dated 08/01/24 at 12:46 P.M., and located in the 'Progress Notes tab of the EMR, showed the following: -Licensed Practical Nurse (LPN) #2 documented blood sugar at approximately 12:40 P.M. read 468 milligrams/deciliter (mg/dL). Nurse retook blood sugar on opposite hand with a reading 449 mg/dL. -LPN contacted the physician and received orders to administer 7 units of insulin and recheck blood sugar level in three three hours at 4:00 P.M. Staff to call if the resident's blood glucose level measured over 300 mg/dL. Review of the resident's Progress Notes and Orders tab of the EMR showed no documentation LPN #2 obtained the resident's blood sugar level at 4:00 PM. There was no documentation that the physician was notified of any results. There was no documentation the resident received any insulin. There was no documentation LPN #2 communicated with other nursing staff responsible for the resident's care. Review of the resident's nursing Progress Notes, located in the Progress Notes tab of the EMR and dated 08/01/24 at 10:19 PM, showed LPN #4 documented recheck resident blood sugar this time measured 371 mg/dL. The LPN notified the physician and received orders to administer 4 units of Humalog (short-acting insulin) per resident sliding scale. The nurse administered insulin. The LPN did not document why the resident's blood sugar was checked at this time. During an interview on 08/20/24, at 9:32 A.M., the resident said his/her sugars have been over 200 mg/dL since he/she has been at the facility. There was one time it was over 400 mg/dL. During an interview on 08/23/24, at 8:13 A.M., LPN #8 said there was no documention of the resident's blood sugaring being obtained on 08/01/23, at 4:00 P.M. The LPN said if it was not documented, then the blood sugar was not done as ordered. During an interview on 08/23/24, at 9:38 A.M., LPN #2 said at 4:17 P.M., the resident's blood sugar level was 330 mg/dL and he/she notified the physician. The physician gave an order to administer five units of insulin plus the resident's sliding scale insulin to equal eight units of insulin. He/she was supposed to recheck the resident's blood sugar in one hour and call the physician if it was over 300. Dinner had been served late, so she gave the resident the insulin at 5:30 P.M. He/she should have documented the physician order, but forgot to. He/she remembered at 8:30 P.M., called LPN #4, and told him/her to get the blood sugar and call the physician if it was over 300. LPN #2 said he/she failed to document the blood sugar and write a nursing Progress Note regarding the phone call with the physician and write the order. During an interview on 08/23/24, at 12:25 P.M., the Director of Nursing (DON) said physician orders, blood sugar checks, and communication between staff in regard to the resident's blood sugar levels should have been documented in the EMR as an order, a progress note written, and it should be reported to the next nurse at shift change.

Based on record review and interview, the facility failed to ensure an environment as free of hazards of possible when staff failed to transfer one resident (Resident #38), of 22 sample residents, with two staff members as care planned when using the mechanical lift (Hoyer Lift). 1. Review of Resident #38's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, showed the following: -admission date of 07/20/19; -Diagnoses included of type II diabetes mellitus with diabetic neuropathy (causes weakness, numbness and pain, usually in the hands and feet), cerebral infarction (stroke), and acquired absence of left leg below the knee (BKA). Review of the resident's comprehensive care plan, initiated 07/14/21, located under the RAI tab in the EMR, showed an identified problem as required assistance of 2+ people for mobility and transfers/Hoyer lift to wheelchair and toilet. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), with an assessment reference date (ARD) of 04/04/24, showed the resident was cognitively intact. Review of the Incident Report provided by the Administrator showed the following: -On 08/09/24, at 12:52 A.M., called to resident room by Certified Nurse Aide (CNA). The resident's right great toenail was bleeding and slightly pulled back from nail bed. The CNA reported it happened during transfer via Hoyer lift. It was hit and then started bleeding. -Resident is diabetic and will need close monitoring for the wound. Area cleaned with pure and clean, wrapped with gauze, and taped. New order placed. Wound nurse will assess and adjust treatment as necessary. Resident denied pain. Review of the resident's Progress Notes, located in the EMR under the Resident tab, showed the following: -On 08/09/24, 12:52 A.M., called to resident room by CNA. The resident's right great toenail bleeding and slightly pulled back from nailbed. CNA reported it happened during transfer via Hoyer lift. It was hit and then started bleeding. The resident is diabetic and will need close monitoring for the wound. Staff cleaned the area with pure and clean, wrapped with gauze, and taped. New order placed. Wound will nurse assess and adjust treatment, as necessary. Resident denied pain. -On 08/09/24, 10:40 A.M., nurse notified that resident toenail had been bumped and was bleeding. Upon assessment the bottom of the toenail has a small open area between toenail and cuticle, the toenail is intact at this time. No sign/symptom of infection noted. Orders placed. Staff will monitor daily and discontinue when healed. -On 08/11/24, at 9:24 P.M., reassessed resident's great toe for signs and symptoms of infection. No signs noted with no increased warmth, no redness, and no pain noted. Resident requested prophylactic antibiotic due to previous difficulties with wounds to his left foot and is requested an urgent podiatry appointment; -On 08/10/24, at 9:21 P.M., recorded as late entry on 08/11/24, at 9:24 P.M., resident requested that this nurse look under bandage to right great toe while administering bedtime insulin. When removing bandage, noted toenail to be disconnected from nail bed except small amount of tissue in inner aspect of nail bed. No new bleeding, no signs/symptoms of infection noted, and no redness or pain noted. Staff reapplied bandage. -On 08/12/24, 5:50 P.M., Nurse Practitioner (NP) rounded on resident and gave new orders for Keflex (antibiotic) 500 mg (milligrams) PO (by mouth) BID (twice a day) for five days for pulled away toenail. Staff entered orders entered in the electronic medical record. Staff updated resident on treatment plan during rounds. During an interview on 08/20/24, at 4:15 P.M., the resident said CNA #2 bumped his/her foot into the wall and he/she is now losing the nail. The CNA had the resident on the crane (mechanical lift) by him/herself. During an interview on 08/22/24, at 4:20 A.M., CNA 5 said there are five mechanical lifts on the resident's. The CNAs we always help each other with the lifts. If the float CNA isn't available, the nurse will help. Staff safely transfer the resident with only one person. During an interview with CNA #2, on 08/23/24 at 8:48 A.M., the CNA confirmed that he/she was the CNA transferring the resident with the Hoyer lift at the time of the incident. The resident hit his/her toe on the doorframe. The CNA #2 declined to respond when asked if he/she was transferred the resident by him/herself, or if a Hoyer lift required two staff members to use. During an interview on 08/23/24, at 8:58 A.M., the Director of Nurses (DON) said the Hoyer lift has to be two people. CNA #2 did not have another staff with him/her during the transfer. The DON confirmed there was no identification of a second staff person noted on the incident report, nor was there an identification of a second staff person noted in the progress notes.

Based on observation, interview, and record review, the facility failed to ensure insulin pens were dated when opened for seven of 13 residents (Residents #8, #53, #49, #33, #55, #34, and #11) who were administered insulin in the facility. The facility failed also failed to ensure five vials of influenza vaccines were not expired in two of two medication rooms. Review of an undated facility policy titled, Labeling Drugs and Medications, showed all drugs and biologicals must be properly labeled and legible at all times. Review of an undated facility policy titled, Medications, Storage of, showed no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. 1. Observation and interview on 08/21/24, at 1:36 P.M., of the Magnolia medication room with Licensed Practical Nurse (LPN) #6 showed two boxes containing vials of influenza vaccine that were noted to have an expiration date of 06/30/24. LPN #6 confirmed that the vials were expired and should have been removed from the refrigerator. Observation and interview on 08/22/24, at 4:50 A.M., of the Dogwood/Willow medication room with LPN #5 showed three boxes containing vials of influenza vaccine that were noted to have an expiration date of 06/30/24 on the box. LPN #5 confirmed that the vials were expired and should have been removed from the refrigerator. On 08/21/24, at 1:53 P.M., the Administrator said the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the unit nurses were responsible for ensuring expired medications were properly disposed of. 2. Observation and interview of the Dogwood medication cart on 08/22/24, at 4:43 A.M., with LPN #5 showed the following: -An opened and undated Novolin R Flex Pen for Resident #8; -An opened and undated Degludec insulin pen and Ozempic flex pen for Resident #53; -An opened and undated Novolog insulin pen and Tresiba insulin pen for Resident #49. -LPN #5 confirmed all the insulin pens and the Ozempic were open and undated. The LPN said the pens should have been dated with an open date. Observation and interview of the [NAME] medication cart on 08/22/24, at 4:57 A.M., with LPN #1 showed the following: -An opened and undated Humalog insulin pen for Resident #33; -An opened and undated Degludec insulin pen for Resident #55; -An opened and undated Novolog insulin pen for Resident #34; -An opened and undated Novolog insulin pen for Resident #11; -LPN #1 confirmed that the insulin pens had been opened and should have been dated when opened on the label. During an interview on 08/22/24, at 7:53 A.M., the Director of Nursing (DON) said the nurses were responsible for ensuring insulin pens were dated with open dates.

Based on observation, interview, and record review, the facility failed to maintain food at a palatable temperature on one of three halls (300 hall) when six on the hall (Residents #17, #18, #21, #29, #33, and #38) complained of cold food on the hall of 27 residents. Review of the facility's policy titled Food Temperatures, dated May 2015, showed the following guidance: -Temperatures of hot foods should be maintained at no less than 140.0 degrees Fahrenheit (F) during meal service; -Hot food should be at least 120 degrees F when served to the resident. 1. Review of Resident #21's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 05/07/24, showed the resident was moderately cognitively impaired. During an interview on 08/20/24, at 11:41 A.M., the resident said most times the food is adequate, but it can be cold. He/she ate his/her meals in the dining room. 2. Review of Resident #18's quarterly MDS, with an ARD of 06/12/24, showed the resident was moderately cognitively impaired. During an interview on 08/20/24, at 1:40 P.M., the resident said the food is often cold which doesn't make sense since the kitchen is right there. The resident said he/she ate his/her meals in the dining room. 3. Review of Resident #29's re-entry MDS, with an ARD of 07/08/24, showed the resident was severely cognitively impaired. During an interview on 08/20/24, at 4:06 P.M., the resident, along with his/her family member said the food was cold. The resident received meals in his/her room and was often assisted by family member. 4. Review of Resident #38's quarterly MDS, with an ARD of 04/04/24, showed the resident was cognitively intact. During an interview on 08/20/24, at 4:19 P.M., the resident said the food is cold and he/she ate meals both in the dining room and in his/her room. 5. Review of Resident #33's quarterly MDS, with an ARD of 05/16/24, showed the resident was cognitively intact. During an interview on 08/20/24, at 4:25 P.M., the resident said the food can be cold sometimes and he/she ate his/her meals in the dining room at the table right next to the serving window. 6. Review of Resident #17's quarterly MDS, with an ARD of 06/20/24, showed the resident was cognitively intact. During an interview on 08/20/24, at 5:03 P.M., the resident said he/she did not understand how the food could get cold from the kitchen directly to the table. The resident said he/she ate his/her meals in the dining room and in his/her room. 8. During a group interview on 08/22/24, at 9:00 A.M., with six residents (Resident #1, #18, #19, #21, #34, and #50), chosen by the facility as alert and oriented and regularly attended the monthly Resident Council meetings, the residents said the food was served cold on the 100 and 300 halls. 9. During an interview and record review on 08/23/24, at 11:10 A.M., the Dietary Manager (DM) said three insulated carts leave the kitchen at the same time for the 100, 200, and 300 hall kitchenettes. The dietary staff member who was to serve the meal transports the cart. The food temperatures are taken prior to placing the food in the food carts and on the steam table prior to meal service on each unit. Review of the food temperature logs showed appropriate temperatures from the kitchen. 10. During observation and test tray of the 300 hall meal service on 08/23/24, at 11:50 A.M., showed 13 residents seated in the dining room. The steam table was observed on and lids covered two steam table wells (one contained fish fillets and one contained onion rings). A container of coleslaw was observed on an ice bath. Food temperatures of the hot food were taken by the dietary staff member and measured 135.0 degrees F. After all the resident meals had been served in the dining room and resident rooms, a test tray was obtained and the DM took the food temperatures at 12:30 P.M. The fried fish fillet with cream sauce was 103.0 degrees F. The fish was cold and unpalatable when tasted. The onion rings were 127.0 degrees F. The onion rings were soft, marginally warm, and difficult to chew. 11. During an interview and observation on 08/23/24, at 12:45 P.M., the DM said it must be the steamer bay. It had been fixed within the past two months. The DM took the temperature of the steamer bay which held the fish fillets and it registered 117.0 degrees F. The DM said that's too low. The DM said he had not looked at the temperature log prior to the meal service on the 300 hall and was unaware the steamer bay was not functioning properly. He/she had no additional monitoring system beyond taking food temperatures prior to service from the kitchenette.

Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) for one resident of one resident (Resident #216) reviewed for EBP, out of a total sample of 22, who had had a peripherally inserted central catheter (PICC line - a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) and received antibiotics. Review of the facility's policy titled, Enhanced Barrier Precautions, dated March 2024, showed the following: -The purpose of the policy is to prevent broader transmission of MDRO (multi-drug resistant organisms) and to help protect patients with chronic wounds and indwelling devices; -EBP (enhanced barrier precautions) should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed. Review of the EBP-Enhanced Barrier Precautions in-service, dated April 2024, provided by the Administrator showed the following: -Staff will notice a new dot on the name tags by residents' doors; -EBP is indicated for residents with infection or colonization with a CDC (Centers for Disease Control) targeted MDRO when contact precautions do not otherwise apply; or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. (The inservice did not address EBP for high-contact care such as showering/bathing and toileting, use of gown and gloves for high contact cares, or where the PPE was located.) 1. Review of Resident #216's Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), showed the following: -admission date of 08/16/24; -Diagnoses included bacteremia (the presence of bacteria in the blood stream). Review of the resident's admission Minimum Data Set (MDS - federally mandated assessment instrument completed by facility staff), located in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 08/23/24, showed the resident was cognitively intact. Observation on 08/20/24, at 2:58 P.M., showed the resident showed the resident had a PICC line in her right arm. Licensed Practical Nurse (LPN) #1 washed his/her hands and disconnected the intravenous (IV) antibiotic from the resident's PICC line. LPN #1 did not wear a gown or gloves during the high-contact care. During an interview on 08/02/24, at 3:00 P.M., LPN #1 said he/she had not received any training or in-services on EBP when administering or removing IV antibiotics from a PICC line. LPN #1 said there was no readily accessible PPE (personal protective equipment) to use when administering IV antibiotics to the resident. During an interview on 08/21/24, at 2:20 P.M., the resident said nursing staff had not been using gowns or gloves when administering his/her IV antibiotics since admission to the facility and the Certified Nurse Aides (CNAs) had been not been utilizing protective equipment when assisting his/her with showers or high-contact cares. During an interview on 08/21/24, at 2:30 P.M., CNA #1 said he/she had not received any training or in-services on EBP. During an interview on 08/21/24, at 3:00 P.M., the Infection Preventionist (IP) said he/she had talked to the charge nurses and administration about EBP. There was a dot next to a resident's name on the name plate if staff needed to use EBP. The PPE was in a three-drawer dresser located in the lounge area on the unit. During an interview on 08/21/24, at 3:05 P.M., the Director of Nursing (DON) and the Regional Quality Assurance (QA) nurse were informed of the lack of EBP during the resident's IV care and the staff's lack of knowledge on EBP requirements. The DON said they had training for all staff twice. During an interview on 08/22/24, at 3:50 P.M., LPN #1 said he/she did not think he/she needed to wear precautions for IV administration, but was aware of it for indwelling urinary catheters.

Based on observation and interview, the facility failed to maintain ceiling vents to ensure condensation and/or peeling paint did not drop from the vent onto the food preparation area. This had the potential to affect all 65 residents of the facility who received their meals from the facility kitchen. 1. During the initial tour of the kitchen on 08/20/24, at 9:00 A.M., with the Dietary Manager (DM), three ceiling vents were observed to have rust, dust, and peeling paint on and around the vents. One vent, located in front of the freezer, was observed to be falling from the ceiling. Another vent, located above the edge of the food preparation table, had condensation dripping from the edges of the vent, landing in front of the food preparation table. The drips were confirmed by the DM and [NAME] #1. They both confirmed there was a potential for the condensation and/or peeling paint to fall into food being moved from the stove to the preparation table and vice versa. During an interview on 08/23/24, at 1:20 P.M., the Maintenance Director (MD) said that he was responsible for the maintenance of the ceiling vents and that he was aware of their condition, but had not fixed the concerns. During an interview on 08/23/24, at 2:02 P.M., the Administrator said they did not have a policy for monitoring the ceiling vents in the kitchen.

Based on interview and record review, the facility failed follow standards of practice when the staff failed to monitor and follow-up on STAT (immediate) lab results resulting in treatment for one resident (Resident #1) infection. The facility census was 57. Record review of the Cleveland Clinics Website (myclevelandclinic.org), dated 11/05/21, showed the following: -A urinalysis (UA - is a quicker test that screens urine for the presence of red and white blood cells and bacteria that can indicate an infection); -A urinalysis can't identify the specific bacteria causing a urinary tract infection (UTI). A urine culture is completed for that. If bacteria grow in the urine culture test; -After the lab receives the urine sample, they grow the culture in an incubator for 24 to 48 hours; -The lab conducts an antibiotic sensitivity test on the bacteria in the cultured sample. Also called an antibiotic susceptibility test, this test identifies the type of bacteria causing the infection and which antibiotics the bacteria is sensitive to, meaning which antibiotics will kill the bacteria. This information helps the healthcare provider select the most effective antibiotic medicine. Record review of the facility's policy, Lab Reporting Guidelines, undated, showed the following: -The following guidelines will be followed to ensure that lab recommendations are completed timely; -The nurse will receive the order for the lab draw, enter the order in the orders, and document the telephone order, verbal order, or written order; -The lab order will be transcribed in the lab computer system for processing by the lab; -If the lab is STAT, call the lab to report the new order; -Once routine lab results are returned to the facility, the nurse will notify the physician via fax and follow up call in 12 hours if no return documentation. If there is a critical result, follow STAT protocol; -Once STAT lab results are returned to the facility, the physician will be notified via fax and phone call within one hour; -The nurse will document in nurses' notes that the lab results were received and sent to the physician for review. Any new orders will be documented in the nurses' notes and entered into the orders. 1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admission date of 11/2/22; -Diagnoses included fracture of UTI, retention of urine, and cognitive communication deficit. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/8/22, showed the following: -Cognitively intact; -Required extensive assistance with transfers and toileting. Record review of the facility's, STAT Same Day Requisition, dated 12/10/22, showed the following: -Ordered tests: UA with culture if indicated. Record review of the resident's physician's order sheet, dated December 2022, showed no order for a UA or culture. Record review of the resident's nurses' notes showed the following: -On 12/10/22, at 11:15 A.M., Licensed Practical Nurse (LPN) A said the resident notified him/her of concerns of urinary frequency/urgency following scant output and burning upon voiding. On-call nurse was notified of resident's symptoms of possible UTI. The nurse notified the on-call nurse practitioner (NP) and awaiting new orders; -On 12/10/22, at 11:43 A.M., LPN A received STAT orders from on-call NP for a STAT UA with culture if indicated. Orders placed in medication administration record (MAR) and online. Staff called the lab for confirmation. Lab technician informed him/her that STAT labs are completed anywhere from two to four hours. Will continue to observe; -On 12/10/22, at 2:10 P.M., LPN A said at 1:00 P.M., 18 cc (cubic centimeter) of urine collected with hat/clean catch. The lab verified they must have at least 20 cc of urine for UA with culture if indicted. Small, frequent voids about one hour with approximately 15 to 60 cc of urine. Resident said burning feels like it's internal. Specimen left in sterile cup in the refrigerator with requisition. Awaiting Lab tech estimated time of arrival to facility; -On 12/10/22, at 9:58 A.M., LPN A said lab technician in facility to pick-up stat UA sample and drew stat labs per nurse practitioner. Lab departed facility with urine cup and vials of blood; -On 12/11/22, at 9:50 P.M., LPN A said STAT UA/lab result: Results pending for UA. The lab is aware of the STAT urgency; -On 12/12/22, at 11:35 A.M.,LPN B said UA results faxed from the lab. Lab faxed to the physician. UA was positive and are awaiting culture results. Record review of resident's medical records showed the following: -Urinalysis results from collection 12/10/22 at 1:00 P.M.; -Appearance was turbid (cloudy, opaque, or thick with suspended matter), showing an abnormal result. -Color:dark yellow, -Positive for nitrates (a sign of a possible urinary tract infection (UTI)), indicating an abnormal result ; -Leuko esterase UA (a screening test used to detect a substance that suggests there are white blood cells in the urine.), 3+ indicating an abnormal result -White blood cells, 11-20/hpf (high power field), indicating an abnormal result; -Bacteria 4+, indicating an abnormal result; -Crystals, triple phosphate present (neutral and alkaline urine and are associated with upper urinary tract infections with urease-producing organisms), indicating an abnormal result. Record review of resident's records showed the following: -A lab report inquiry showed the resident's lab was reported on 12/12/2022; -A urine culture final report dated 12/13/22; -Positive for entercoccus faecalis (a gram-positive bacterium that can cause a variety of infections of which urinary tract infections are the most common); -Susceptibility testing on entercocci isolated from lower urinary tract or minor infections is not routinely performed. These infections generally response to treatment with high doses of ampicillin (antibiotic) or penicillin (antibiotic). Alternates include erythromycin (antibiotic), ciprofloxacin (antibiotic), nitrofurantoin (antibiotic) or tetracycline. Record review of the resident's physician progress notes, dated 12/20/22, showed the following: -The resident's family present and reported that a UA was collected and was positive for a UTI. The culture results are available and shows sensitivity to Cipro. Will start on Cipro today as well a probiotic and order labs; -Plan: Cipro 500 mg daily for 5 days and probiotics 1 capsule daily. Record review of the resident's medical record showed staff did not document regarding the resident's culture results 12/20/22 (seven days later after the culture results were finalized). Record review of the resident's nurses' notes showed the following: -On 12/20/22, at 3:36 P.M., LPN C said NP saw the resident. New orders Cipro 500 milligram (mg) one time daily for 5 days due to results from culture and previous U/A obtained. Record review of the resident's December 2022 MAR, showed an order for Cipro 500 mg, 1 tablet, once a day, with a start date 12/20/22, for urinary tract infection. Record review of the resident's plan of care, dated 12/20/22, showed the following: -Received antibiotics for a urinary tract infection. He/she took Cipro (antibiotic) from 12/20/22 to 12/25/22; -Resident will be on the most appropriate antibiotic During an interview on 1/23/23, at 12:51 P.M., LPN B said the following: -He/she was aware that the UA was positive and the facility had been waiting to get back the urine culture for the resident to see what type of bacteria he/she had. The physician will not prescribe an antibiotic based on a UA being positive. The physician wants a culture completed first to make sure the correct antibiotic is prescribed; -He/she only worked the first few days after the resident had the culture. He/she checked and the results had not come in yet. He/she is not sure what happened after that; -The expectation is that results of a culture will come back within five days. He/she is not sure why they did not have the results until ten days after sending it to the lab; -Staff should follow up on the culture by contacting the lab if they have not received results from a culture within three to five days. During an interview on 1/23/23, at 2:15 P.M., Certified Nurse Aide (CNA) D said the following: -He/she lets the nurse know if he/she notices any residents having symptoms of a UTI such as pain/burning, increased frequency/urgency or odor/color change; -The nurse notifies the physician and gets orders for a UA. During an interview on 1/24/23, at 11:02 A.M., LPN E said the following: -If a resident is have symptoms of a UTI, such as, pain/burning, increased frequency/urgency or odor, he/she will notify the physician to get an order for a UA. He/she faxes the order to the lab. He/she will also follow up with a phone call it is a STAT lab; -When they receive results of the UA they let the physician know. If it is positive he/she generally will want a culture done which is usually put in the original order; -It can take around three to five days to get a culture back; -The physician will not order antibiotics until the culture results are reviewed; -He/she will follow up with the lab if the results are not showing up in the computer within three days; -He/she was not aware of the resident having a UA or culture ordered. If he/she would have known he/she would have followed up on it. During an interview on 1/24/22, at 11:15 A.M., Registered Nurse (RN) G said the following: - If a resident is having symptoms of a UTI, he/she will notify the physician to get an order for a UA/urine culture. He/she faxes the order to the lab; -When they receive results of the UA they let the physician know and they wait for the culture results; -He/she checks after three days if there are not results in the computer. The nurse should pass the information onto the next nurse in report so they can also be looking for results; -He/she as not aware of the resident having a UA/urine culture. During an interview on 1/24/22, at 12:07 P.M., RN F said the following: -He/she was made aware by the resident's family on 12/20/22 that the resident had a pending urine culture. They were upset because it had been 10 days and he/she had not been started on an antibiotic when the resident had a positive UA; -The resident was having a little increased confusion, but no other symptoms at that time; -The Administrator usually follows up on labs. He/she asked LPN B and he/she said the culture results had not come back yet; -The lab was contacted and the culture had been completed. He/she was not sure when it was completed. The NP reviewed the culture and put in orders to start an antibiotic on 12/20/22; -He/she is not sure why nobody followed up on the culture. He/she follows up on cultures if the results are not in the computer after three days and then sends it to the physician. During an interview on 1/24/22, at 11:28 A.M., the Director of Nursing (DON) said the following: -If a resident is having symptoms of a UTI, the expectation, is the nurse will contact the physician to get orders for a UA/culture. That information should be passed on to the next nurse and should be followed up on; -A different lab completed the culture and it was not obvious that the culture results were available; -It usually takes about five days for the lab they normally use to complete a culture, but the lab used for the resident completed it in three days. The staff was just not aware; -The nurse should have followed up on the resident's urine culture after five days to see why they didn't have results if they weren't seeing it in the computer. He/she is not sure why that didn't happen. During interviews on 1/23/23, at 2:42 P.M., and on 1/24/22, at 12:45 P.M., the Administrator said the following: -The physician will not order an antibiotic until he/she reviews the results from the culture; -The lab that normally does their cultures did not complete it this time and the results were put in the computer in a way that made it difficult for staff to notice the results were completed and put into the computer; -He/she would expect staff to follow up on cultures if results are not received after three days; -The resident's culture should have been followed up on sooner; -Staff had to call the lab on the 12/20/23 to get the results. MO00211766

