Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #5) of 1 sampled resident reviewed for self-administration of medications was assessed to determine if they were clinically appropriate to do so after the resident expressed a desire to self-administer one of their medications. Findings included: A facility policy titled, Self-Administration of Medications, revised in 12/2016, indicated Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. An admission Record revealed the facility readmitted Resident #5 on 07/11/2022. According to the admission Record, Resident #5 had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 04/10/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had an active diagnosis of non-Alzheimer's dementia. Resident #5's care plan included a