Based on observations, interviews, and record reviews, the facility failed to document a thorough investigation completed regarding grievances; failed to document an explanation of the findings and proposed remedies related to grievances, family, and/or staff; failed to identify the current grievance officer; failed to ensure the residents had the right to file a grievance anonymously; and failed to educate and review guidelines on how to file a grievance with the residents and staff. The facility census was 57. Record Review of the facility's policy, Grievance Protocol, undated, showed the following: -The purpose of the grievance/complaint report and Grievance Log is to provide a written record of each resident and family concern and to insure proper follow-up through the appropriate discipline; -The Social Service Director (SSD) is responsible for the program, although the Administrator is ultimately responsible for the proper implementation of the program. The SSD informs the Administrator of each incident; -Any member of the social services staff can complete the Grievance Complaint Report. The appropriate situations for use of the Grievance Complaint Report are resident articles that are lost of cannot be located and continual concern of lost resident items (including laundry concerns); resident care or personal hygiene issues that cannot be immediately resolved; resident or family concerns with dietary issues; diet or temperature of meals; any resident or family concerns with a staff member; and any resident or family issue that would require a resolution; -The SSD will obtain the original Grievance Complaint Report, record the grievances on the Monthly Grievance Log, inform the Administrator of the grievance, and forward a copy of the grievance to the appropriate discipline; -The Administrator and SSD evaluate the Monthly Grievance Log for trends or patterns and devise and action plan to correct issues. A new Grievance Log should be completed each month. Record review of the facility's policy, Your Rights, as a Resident in a Long-Term Care Facility , undated, showed the following: -Residents may voice grievances and recommend changes to facility staff or to outside representatives. Owners and staff of long term care facilities are prohibited by law from retaliating in the case of complaints; -Residents should speak with the Director if Nursing (DON) or Administrator of the home if they encounter problems requiring immediate action. For non-emergencies, residents should speak to the resident council or the Ombudsman. 1. Record review of the facility's Grievance Log showed the following: -On 9/27/22, a grievance was logged for a resident; -Staff did not log any grievances for October 2022, November 2022, or December 2022. 2. During an interview on 12/14/22, at 10:50 A.M., Resident #1 said the following: -On Monday (12/14/22) evening, Certified Nurse Aide (CNA) A yelled at him/her. Resident #2 was taking ornaments off the Christmas Tree and CNA A was not being very nice; -He/she was trying to get CNA A to do something about it and CNA A said if you don't like it you can leave; -He/she reported it to the Administrator yesterday. During an interview on 12/15/22, at 11:24 A.M., CNA A said the following: -On 12/12/22, Resident #1 became upset and started yelling at him/her because he/she was upset about Resident #2 taking ornaments off the Christmas tree and wanted CNA A to do something about it; -He/she is not sure who to direct residents to if they have a grievance. He/she is not aware of who the Grievance Officer is. He/she would probably direct the resident to his/her charge nurse. During an interview on 12/15/22, at 4:29 P.M., Licensed Practical Nurse (LPN) D said the following: -Earlier this week he/she overheard a disagreement between Resident #1 and CNA A. Resident #1 was upset and yelling and CNA raised her voice when speaking to him. LPN D intervened at that time by saying enough due to it sounding like CNA was frustrated and the situation escalating; -He/she did not report the incident because he/she did not feel it was abuse. During an interview on 12/14/22, at 12:15 P.M., the Administrator said the following: -Resident #1 came to him/her yesterday morning and said he/she was upset because he/she had decorated the Christmas tree and Resident #2 was taking the ornaments off the tree; -He told CNA A and did not feel like he/she handled the situation appropriately and did not stop the resident from taking the ornaments; -He/she has not investigated the incident further or started a grievance. 3. During an interview on 12/14/22, at 3:17 P.M., Resident #3 said the following: -He/she recently reported that a roll of five dollars' worth of dimes had gone missing; -He/she told Receptionist E about it and the Administrator overheard and said it had been reported; -He/she has not heard anything more about it since then. The facility did not replace the dimes or inform him/her of the outcome. During an interview on 12/15/22, at 1:02 P.M., Receptionist E said the following: -Resident #3 told him/her that she was missing a roll of dimes (five dollars); -He/she was not sure exactly when it was, but thought it was last week sometime; -The Administrator overheard them talking about it and said it had already been addressed so he/she didn't think she needed to do anything more. During an interview on 12/15/22, at 5:18 P.M., the Administrator said the following: -He/she overheard Resident #3 and Receptionist E talking about something going missing, but he/she thought they were referring to a previous allegation of misappropriation that had been addressed; -The Administrator was not aware of Resident #3's roll of dimes going missing. There was a miscommunication and it was not addressed, but it should have been. The resident should have been grievance/investigation should have been documented. 4. During an interview on 12/15/22, at 2:15 P.M., the SSD said the following: -The facility hasn't really had any grievances recently. He/she had been keeping a binder with concerns/complaints, but he/she was told by the previous Administrator to stop doing that; -He/she does not document any concerns/complaints/grievances if he/she is able to resolve them in 24 to 48 hours; -He/she is not sure what the policy says about addressing grievances; -He/she is not sure if the instructions for filing a grievance is posted for the residents; -During the admission process residents are informed they can file a grievance; -He/she is not sure who the Grievance Officer is; -He/she is not sure how a resident would file a grievance anonymously. The nurses station has forms, but the nurse would have to get it for the resident. 5. During an interview on 12/15/22, at 2:30 P.M., the Social Services Assistant (SSA) said the following: -He/she considers concerns that can't be resolved within 24 to 48 hours to be grievances. He/she has not been filling out a grievance form or putting concern/complaints on the grievance log if it is resolved within 24 hours; -He/she is not sure who the Grievance Officer was. 6. During an interview on 12/15/22, at 2:51 P.M., Certified Medication Tech (CMT) B said he/she would report resident grievances/complaints to his/her charge nurse. 7. During an interview on 12/15/22, at 2:56 P.M., LPN C said the following: -If resident's have a grievance there is a form they can fill out for them. The residents have to ask for the form; -He/she is not sure how to fill out the form; -He/she is not sure there is a way for them to file a grievance with the facility anonymously or instructions on how to file the grievance; -He/she is not sure there is a way -He/she would most likely report grievances to the Director of Nursing (DON). 8. During an interview on 12/15/22, at 5:18 P.M., the Administrator and DON said the following: -Grievances are concerns that the facility cannot solve within 24 hours and concern/complaint form should be completed. A complaint/concern form is not completed if is solved within 24 hours; -There are concern/complaint forms on each unit, but the resident would have to ask the nurse to get them; -The concern/complaint forms have gone by the way side and the staff need to be re-educated about them; -The Grievance Officer would be the SSD; -The facility does not have information about the Grievance Officer posted for the residents in the facility; -Concerns and complaints from residents should be addressed and documented. MO00210652

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff utilized proper infection control practices, to promote healing and prevent infection, during wound care for one resident (Resident #14) with a Stage 4 pressure ulcer (a full thickness tissue loss with exposed bone, tendon or muscle). The facility had a census of 60. Record review of the facility policy titled, Wound Care and Treatment, undated, showed the following: -It is the purpose of this facility to prevent and treat all wounds; -Clean technique is used. Care must be taken to prevent contamination of the supplies and surfaces used in wound care; -If the resident is soiled, wound care must not be done until he/she is cleaned; -There must be a specific order for the treatment; -Handwashing must be done as outlined in the guidance; -Cut the tape with clean scissors; -Put gloves on; -Remove the soiled dressing and place in the trash bag; -Remove the gloves and discard into the bag; -Clean scissors with 60 seconds of contact with alcohol; -Wash hands and put on gloves; -Clean the wound according to the orders; -Remove gloves and put on clean gloves; -Apply clean dressing as ordered; -Wash hands; -Universal precautions and strict and washing procedure for all wound care and/or patient contact.; 1. Record review of Resident #14's face sheet showed: -admitted to the facility on [DATE] and re-admitted from the hospital on 8/15/22; -Diagnoses included cervical (upper spine) spinal stenosis (narrowing of the spinal column), encounter for surgical aftercare following surgery on the nervous system (spine), and pressure ulcer of the right buttock (stage IV). Record review of the resident's 5-day Minimum Data Set (MDS - a federally mandated, comprehensive assessment tool completed by facility staff), dated 8/21/22, showed the following: -Cognitively intact; -Resident required extensive assistance of two or more staff with bed mobility, transfers, dressing, toileting, and required extensive assistance of one staff with personal hygiene; -Presence of indwelling urinary catheter (tube that drains urine from the bladder); -Totally incontinent of bowel; -Used wheelchair for mobility device; -Presence of stage IV (4) pressure ulcer; -Pressure reducing device to chair and bed; -Pressure ulcer care included application of dressings and medications or ointments. Record review of the resident's care plan, updated on 8/22/22, showed the following: -Resident admitted with a buttock stage IV sacral (the triangular-shaped bone at the base of the spine) pressure ulcer and is seen by a wound care specialist and treatment order are carried out by nurses daily; -Nurses and wound care specialist monitor of signs/symptoms of infection; -Dietary consult; -Reposition per turning schedule; -Treatment as ordered. Record review of the resident's wound care plus progress note, dated 9/6/22, showed the following: -Chronic stage 4 pressure ulcer to the right buttock; -Measurements were 5.9 centimeters (cm) in length by 5.2 cm in width by 3.0 cm in depth; -Undermining noted from 12:00 to 3:00 with a maximum distance of 2.3 cm; -There is a moderate amount of sero-sanguineous (blood and serum) drainage noted which has not odor; -The wound bed was 1-25 % slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture), 76-100 % granulation (pink-red moist tissue that fills an open wound, when it starts to heal); -No signs or symptoms of infection. Record review of the resident's September 2022 Physician Order Sheet (POS) showed the following; -An order, dated 9/8/22, for staff to cleanse wound to the resident's buttocks, pack pure and clean (a wound cleanser) soaked gauze into the wound, cover with an ABD (absorbent dressing), and secure with tape, change the dressing twice per day and as needed. During an interview on 9/8/22, at 4:00 P.M., Licensed Practical Nurse (LPN) E said the following: -The resident had a stage 4 pressure ulcer to his/her buttocks; -The wound care specialist sees the resident on a weekly basis; -The wound care specialist saw the resident earlier this week and downgraded his/her treatment from twice daily to once daily, but the night nurse last night reported the wound had a foul odor, so the wound care specialist increased the frequency of the treatment back to twice daily. Observation of on 9/8/22, at 4:00 P.M., showed: -LPN E entered the resident's room with wound care supplies to perform wound care to the resident's pressure ulcer; -LPN E washed his/her hands and donned gloves; -Certified Nurse Assistant (CNA) L knocked and entered the resident's room to assist and donned gloves without washing or sanitizing his/her hands; -The nurse informed the resident of the need to change his/her wound dressing; -Staff assisted the resident to turn to his/her left side on the bed and the nurse removed the resident's incontinent soiled brief; -The resident had visible feces on the brief and on his/her buttocks and feces on the edge of the wound dressing; -Using disposable wipes, the nurse wiped the resident's skin; -In the midst of cleaning feces from the resident's skin, the nurse removed the resident's pressure ulcer wound dressing and saturated wound packing which was yellow in color, exposing a large (softball sized) open wound to the resident's upper buttocks/coccyx area. The full thickness pressure ulcer appeared to have exposed bone/ligament type structures at the base of the wound with red and yellow tissue visible. -The nurse did not wipe in the direction of the open wound, but continued to clean feces from the resident's rectal area and buttocks; -The nurse then removed his/her gloves and looked in his/her pockets for hand sanitizer, but said he/she could not find any; -The nurse then applied new gloves (without washing or sanitizing his/her hands) picked up gauze that he/she had pre-moistened with pure and cleanse and inserted his/her gloved hands into the resident's open pressure ulcer, touching the wound with his/her gloved hand and wiped the surface of the pressure ulcer with the moistened gauze; -The nurse then changed his/her gloves again (without washing or sanitizing his/her hands) and again wiped the inside of the wound with pure and cleanse moistened gauze; -The nurse then changed his/her gloves (without washing or sanitizing his/her hands) then reached into his/her pocket and removed a set of keys, looking down in his/her front pocket, the nurse said, I had sanitizer in my pocket, but it fell out. -The nurse then removed bandage scissors from his/her pocket and again changed his/her gloves (without washing or sanitizing his/her hands); -The nurse sprayed the peri-wound with sure prep rapid dry spray and packed moistened gauze into the wound bed, the nurse cut the wound with the bandage scissors (without cleaning the scissors after pulling them from his/her pocket). The nurse's gloved hands/fingers again touched the wound bed; -The nurse changed his/her gloves (without washing or sanitizing his/her hands) and covered the wound with an ABD pad (absorbent dressing); -The nurse then asked CNA L to hold the ABD pad in place over the resident's wound, which the aide did and the nurse then placed tape over the ABD to secure. During an interview on 9/13/22, at 11:16 A.M., LPN E said the following: -When performing wound care treatment, the nurse should wash his/her hands and apply clean gloves, remove the soiled bandage, and remove the gloves and sanitize hands. The nurse should then put new gloves on, clean the wound, then remove the gloves and sanitize hands. The nurse should then put new gloves on and apply clean treatment/dressing; -If a resident was soiled, staff should clean the feces off the resident's skin before performing the wound care, and then remove the gloves and sanitize hands. The nurse should then apply clean gloves and begin the wound care; -On 9/8/22, during the treatment observation, he/she did not have hand sanitizer in the resident room and that is why he/she did not sanitize his/her hands during the treatment. During an interview on 9/13/22, at 12:17 P.M., the Administrator and Director of Nursing (DON) said the following: -They expected nurses to wash or sanitize their hands during wound care when going from dirty to clean and after incontinent care.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #24) had a complete order for a catheter (a sterile tube inserted into the bladder to drain urine) with the size of catheter/balloon bulb included. The facility census was 60. Record review showed the facility did not provide a policy regarding catheter orders. Record review of the facility's Charting and Documentation Policy, undated, showed the following for catheter care documentation should include: -Type of procedure performed and who performed it; -Date and time the procedure was performed; -Type of and size of catheter used. 1. Record review of Resident #24's face sheet (admission data) showed the following: -admission date of 3/21/21 with a latest return of 2/25/22; -Diagnoses included chronic kidney disease (kidneys are damaged and cannot filter blood the way they should), and type two diabetes mellitus (condition that occurs when the body cannot use glucose (type of sugar) normally) with diabetic nephropathy (kidney disease) and neuromuscular dysfunction of bladder (lacks bladder control due to brain, spinal cord or nerve problems). Record review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 6/27/22, and showed the following: -Indwelling catheter. Record review of the resident's care plan, revised on 6/28/22, showed the following: -The resident has an indwelling Foley catheter due to urinary retention and seeing urologist for ureteral stents; -Catheter will be taken care of by nurses and physician will decide when and if it can come out; -Change catheter (frequency per orders); -Foley catheter care every shift and when needed. Record review of the resident's August 2022 and September 2022 Physician's Order Sheet (POS), Medication Administration Record (MAR), and Treatment Administration Record (TAR) showed the following: -Foley catheter care every shift; -Change Foley catheter monthly, on the 24th of the month. During an interview on 9/13/22, at 10:37 A.M., Certified Nursing Assistant (CNA) D said the following: -Nurses let the CNAs know if they have a resident with a catheter; -Nurses change the catheters; -CNAs do care every shift and makes sure it is clean; -Nurses will tell the CNAs the size of the catheter if the CNAs get the new catheter out of the supply room. During an interview on 9/13/22, at 10:45 A.M., Licensed Practical Nurse (LPN) E said the following: -The physician orders will have catheter size (including balloon size), care, and how often to change the catheter; -To setup orders for the catheter, the facility will talk to doctor is get the size of the Foley catheter, how often to change the catheter, and how often to care for the catheter; -Staff will follow the physician orders; -The resident's PO's should state the size and care; -The resident's PO's showed to change catheter on 24th of each month and check it at least once a shift. There was no order for the catheter, including size. The facility should be getting that information from the doctor. During an interview on 09/13/22, at 11:10 A.M., the Assistant Director of Nursing (ADON) said the following: -Catheter care includes orders for changing the catheter, usually monthly; -Catheter care is done per shift or when visibly soiled; -The catheter care orders should have the catheter size; -The resident's medical record did not have orders for the catheter that included appropriate size. During an interview on 09/13/22, at 12:18 P.M., the Director of Nursing (DON) said the following -The facility should get a catheter order from urologist or the medical director: -The PO's should show catheter care, when to change the catheter, and size of catheter; -There was no order for size or balloon bulb order; -There should be an order with the size of catheter and balloon bulb. During an interview on 09/13/22, at 5:03 P.M., the Administrator said the following: -The Administrator would expect orders to have daily care for a catheter, size of the catheter, and when to change the catheter; -The resident came to the facility from hospital with a Foley catheter and staff should have gotten an order with the correct size with a balloon; -The size should be on the POs or the TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's choice of code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was clearly and consistently documented throughout the resident's medical record for three residents (Resident #8, Resident #47 and Resident #104). The facility census was 60. Record review of the facility's policy titled Do Not Resuscitate (DNR- do not attempt cardiopulmonary resuscitation (CPR-an emergency procedure that is performed when a person's heartbeat or breathing has stopped)) Guidelines, undated, showed the following: -The facility recognizes the right of any competent resident or person responsible for making health care decisions for the resident to request the cardiopulmonary resuscitation (CPR) be withheld in the event of cardiac or respiratory arrest; -Upon admission, the social services designee will provide information on CPR to the resident and/or resident's legal representative and will review the Outside of the Hospital Do-Not Resuscitate (OHDNR) order form. The OHDNR can only be signed by the resident or legal representative; -After review of the OHDNR form, the resident or legal representative will make their decision known by signing the form; -It will be explained to the resident or legal representative that at any time the resident or legal representative may revoke the OHDNR order; -Once the OHDNR form has been signed it will be placed in the medical record under the advanced directive tab (in the computer system); -The resident's face sheet, door dot, care plan, physician orders, and 'computer banner' shall be up to date with the current status. Record review of the OHDNR form showed the following: -Area for patient's name and patient's signature or patient representative's signature; -Area for attending physician's signature with date, physician' license number, telephone number physician printed or typed name and address, and facility or agency name. 1. Record review of Resident #8's face sheet (admission data) showed the following: -admission date of [DATE] and readmission date of [DATE]; -Code status of DNR. Record review of the resident's OHDNR form showed the following: -The resident signed the form on [DATE]; -The physician signed the form on [DATE]. Record review of the resident's care plan, revised [DATE], showed a code status of DNR. Record review of the resident's current physician's order sheet (POS) showed the resident's code status, dated [DATE], of full code (wishing to receive CPR). During an observation on [DATE], at 2:00 P.M. of the resident's door showed the resident had a green dot (full code) on his/her door name plate During an observation and interview on [DATE], at 10:33 A.M., Certified Nurse Aide (CNA) A opened the resident's electronic medical record (EMR) which showed the resident's code status of DNR. During an interview and record review on [DATE], at 12:46 P.M., Licensed Practical Nurse (LPN) B said the following: -The resident's physician orders on the computer, dated [DATE], showed a full code status; -The resident and physician signed the uploaded DNR form in the computer on [DATE]; -The resident had a green folder (located in the nurses' station) which showed a face sheet, dated [DATE], with a full code status at the top of the sheet; -The resident's code status is not up to date and should be consistent in the medical record. During an interview on [DATE], at 1:15 P.M., the Minimum Data Set (MDS)/Care Plan Coordinator said the resident was admitted to hospice. The resident's POS showed a code status of full code and the care plan showed a code status of DNR. During an interview on [DATE], at 1:21 P.M., the Director of Nursing (DON) said the following: -The resident's code status in the resident's EMR showed DNR code status; -The resident's physician's order, dated [DATE], showed a full code status; -The DNR form uploaded in the computer dated [DATE] is signed by the physician and resident; -The resident's code status should be clear and consistent throughout the medical record. 2. Record review of Resident #47's face sheet showed the following: -admission date of [DATE] and readmission date of [DATE]. Record review of the resident's OHDNR form showed the following: -The resident signed the form on [DATE]; -The resident's physician signed the form on [DATE]. Record review of the resident's care plan, revised [DATE], showed code status of a full code. Record review of the resident's current POS, dated [DATE], showed the resident code status as a DNR. During an observation on [DATE] at 2:00 P.M. of the resident's door showed the resident had a red dot (indicated DNR) on his/her door name plate. During an interview on [DATE], at 10:33 A.M., CNA A said the resident's EMR showed the resident's code status of DNR. During an observation and interview on [DATE], at 12:46 P.M., LPN B said the following: -The EMR showed a code status of DNR; -The POS, dated [DATE], showed a code status of DNR; -The resident's red folder showed a DNR form dated [DATE] that was signed by the resident and physician; -The face sheet (printed [DATE]) in the resident's red folder showed a full code status. During an interview on [DATE], at 1:15 P.M., the MDS/Care Plan Coordinator said the following: -The EMR showed the resident's code status of DNR; -The resident's care plan showed a code status of full code; -The resident's code status should be consistent throughout the medical record. During an interview on [DATE], at 1:21 P.M., the DON said the following: -The resident's EMR showed code status of DNR; -The resident's POS, dated [DATE], showed a code status of DNR; -The resident's care plan showed a code status of full code; -The resident's DNR form was signed by the resident [DATE] and the physician signed the order on [DATE]; -The physician may not have signed the DNR form until the resident was readmitted on [DATE] from the hospital. 3. Record review of Resident #104's face sheet showed the following: -admission date of [DATE]; -Code status of DNR. Record review of the resident's OHDNR form showed the following: -The resident signed the form on [DATE]; -The resident's physician signed the form on [DATE]. Record review of the resident's care plan, dated [DATE], showed code status of full code. Record review on [DATE], at 9:10 A.M., of the resident's POS, dated [DATE], showed the resident's code status as a full code. Record review on [DATE], at 3:52 P.M., showed the DNR form, dated [DATE], in a red folder inside of the nurses station. During an observation on [DATE], at 2:00 P.M., of the resident's door showed the resident had no name or dot on his/her nametag to indicated code status. During an interview on [DATE], at 10:33 A.M., CNA A said the resident's code status showed full code in the resident's EMR. During an interview on [DATE], at 12:46 P.M., LPN B said the following: -The resident's EMR showed a code status of full code; -The POS showed an order, dated [DATE], of full code status; -The DNR uploaded in the computer showed the DNR form signed on [DATE]; -The red folder has the DNR form; -Staff did not update the resident's code status in the EMR. During an interview on [DATE], at 1:15 P.M., the MDS/Care Plan Coordinator said the following: -The resident's EMR showed a code status of full code; -The resident's care plan showed a code status of full code; -The DNR form is uploaded in the computer with the resident signature on [DATE] and physician signature on [DATE]; -Staff must have missed the resident's change of code status and medical records have been piled up. During an interview on [DATE], at 1:21 P.M., the DON said the following: -The resident's EMR showed code status of full code; -The DNR signed form was uploaded in the computer; -The POS showed a code status of full code dated [DATE]. 4. During an interview on [DATE], at 10:33 A.M., CNA A said the following: -CNA's find the code status in the activities of daily living (ADL's) on the computer; -Staff also find the code status on the care plans located in the nurses' station; -He/she would get the nurse if he/she finds a resident unresponsive. 5. During an interview on [DATE], at 11:21 A.M., Certified Medication Technician (CMT) C said the following: -Staff find a resident's code status in the chart; -Staff click on the resident's name in the computer to find a resident's code status; -Staff alert the charge nurse if a resident is found unresponsive and look for the resident's code status; -The green color is for full code and red color is for DNR; -Full code means not breathing and to start CPR; -DNR means do not resuscitate; -The code status should be on the resident's care plan. 6. During an interview on [DATE], at 11:34 A.M., CNA D said the following: -Staff find a resident's code status on every resident's door; -The resident's door tag has their name and a red or green sticker; -The red sticker is DNR and the green sticker is full code; -The nurses' station has folders which have the resident room numbers and are color coded, red for DNR and green for full code; -Staff should inform the charge nurse of any updates to a resident's care plan; -The resident's code status should be consistent throughout the medical record. 7. During an interview on [DATE], at 12:46 P.M., LPN B said the following: -Staff find a resident's code status with the dot system on the resident's names on the doors. The red dot means DNR and the green dot means full code; -DNR means do not resuscitate and full code means to start CPR; -Staff find the resident's code status in the chart; -The CNA's find the code status on the computer at a kiosk; -Staff check a resident for a heart beat if found unresponsive; -Staff check a resident's code status on the computer (the chart) if no heartbeat; -He/she thinks the social service staff review a resident's code status upon admission with the resident and family; -Medical record staff upload the DNR form into the computer; -He/she did not know what staff upload the information in the computer if there is a change in code status; -There is a cubby system in the nurses station with green folders which mean full code and the red folders mean DNR; -The green folder has the emergency transfer form and face sheet with full code on the face sheet; -The red folder should have the OHDNR form and the face sheet should have DNR on it; -The code status should be consistent throughout the medical record. 8. During an interview on [DATE], at 1:15 P.M., the MDS/Care Plan Coordinator said the following: -She finds the resident's code status in the EMR when she completes the five day and admission entries; -Staff discuss updates to resident care plans in the morning meetings; -Nurses enter the code status in the computer; -A resident's code status should be consistent throughout the medical record. 9. During an interview on [DATE], at 1:21 P.M., the DON said the following: -Staff find a resident's code status in the computer system; -Nurses enter a resident's name in the computer and find the resident's current code status under the resident's name; -Social service staff assist the nursing staff to get the resident's code status paperwork signed; -There are folders at the nurses' station. The red folder for DNR and a green folder for full code; -The computer is the most updated code status for a resident; -Staff should grab the resident's folder in the cubby inside of the nurses' station if they send a resident to the hospital; -Medical record staff upload the DNR forms into the computer; -Staff should document in the progress notes and inform nursing staff a resident has a change in code status; -Staff find a resident's code status on the resident's name plate on their doors with red or green stickers; -Administration staff review resident's progress notes every morning. Staff report any updates or changes to staff; -Care plans should have resident's updated code status; -A resident's code status should be clear and consistent throughout medical record. 10. During an interview on [DATE], at 1:38 P.M., the Administrator said a resident's code status should be consistent throughout medical record. 11. During an interview on [DATE], at 3:23 P.M., the Medical Record Staff said the following: -The hospital sends a resident's code status upon admission; -Social service staff explain the code status upon admission to the resident or representative; -Social service staff get the signed DNR form to the physician to sign; -Social Service staff scan the signed DNR form and gives him/her a copy of the DNR form; -He/she uploads the signed DNR form into the advance directive section in the computer; -He/she places a signed DNR form to the folder in the nurses' station. [NAME] folder means full code and the red folder means DNR; -The MDS/Care Plan Coordinator reviews physician orders and uploaded documents and has a 14 day window to develop a resident's care plan; -Social service staff get the appropriate forms signed if a change in code status, gives to the physician and scans the documents in the computer and gives him/her a copy; -The business office manager sets up the chart in the electronic health record and enters the resident's name, race, address and code status; -The resident's code status should be consistent throughout the medical record. 12. During an interview on [DATE], at 3:33 P.M., the Social Service Designee said the following: -She reviews code status with the resident or representative upon admission; -She faxes the physician the DNR form once the resident or representative signs it. She makes a copy of the completed DNR form for medical record staff and gives one to the nursing staff; -The DNR form should be in the red folder in the cubby located in the nurses's station; -The green folder in the cubby located in the nurses' station means full code; -Medical record staff upload the DNR form into the computer; -Medical record staff and/or the DON place the dots on the resident's door; -Medical record staff give the code status to the Care Plan Coordinator who updates the care plan. 13. During an interview on [DATE], at 10:49 A.M., the Business Office Manager said she did not do anything with the code status. The nursing staff enters the resident's code status in the computer. 14. During an interview on [DATE], at 11:01 A.M., the Social Service Director said the following: -Social service staff complete the code status with the resident/representative upon admission; -Social services fax the DNR form to the physician to sign, scans the signed form to medical record staff, make a purple copy and white copy and gives to medical record staff to file.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document identification and use of possible alternatives prior to use of side rails; failed to document assessing risk versus benefits of side rail use; failed to obtain informed consent for the use of side rails prior to installation; failed to obtain physician's orders for side rail use; and failed to include the side rail on the care plan for three residents (Resident #7, Resident #43, and Resident #50). Staff failed to complete ongoing assessments to ensure the side rails are appropriate for use, failed to include the side rail on the care plan for four residents, and failed to obtain physician's orders for the use of side rails for one resident (Resident #12). The facility's census was 60. Record review of the facility's policy titled Side Rail Protocol, undated, showed the following: -Before placing a side rail read the following process to ensure the appropriateness and safety for the resident; -Physician/Director of Nursing (DON)/therapy department make side rail requests for side rails to be placed on a specific resident bed; -Since the side rail that is typically used for positioning, make sure to ask if the side being placed is left, right or both; -Begin the side rail assessment in electronic medical record (EMR) and discuss the risks/benefits with the resident (if responsible party) or family/friend (responsible party) and receive consent; -If a family/friend is the responsible party then you may take a verbal consent over the phone, but the verbal must be noted within the additional information section of the observation; -Request for the maintenance director to place the side rail on the bed and maintenance will then measure to ensure the safety of the rail. As long as the measurements pass the safety requirements the side rail will stay in place. If the side rail do not pass (fail) the safety requirements then maintenance will remove the side rail; -Maintenance director will not place a side rail without consent being in place; -If the measurements fail then the nurse will need to notify the resident/family that the side rail cannot remain due to the measurements not meeting the safety requirements; -Once the observation is completed, the observation should be printed and the resident/family will sign the consent line; -Please give completed signature form to medical records to be uploaded into resident's EMR; -A final nursing progress note summarizing the side rail observation, measurement and consent was completed upon placing the left, right or both side rail. 1. Record review of Resident #7's face sheet (admission data) showed the following: -admission date of 9/14/21; -Diagnoses include chronic atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria (the two upper chambers of the heart) fire rapidly at the same time), hypertension (HTN-high blood pressure) and edema (swelling caused by excess fluid in body tissues). Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/25/22, showed the following information: -Severely impaired cognition; -Extensive assistance required with bed mobility, transfer, dressing and toilet use Record review of the resident's care plan, revised on 9/12/22, showed the following: -Required total care for dressing, bathing, toileting, hygiene, transfers and mobility. (Staff did not care plan the use of an enabler or side rail.) Record review of the resident's September 2022 Physician's Order Sheet (POS) showed no order for bed rail or a 'U' shaped bar. Observation on 9/13/22, at 10:23 A.M., showed an enabler ('U' shaped 'bar') attached to the left side of the bed up by the head of the bed. During an interview on 9/13/22, at 10:26 A.M., CNA D said the resident uses the enabler on his/her bed. The resident holds the rail when staff roll him/her in bed for assistance with care. The resident has days when more confused. During an interview on 9/13/22, at 11:15 A.M., the Director of Nursing (DON) said the resident uses the enabler. The resident is confused and tries to get out of his/her bed at times. During an interview on 9/13/22, at 2:17 P.M., the Care Plan Coordinator said the resident's side rail is not on his/her care plan. Record review of the resident's current medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, obtaining informed consent for the use of side rails prior to installation, measurements, or ongoing assessments to ensure the side rails were appropriate for use. 2. Record review of the Resident #12's face sheet showed the following: -admitted on [DATE], readmission on [DATE]; -Diagnoses included HTN, chronic kidney disease stage 3, and paroxysmal (sudden episode) atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). Record review of the resident's side rail assessment and consent, dated 6/2/21, showed the following: -The resident used side rails for positioning or support; -The resident expressed a desire to have side rails raised in his/her bed for safety and/or comfort; -The resident has a quarter rail used to assist in positioning and transfers; -Assessment of potential entrapment zones completed on 5/5/21; -Risks and benefits explained to resident/family on 6/2/21. Record review of the resident's care plan, revised on 6/12/22, showed the following: -The resident is at risk for falls due to his/her limited mobility, weakness, pain and use of assistive devices; (Staff did not care plan the use of an enabler or side rail.) Record review of the resident's September 2022 POS showed no order for use of a bed rail. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderately impaired cognitive skills; -Independent with bed mobility and dressing; -Limited assistance required with transfer and toilet use. Observations on 9/8/22, at 10:54 A.M., and on 9/12/22, at 3:28 P.M., showed the resident's bed had a quarter size rail in the up position on the left side of the bed. During an interview on 9/13/22, at 11:15 A.M., the DON said the resident requested the quarter size side rail. During an interview on 9/13/22 at 2:17 P.M., the Care Plan Coordinator said the resident's side rail is not on his/her care plan. Record review of the resident's current medical record showed staff did not document ongoing assessments to ensure the side rails were appropriate for use. 3. Record review of Resident #43's face sheet showed the following: -admitted on [DATE] with readmission on [DATE]; -Diagnoses included unspecified dementia without behavioral disturbance, repeated falls, heart failure, and HTN. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderately impaired cognitive skills; -Extensive assistance required with bed mobility, transfer and dressing. Record review of the resident's care plan, revised on 8/2/22, showed the following: -The resident is at risk for falls due to generalized weakness and balance problems. (Staff did not care plan the use of an enabler or side rail.) Record review of the resident's September 2022 POS showed no order for an enabler/side rail. Observation on 9/8/22, at 9:57 A.M., showed the resident on his/her bed with the head of the bed elevated with the inverted U-shaped bars on each side of his/her bed. These bars extended up from the bed frame to a height of approximately one foot above mattress level and were located approximately 1/3 of the way down from the head of the bed and were approximately 6 inches wide. During an interview on 9/13/22, at 11:15 A.M., the DON said the resident is alert and follows directions. The resident holds the rail when staff assist with care and rolling in bed. During an interview on 9/13/22, at 2:17 P.M., the Care Plan Coordinator said resident's enabler is not on his/her care plan. Record review of the resident's current medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, obtaining informed consent for the use of side rails prior to installation, measurements or ongoing assessments to ensure the side rails were appropriate for use. 4. Record review of Resident #50's face sheet showed the following: -admission on [DATE]; -Diagnoses include Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Alzheimer's disease, and HTN. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Moderately impaired cognitive skills; -Extensive assistance required with bed mobility, transfer, and dressing. Record review of the resident's care plan, dated 8/11/22, showed the following: -The resident is at risk for falls due to his/her cognitive deficits, need for assistance for bed mobility and for transfers; -Staff should observe the resident for behaviors and lack of safety awareness that would place him/her at increased risk for falls. (Staff did not care plan the use of an enabler or side rail.) Record review of the resident's September POS showed no order for an enabler/side rail. Observation on 9/12/22, at 3:38 P.M., showed the resident rested quietly on his/her low bed with inverted U-shaped bars on each side of his/her bed. These bars extended up from the bed frame to a height of approximately one foot above mattress level and were located approximately 1/3 of the way down from the head of the bed and were approximately 6 inches wide. During an interview on 9/13/22, at 11:15 A.M., the DON said the resident is very confused and uses the enabler to reposition. The resident tries to get out of his/her bed and has had falls. During an interview on 9/13/22, at 2:17 P.M., the Care Plan Coordinator said the resident's enabler is not on his/her care plan. Record review of the resident's current medical record showed staff did not document identification and use of possible alternatives prior to use of side rails, assessing risk versus benefits of side rail use, obtaining informed consent for the use of side rails prior to installation, measurements or ongoing assessments to ensure the side rails were appropriate for use. 5. During an interview on 9/13/22, at 10:26 A.M., Certified Nurse Aide (CNA) D said the following: -All the residents have the 'U' shaped bars on their beds; -Staff request therapy staff for an evaluation if a resident needs a side rail; -Maintenance staff installs the rails on the resident's bed. 6. During an interview on 9/13/22, at 10:33 A.M., Certified Medication Technician (CMT) F said the following: -Maintenance staff installs the bed rails; -Nurses and therapy staff complete the side rail assessment. 7. During an interview on 9/13/22, at 10:39 A.M., Licensed Practical Nurse (LPN) E said the following: -Staff look at the computer or on the care plan to see if a resident has a side rail, enabler, or grab bar; -The Care Plan Coordinator updates the care plans. Staff inform the DON of any updates to care plans; -The DON or nurses complete the side rail assessments; -He/she did not not of measurements for the side rails; -He/she did not know if reassessments or reevaluations were completed after the first assessment of a side rail; -He/she did not know if staff get a physician order for a side rail. 8. During an interview on 9/13/22, at 11:07 A.M., the Maintenance Supervisor said the following: -Nurses inform him if a resident needs a bar or side rail on a bed; -He contacts the manufacturer and orders the rails; -He installs the bed rails; -He informs the manufacturer of the model of bed. There are two different styles of beds in the facility; -The manufacturer has the appropriate rail or grab bar of exact fit and does the measurements when sends the rail to the facility; -He did not know of measurements or zones to inspect for bed rails on the beds; -He checks one or two rooms every month and checks the rails to see if tight; -Nursing documents in the maintenance log book at the nursing station if any rails are loose. 9. During an interview on 9/13/22, at 11:15 A.M., the DON said the following: -Enabler bars are to help a resident roll or position in bed; -The enablers are the 'U' shaped bars; -Maintenance staff install the enabler bars; -Facility protocol did not require any observations to measure the enabler; -The enabler bars are smaller than the quarter size side rail and not in the EMR system for documentation. The EMR just has observations for quarter size, half size and full rails. The nurse completes the assessments that 'pops' up once a year; -The facility staff did not complete any assessments, observations or measuring for gaps or zones for the enabler bars. 10. During an interview on 9/13/22, at 11:55 A.M., Director of Rehabilitation said the following: -The therapy staff did not complete assessments for side rails or enablers; -Therapy staff make suggestions for a side rail if a residents needs one for turning or bed mobility and inform maintenance staff. 11. During an interview on 9/13/22, at 1:50 P.M., the Administrator said the following: -Maintenance staff install the 'U' shaped rail on the beds; -The facility did not consider the enabler ('U shaped bar) a side rail; -The facility did not conduct measurements on the enablers; -The enabler bars are for residents to hold self over for incontinent, care and changing the bed; -Side rails are the quarter size, half size and full size rails; -There is no written assessment for an enabler bar and is based on if the resident is able to assist in positioning; -The enabler or side rail should be on the resident's care plan. 12. During an interview on 9/13/22 at 2:17 P.M., the care plan coordinator said the following: -She is not involved in the process of residents getting side rails or enablers; -She did not know if the enabler is suppose to be on the care plan.

Based on interview and record review, the facility failed to ensure all controlled drugs were reconciled periodically per standards of practice when off going and on coming nurses/certified medication technicians (CMTs) failed to count narcotics/controlled medications and failed to sign the controlled substance shift change record during shift change for two of two medication carts, two of two nurse treatment carts, and one of two refrigerator lock boxes located in the facility. The facility census was 60. Record review of the facility policy titled, Narcotic Count, undated, showed the following: -Purpose is to complete a physical inventory of narcotics at each shift change to identify discrepancies; -One registered nurse (RN), licensed practical nurse (LPN), or certified medication technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift.; -Narcotic records are reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse. Records are to be retained for at least one year. Emergency kits containing narcotics will be checked at the same time to be sure seal has not been broken or will be reconciled if seal is broken; -After the supply is counted and justified, the nurse/CMT records the date and his/her signature, verifying that the count is correct; -The nurse going off duty surrenders the narcotic key to the nurse coming on duty after the narcotic count is reconciled. 1. Record review of the facility's September 2022 Controlled Substance Shift Change Record for the Dogwood Unit medication cart locked narcotic drawer showed the following: -On 9/1/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/1/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/7/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/7/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/8/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/11/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count. Record review of the facility's September 2022 Controlled Substance Shift Change Record 2022, for the Dogwood Unit nurse treatment cart locked narcotic drawer showed: -On 9/1/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count;; -On 9/7/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/8/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/11/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count. Record review of the facility's September 2022 Controlled Substance Shift Change Record for the Dogwood Unit medication refrigerator locked narcotic box showed: -On 9/1/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/5/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/7/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/7/22, at 6:00 P.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/8/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/11/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count. Record review of the facility's September 2022 Controlled Substance Shift Change Record for the [NAME] Unit medication cart locked narcotic drawer showed: -On 9/1/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 A.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/11/22. at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count. Record review of the facility's September 2022 Controlled Substance Shift Change Record for the [NAME] Unit nurse treatment cart locked narcotic drawer showed: -On 9/1/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/1/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/2/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/3/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/4/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/5/22, at 6:00 A.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/5/22, at 6:00 P.M., the off going and oncoming nurse/CMT failed to initial the narcotic count; -On 9/6/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/8/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count; -On 9/9/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/10/22, at 6:00 P.M., the oncoming nurse/CMT failed to initial the narcotic count; -On 9/11/22, at 6:00 A.M., the off going nurse/CMT failed to initial the narcotic count. During an interview on 9/13/22, at 10:01 A.M., Licensed Practical Nurse (LPN) J said the following: -At the beginning of each day shift, the off going night nurse handed the narcotic keys to LPN J, but did not count the narcotics with LPN J; -At the end of each day shift, LPN J handed the narcotic keys to the oncoming night nurse, but LPN J did not count narcotics with the night nurse. During an interview on 9/13/22, at 10:55 A.M., the Director of Nursing said the following: -She expected the off going and oncoming nurse or CMT to count all narcotics at the change of shift and sign/initial the narcotic count records; -The night shift nurse/CMT should count the medication cart narcotics with the day shift CMT/nurse; -The night shift nurse should count the nurse cart narcotics and the refrigerated narcotics with the day shift nurse; -Two staff should be present during the narcotic count and both should sign the narcotic shift change record each shift. During an interview on 9/13/22, at 11:28 A.M., CMT F said the following: -He/she noticed gaps in the signatures on the narcotic book/record; -Occasionally, some of the nurses forgot to sign, but he/she always counted the narcotics at the beginning and end of his/her shift with a nurse or CMT. During an interview on 9/13/22, at 11:44 A.M., CMT K said the following: -Some of the night shift nurses failed to sign the narcotic record at shift change; -He/she always counted narcotics and signed the narcotic shift change record at the beginning and end of each shift. During an interview on 9/13/22, at 12:17 P.M., the Administrator said the following: -He/she expected the off going nurse/CMT and the oncoming nurse/CMT to count narcotics and sign the narcotic count record each time the narcotic keys changed hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate below five percent when staff made three errors out of 27 opportunities, resulting in an error rate of 11.11 percent, affecting three residents (Resident #6, #24, and #37). The facility census was 60. Record review of the facility provided information titled, Insulin By Kwikpen (or similar pen type device) showed the following: -Staff need to prime the pen before each use to assure the unit accuracy. Turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue to hold the pen with the needle pointed up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose in and count to five slowly. Staff should see insulin at the tip of the needle, if not re-prime. Record review of the Novolog FlexPen (a fast-acting insulin) manufacturer's guidance, dated 3/2021, showed the following: -Before each injection small amounts of air may collect in the cartridge during normal use; -To avoid injecting air and to ensure proper dosing, -Prime (referred to as an air shot) the flex pen before each injection; -Turn the dose selector to select two units; -Hold the flex pen with the needle pointing up. Tap the cartridge gently to make any air bubbles collect at the top of the cartridge -Keep the needle pointing upward, and press the push button all the way in. The dose selector returns all the way to 0; -Make sure a drop appears; -If a drop of insulin does not appear, change the needle and repeat the procedure, no more than six times. Record review of the Humalog (name brand of lispro-a fast acting insulin) FlexPen (device used to administer the insulin) manufacturer's insert, dated November 2019, showed the following information: -Humalog insulin should be administered 15 minutes before a meal or immediately after a meal; -Hypoglycemia (low blood sugar) is the most common adverse reaction to insulin therapy and may be life-threatening. Symptoms may be different for each person and may change from time to time. Severe hypoglycemia can cause seizures and may be life threatening or cause death. -Prime the pen before each injection: Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly; If you do not prime before each injection, you may give too much or too little insulin; -To prime the pen, turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top, continue holding the pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly; -You should see insulin at the tip of the needle; -If you do not see insulin, repeat priming steps six to eight, no more than four times; -If you still do not see insulin, change the needle and repeat priming steps six to eight; -Small air bubbles will not affect the dose; -Turn the dose knob to select the number of units you need to inject. The dose indicator should line up with the dose. 1. Record review of Resident #6's face sheet showed an admission date of 10/4/16. Record review of the resident's September 2022 physician orders (POS) and medication administration record (MAR) showed the following: -Diagnosis of Type 2 diabetes mellitus (a chronic condition that affects how a person processes blood sugar) with hyperglycemia (high blood sugar); -An order, dated 8/22/20, for Novolog R Flexpen insulin, administer subcutaneously (SQ - to inject between the skin and the muscle) per sliding scale before meals and at bedtime, as follows: -Blood sugar level of less than 70 milligrams/deciliter (mg/dL), call physician; -Blood sugar level of 70 mg/dL to 130 mg/dL, administer 0 units of insulin; -Blood sugar level of 131 mg/dL to 180 mg/dL, administer 2 units of insulin; -Blood sugar level of 181 mg/dL to 240 mg/dL, administer 4 units of insulin; -Blood sugar level of 241 mg/dL to 300 mg/dL, administer 6 units of insulin; -Blood sugar level of 301 mg/dL to 350 mg/dL, administer 8 units of insulin; -Blood sugar level of 351 mg/dL to 400 mg/dL, administer 10 units of insulin; -Blood sugar level of greater than 400 mg/dL, administer 12 units of insulin and notify the physician. Observation on 9/09/22, at 11:05 A.M., of Licensed Practical Nurse (LPN) I showed the following: -The nurse entered the resident's room and performed a blood glucose test via finger stick (Accucheck) with a result of 159 mg/dL; -The nurse then reviewed the resident's order on the medication administration record for Novolog insulin showing to administer two units per sliding scale for blood sugar level between 131 mg/dL and 180 mg/dL; -The nurse removed the cap from the resident's Novolog Flexpen, cleansed the rubber stopper with alcohol, inserted a disposable needle, and dialed to two units; -The nurse then entered the resident's room cleansed the resident's right upper arm with an alcohol wipe and administered the two units of insulin via the Novolog Flexpen. (The nurse did not prime the insulin pen prior to the SQ administration.) 2. Record review of Resident #37's face sheet the resident admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the resident's September 2022 POS and MAR showed the following: -Diagnosis of Type 2 diabetes mellitus; -An order, dated 2/10/21, for Humalog Kwikpen, administer SQ per sliding scale before meals and at bedtime, as follows: -Blood sugar level of less than 60 milligrams/deciliter (mg/dL), call the physician; -Blood sugar level of 150 mg/dL to 200 mg/dL, administer 3 units of insulin; -Blood sugar level of 201 mg/dL to 250 mg/dL, administer 6 units of insulin; -Blood sugar level of 251 mg/dL to 300 mg/dL, administer 9 units of insulin; -Blood sugar level of 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -Blood sugar level of 351 mg/dL to 400 mg/dL, administer 15 units of insulin; -Blood sugar level of greater than 400 mg/dL, administer 18 units of insulin; -If the blood sugar is greater than 401 mg/dl, notify the physician. Observation on 9/09/22, at 11:16 A.M., of LPN I showed the following: -The nurse entered the resident's room and performed a blood glucose test via finger stick (Accucheck), with a result of 183 mg/dL; -The nurse then reviewed the resident's order on the medication administration record for Novolog insulin showing to administer three units per sliding scale for blood sugar level between 150 mg/dL and 200 mg/dL; -The nurse removed the cap from the resident's insulin lispro (generic for Humalog Kwikpen), cleansed the rubber stopper with alcohol, inserted a disposable needle, and dialed to three units; -The nurse then entered the resident's room cleansed the resident's left upper arm with an alcohol wipe and administered the three units of insulin via the Insulin lispro pen. (The nurse did not prime the insulin pen prior to the SQ administration.) 3. Record review of Resident #24's face sheet showed the resident admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of the resident's September 2022 POS and MAR showed the following: -Diagnosis of Type 2 diabetes mellitus with diabetic nephropathy (kidney disease); -An order, dated 2/10/21, for Novolog Flexpen, administer SQ per sliding scale before meals and at bedtime, as follows: -Blood sugar level of 0 milligrams/deciliter (mg/dl) to 149 mg/dl, administer 0 units of insulin; -Blood sugar level of 150 mg/dL to 200 mg/dL, administer 3 units of insulin; -Blood sugar level of 201 mg/dL to 250 mg/dL, administer 6 units of insulin; -Blood sugar level of 251 mg/dL to 300 mg/dL, administer 9 units of insulin; -Blood sugar level of 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -Blood sugar level of 351 mg/dL to 400 mg/dL, administer 15 units of insulin; -Blood sugar level of 401 mg/dL to 450 mg/dL, administer 18 units of insulin; -If the blood sugar is greater than 450 mg/dL, notify the physician. Observation on 9/09/22, at 11:35 A.M., of Assistant Director of Nursing (ADON) showed the following: -The nurse entered the resident's room and performed a blood glucose test via finger stick (Accucheck), with a result of 326 mg/dL; -The nurse then reviewed the resident's order on the medication administration record for Novolog insulin showing to administer twelve units per sliding scale for blood sugar level between 301 mg/dL and 350 mg/dL; -The nurse removed the cap from the resident's Novolog Flexpen, cleansed the rubber stopper with alcohol, inserted a disposable needle, and dialed to two units; -The nurse then entered the resident's room cleansed the resident's left lower abdomen with an alcohol wipe and administered the twelve units of insulin via the Novolog Flexpen. (The nurse did not prime the insulin pen prior to the SQ administration.) 4. During an interview on 9/9/22, at 11:40 A.M., the ADON said the following: -He/she was not aware of the need to prime the resident insulin pens before each use. 5. During an interview on 9/12/22, at 3:18 P.M., the Director of Nursing (DON) said the following: -She expected all facility nurses to prime insulin pens with two units of insulin before each dose; -She had not provided any recent training to nurses about this because she was not aware there was an issue with insulin administration. 6. During an interview on 9/13/22, at 12:17 P.M., the Administrator said: -She expected all facility nurses to prime insulin pens with two units of insulin before administering each insulin dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure significant medication errors did not occur, when staff failed to properly administer insulin to two residents (Resident #6 and Resident #37) and failed to properly administer insulin and failed to administer an oral diabetes medication as ordered for multiple consecutive days to one resident (Resident #24). The facility census was 60. Record review of the facility provided information titled, Insulin By Kwikpen (or similar pen type device) showed the following: -Staff need to prime the pen before each use to assure the unit accuracy. Turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue to hold the pen with the needle pointed up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose in and count to five slowly. Staff should see insulin at the tip of the needle, if not re-prime. Record review of the Novolog FlexPen (a fast-acting insulin) manufacturer's guidance, dated 3/2021, showed the following: -Before each injection small amounts of air may collect in the cartridge during normal use; -To avoid injecting air and to ensure proper dosing, -Prime (referred to as an air shot) the flex pen before each injection; -Turn the dose selector to select two units; -Hold the flex pen with the needle pointing up. Tap the cartridge gently to make any air bubbles collect at the top of the cartridge -Keep the needle pointing upward, and press the push button all the way in. The dose selector returns all the way to 0; -Make sure a drop appears; -If a drop of insulin does not appear, change the needle and repeat the procedure, no more than six times. Record review of the Humalog (name brand of lispro-a fast acting insulin) FlexPen (device used to administer the insulin) manufacturer's insert, dated November 2019, showed the following information: -Humalog insulin should be administered 15 minutes before a meal or immediately after a meal; -Hypoglycemia (low blood sugar) is the most common adverse reaction to insulin therapy and may be life-threatening. Symptoms may be different for each person and may change from time to time. Severe hypoglycemia can cause seizures and may be life threatening or cause death. -Prime the pen before each injection: Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the Pen is working correctly; If you do not prime before each injection, you may give too much or too little insulin; -To prime the pen, turn the dose knob to select two units. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top, continue holding the pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to five slowly; -You should see insulin at the tip of the needle; -If you do not see insulin, repeat priming steps six to eight, no more than four times; -If you still do not see insulin, change the needle and repeat priming steps six to eight; -Small air bubbles will not affect the dose; -Turn the dose knob to select the number of units you need to inject. The dose indicator should line up with the dose. 1. Record review of Resident #6's face sheet showed an admission date of 10/4/16. Record review of the resident's September 2022 physician orders (POS) and medication administration record (MAR) showed the following: -Diagnosis of Type 2 diabetes mellitus (a chronic condition that affects how a person processes blood sugar) with hyperglycemia (high blood sugar); -An order, dated 8/22/20, for Novolog R Flexpen insulin, administer subcutaneously (SQ - to inject between the skin and the muscle) per sliding scale before meals and at bedtime, as follows: -Blood sugar level of less than 70 milligrams/deciliter (mg/dL), call physician; -Blood sugar level of 70 mg/dL to 130 mg/dL, administer 0 units of insulin; -Blood sugar level of 131 mg/dL to 180 mg/dL, administer 2 units of insulin; -Blood sugar level of 181 mg/dL to 240 mg/dL, administer 4 units of insulin; -Blood sugar level of 241 mg/dL to 300 mg/dL, administer 6 units of insulin; -Blood sugar level of 301 mg/dL to 350 mg/dL, administer 8 units of insulin; -Blood sugar level of 351 mg/dL to 400 mg/dL, administer 10 units of insulin; -Blood sugar level of greater than 400 mg/dL, administer 12 units of insulin and notify the physician. Observation on 9/09/22, at 11:05 A.M., of Licensed Practical Nurse (LPN) I showed the following: -The nurse entered the resident's room and performed a blood glucose test via finger stick (Accucheck) with a result of 159 mg/dL; -The nurse then reviewed the resident's order on the medication administration record for Novolog insulin showing to administer two units per sliding scale for blood sugar level between 131 mg/dL and 180 mg/dL; -The nurse removed the cap from the resident's Novolog Flexpen, cleansed the rubber stopper with alcohol, inserted a disposable needle, and dialed to two units; -The nurse then entered the resident's room cleansed the resident's right upper arm with an alcohol wipe and administered the two units of insulin via the Novolog Flexpen. (The nurse did not prime the insulin pen prior to the SQ administration.) 2. Record review of Resident #37's face sheet the resident admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the resident's September 2022 POS and MAR showed the following: -Diagnosis of Type 2 diabetes mellitus; -An order, dated 2/10/21, for Humalog Kwikpen, administer SQ per sliding scale before meals and at bedtime, as follows: -Blood sugar level of less than 60 milligrams/deciliter (mg/dL), call the physician; -Blood sugar level of 150 mg/dL to 200 mg/dL, administer 3 units of insulin; -Blood sugar level of 201 mg/dL to 250 mg/dL, administer 6 units of insulin; -Blood sugar level of 251 mg/dL to 300 mg/dL, administer 9 units of insulin; -Blood sugar level of 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -Blood sugar level of 351 mg/dL to 400 mg/dL, administer 15 units of insulin; -Blood sugar level of greater than 400 mg/dL, administer 18 units of insulin; -If the blood sugar is greater than 401 mg/dl, notify the physician. Observation on 9/09/22, at 11:16 A.M., of LPN I showed the following: -The nurse entered the resident's room and performed a blood glucose test via finger stick (Accucheck), with a result of 183 mg/dL; -The nurse then reviewed the resident's order on the medication administration record for Novolog insulin showing to administer three units per sliding scale for blood sugar level between 150 mg/dL and 200 mg/dL; -The nurse removed the cap from the resident's insulin lispro (generic for Humalog Kwikpen), cleansed the rubber stopper with alcohol, inserted a disposable needle, and dialed to three units; -The nurse then entered the resident's room cleansed the resident's left upper arm with an alcohol wipe and administered the three units of insulin via the Insulin lispro pen. (The nurse did not prime the insulin pen prior to the SQ administration.) 3. Record review of Resident #24's face sheet showed the resident admitted to the facility on [DATE] and re-admitted on [DATE]. Record review of the resident's care plan, revised on 6/28/22, showed the following: -Accu checks per physician orders. Document results of blood glucose testing with physician notification as indicated as and follow up action taken; -Administer/monitor side effects and effectiveness of medications as ordered to include both scheduled and sliding scale insulin; -Observe/document/report for signs and symptoms of hypoglycemia (low blood sugar). Record review of the resident's September 2022 POS and MAR showed the following: -Diagnosis of Type 2 diabetes mellitus with diabetic nephropathy (kidney disease); -An order, dated 2/10/21, for Novolog Flexpen, administer SQ per sliding scale before meals and at bedtime, as follows: -Blood sugar level of 0 milligrams/deciliter (mg/dl) to 149 mg/dl, administer 0 units of insulin; -Blood sugar level of 150 mg/dL to 200 mg/dL, administer 3 units of insulin; -Blood sugar level of 201 mg/dL to 250 mg/dL, administer 6 units of insulin; -Blood sugar level of 251 mg/dL to 300 mg/dL, administer 9 units of insulin; -Blood sugar level of 301 mg/dL to 350 mg/dL, administer 12 units of insulin; -Blood sugar level of 351 mg/dL to 400 mg/dL, administer 15 units of insulin; -Blood sugar level of 401 mg/dL to 450 mg/dL, administer 18 units of insulin; -If the blood sugar is greater than 450 mg/dL, notify the physician. Observation on 9/09/22, at 11:35 A.M., of Assistant Director of Nursing (ADON) showed the following: -The nurse entered the resident's room and performed a blood glucose test via finger stick (Accucheck), with a result of 326 mg/dL; -The nurse then reviewed the resident's order on the medication administration record for Novolog insulin showing to administer twelve units per sliding scale for blood sugar level between 301 mg/dL and 350 mg/dL; -The nurse removed the cap from the resident's Novolog Flexpen, cleansed the rubber stopper with alcohol, inserted a disposable needle, and dialed to two units; -The nurse then entered the resident's room cleansed the resident's left lower abdomen with an alcohol wipe and administered the twelve units of insulin via the Novolog Flexpen. (The nurse did not prime the insulin pen prior to the SQ administration.) Record review of the resident's August 2022 and September 2022 (POS), MAR, and treatment administration record (TAR) showed the following: -An order for Januvia (anti-diabetic medication, used to treat type 2 diabetes) tablet, 25 milligrams (mg), once a day 7:00 A.M. to 11:00 A.M.; -The MARs showed staff did not administer the Januvia to the resident from 08/29/22 through 09/06/22. Staff noted, Not Administered: Drug/item unavailable. Record review of the resident's medical record showed staff did not document reordering the medication, notifying the physician of the missed doses, or steps taken to obtain the medication. Record review of refill history for Januvia to the pharmacy showed the following: -A refill request for Januvia was ordered on 7/24/22 and 9/3/22; -Januvia was last filled on 9/6/22 for 14 tablets. During an interview on 9/13/12, at 1:49 P.M., Certified Medication Technician (CMT) F said the following: -When the bubble pack gets to the blue, staff pull the sticker and order them; -CMT or nurses can order the medication; -If a medication is out, staff can check the emergency kit (E-kit) for the medication. Januvia is not in the E-kit; -The pharmacy won't send the Januvia right away; -Januvia was not given during the time period question because it was unavailable; -Medications are usually delivered at night if staff order the medication during the day. sure if he/she contacted nurse about the During an interview on 9/13/12, at 2:02 P.M., the Director of Nursing (DON) said the following: -CMT orders medications; -Staff can pull medication from the E-kit, but Januvia would not be in the E-kit; -If a drug is unavailable, staff can order by 3 P.M. to get that night or staff can stat order between 3:00 P.M. and 5:00 P.M. and get the order that night; -Records showed an order was put in on 7/24/22, 9/3/22, and 9/6/22. During an interview on 9/13/12, at 2:11 P.M., CMT G said the following: -He/she will reorder prescriptions through the computer; -If the order is too early, the CMT will fax the order; -If staff called the pharmacy about a prescription, they will send the order the same night staff called. During an interview on 9/13/12, at 2:11 P.M, the Pharmacy Technician H said the following: -Januvia comes in a 14 day supply only; -The facility requested on 7/24/22 and it was too soon, the order was refilled on 7/26/22 and on 9/6/22; -The pharmacy does not have auto fill and only fill on request; -The facility can send refill request by faxing, over the phone or on the website. During an interview on 9/13/12, at 3:50 P.M., Licensed Practical Nurse (LPN) E said the following: -When a medication it out, the nurse should be told so they can tell the doctor; -CMTs should notify the pharmacy and the nurses so the nurses can contact the doctor on each day; -Nurses should notify the doctor of a medication that is out to see if there anything else the doctor wants done; -Nurses should contact the doctor and put the information into the progress notes; -Misisng the medication could cause issues with blood sugars; -The facility is having issues with deliveries. During an interview on 9/13/12, at 2:02 P.M., the DON said the following: -The DON would expect the CMT to check the E-kit or to purchase over the counter medications; -The CMTs should notify the nurses if out of a medication and try to reorder the medication; -The nurse would contact the the physician if a dose is missed more than a day and document in the progress notes; -The pharmacy did not deliver on Sunday or Monday of Labor Day Weekend and the pharmacy was contacted on the Saturday of Labor Day Weekend; -It is not acceptable to be out of a medication for a week; -It would be expected that the pharmacy be contacted 7 days before the medication is out; -There is an on-call pharmacist for emergencies; -The nurse should notify the physician if something is not available and would want staff to contact the DON on the first day the medication is out. During an interview on 9/13/12, at 5:03 P.M., the Administrator said the following: -Medication should be reordered when the prescription is in the reorder zone; -The pharmacy should be contacted; -The nurse should be told of a medication is out so they can contact the physician to see if there are other medication to be given or follow the expectation of the doctor; -There was an order placed on 9/3/22 and 9/6/22. 4. During an interview on 9/9/22, at 11:40 A.M., the ADON said the following: -He/she was not aware of the need to prime the resident insulin pens before each use. 5. During an interview on 9/12/22, at 3:18 P.M., the Director of Nursing (DON) said the following: -She expected all facility nurses to prime insulin pens with two units of insulin before each dose; -She had not provided any recent training to nurses about this because she was not aware there was an issue with insulin administration. 6. During an interview on 9/13/22, at 12:17 P.M., the Administrator said: -She expected all facility nurses to prime insulin pens with two units of insulin before administering each insulin dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer the pneumococcal (pneumonia) vaccine to one resident (Resident #7) and failed to offer the pneumococcal vaccine to two residents (Resident #35 and Resident #36). The facility census was 60. Record review of the facility policy titled, Immunization Recommendations for Residents of Long-Term Care Facilities, undated, showed the following: -Timing of Immunizations: -Pneumococcal: PCV20 (PREVNAR 20) and PPSV23 (Pneumococcal Polysaccharide vaccine); -Pneumococcal vaccination in persons ages 65 and older years, unless contraindicated will be administered according to the following guidelines when determining the vaccination status; -Adults 19 and [AGE] years old with certain medical conditions or other risk factors (Medical Conditions or Risk Factors) who have not already received a pneumococcal conjugate vaccine should receive either: A single dose of PCV 15 followed by a dose of pneumococcal polysaccharide vaccine (PPSV23) or a single dose of PCV20. If PCV20 is administered, a dose of PPSV23 is not indicated; -Adults 65 years or older who have not already received a pneumococcal conjugate vaccine should receive either a single dose of PCV15 followed by a dose of PPSV23 one year later, or a single dose of PCV 20. If PCV20 is administered, a dose of PPSV23 is not indicated; -Adults 65 years or older who have only received PPSV23, should receive: a single dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless whether PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it; -Contraindications to pneumococcal conjugate vaccine (PCV15 or PCV20) to include: has had an allergic reaction after a previous dose of any type of pneumococcal conjugate vaccine (PCV13, PCV15, PCV20, or an earlier pneumococcal conjugate vaccine known as PCV7), or allergic to any vaccine containing diphtheria toxoid (for example, DtaP), or has any severe, life-threatening allergies; -Contraindications to pneumococcal polysaccharide vaccine (PPSV23) include: has had an allergic reaction after a previous dose of PPSV23, or has any severe, life-threatening allergies; -Requirements to administer the vaccine includes: physician order, consent to receive signed by resident and or legal representative, information sheet included with the consent to administer pneumococcal vaccine, includes general information, risks and side effects; -The resident will be monitored for fever for up to 72 hours. 1. Record review of Resident #7's face sheet (admission data) showed the following: -admission date of 9/14/21; -Diagnoses include chronic atrial fibrillation (an irregular heartbeat that occurs when the electrical signals in the atria (the two upper chambers of the heart) fire rapidly at the same time), hypertension (HTN-high blood pressure), and edema (swelling caused by excess fluid in body tissues). Record review of the resident's immunization consent or refusal form, dated 9/14/21, showed the resident signed the consent showing he/she wanted the PPSV23 and PCV13 vaccine. Record review of the resident's medical record showed staff did not document administration of the pneumococcal vaccine. During an interview on 9/12/22, at 3:46 P.M., the Director of Nursing (DON) said the facility did not find any documentation of administration of the pneumonia vaccine for the resident. During an interview on 9/12/22, at 3:52 P.M., medical record staff/infection preventionist said the resident was admitted from another facility. She contacted the resident's physician and followed up, but had not received any documentation on the resident's pneumonia vaccine. 2. Record review of Resident #35''s face sheet showed the following: -admission date of 3/10/20 and readmission date of 5/8/21; -Diagnoses include HTN, heart failure and chronic pulmonary edema. Record review of the resident's medical record showed staff did not document administration of the pneumococcal vaccine or signed consent or declination form for the vaccine. During an interview on 9/12/22, at 3:46 P.M. , the DON said the facility did not find any documentation of the pneumonia vaccine dates or information for the resident. 3. Record review of Resident #36's face sheet showed the following: -admission date of 10/18/18 and readmission date of 5/7/21; -Diagnoses include chronic obstructive pulmonary disease (COPD - refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath), HTN and congestive heart failure (CHF). Record review of the resident's immunization: consent or refusal form, dated 10/22/18, showed the resident signed the consent form and initialed to receive the influenza vaccine, but did not mark for the pneumococcal vaccines. Record review of the resident's medical record showed staff did not document administration of the pneumococcal vaccine or signed consent or declination form for the vaccine. During an interview on 9/12/22, at 3:46 P.M., the DON said the facility could not find any documentation of the pneumonia vaccine dates or information for the resident. 4. During interviews on 9/12/22, at 3:46 P.M., and on 9/13/22, at 11:15 A.M., the DON said the following: -Social services obtain the vaccine consents and inform nursing staff of how many vaccines are needed; -Social services gets the consent form and gives the form to nursing staff. Nursing staff enter the pneumonia vaccine order into the resident's chart and orders the vaccine from the pharmacy to administer. Nursing documents the information in the preventive health care section of the resident's chart; -Nurses administer the pneumonia vaccines and document in the resident's chart; -Social services get a declination form signed if a resident refuses a vaccine; -She did not know who asks the date and type of pneumonia vaccine the resident had upon admission; -The pneumonia vaccine should be part of the admission process. 5. During an interview on 9/12/22, at 3:52 P.M., Medical Record Staff/Infection Preventionist said the following: -She has not been part of the pneumonia vaccine process; -The facility prepared to administer the new pneumonia vaccines in January 2021, but was directed not to administer due to Coronavirus Disease 2019 (COVID-19) (an infectious disease caused by severe acute respiratory syndrome, Coronavirus 2 (SARS-CoV-2)) vaccines were administered; -Staff should document in the resident's chart if they decline the pneumonia vaccine. 6. During an interview on 9/13/22, at 9:55 A.M., the administrator said the following: -Social services gets the vaccine consent forms signed upon admission and uploads the form in the resident's chart; -Medical record staff gets a copy of the vaccine consent form; -The DON gets a copy of the vaccine to know what is to be administered; -The DON audits the vaccines annually to ensure the vaccinations were administered; -Staff calls the resident's physician office if the resident or family do not know the date of the pneumonia vaccine; -The facility tries to get the most accurate information and documents it in the resident's chart; -The facility was doing a pneumonia clinic in January 2022 and the pharmacy told the facility not to administer the pneumonia vaccine two weeks before or after the COVID-19 booster. The facility did not do the pneumonia vaccine clinic since then; -The facility did not have documentation of the residents' receiving the pneumonia vaccines. 7. During an interview on 9/13/22, at 11:01 A.M., the Social Service Director said the following: -The pneumonia vaccine consent form is in the admission packet; -Social services review the vaccines upon admission and ask the resident or representative if they want the vaccine; -The resident or representative initial the form of vaccines they want and residents may know of dates they received any vaccines.

Based on observation and interview the facility failed to ensure required postings including resident rights, abuse/neglect hotline, and Ombudsman contact information, was posted in a prominent location for residents, visitors, and staff. The facility census was 76. 1. Observation on 10/15/19 at 12:45 P.M., showed the facility posted Resident Right information, Ombudsman contact information, and the Department of Health and Senior Services (DHSS) Abuse and Neglect Hotline information in the kitchenette of the main lobby area, in the far right corner on a wall, facing away from the main entrance. The Resident Right poster consisted of fine print which may not be visible to all residents and visitors. The facility did not have the Resident Rights information, Ombudsman contact information, or the DHSS Abuse and Neglect Hotline information posted in any other resident accessible are During an interview on 10/18/19, at 11:52 A.M., the Administrator said the Resident Rights, State agency, and Ombudsman information was posted on a wall in the main lobby; it could be difficult for residents to find the information.

Based on observation and interview, the facility failed to provide a switch in two common-use restrooms, located on the service hall, that would activate the resident call light system. This deficient practice had the potential to affect all residents and visitors who might need to use the toiletsand required staff assistance. The facility had a census of 76. 1. Observation on 10/15/19, beginning at 8:00 A.M., showed two unsecured common-use restroom doors, located in the service hall, in which residents could access. Both restrooms did not have an call light activation switch. During an interview on 10/15/19, at approximately 9:00 A.M., the maintenance supervisor said he did not know the restrooms in the service halls needed a call light activation switch.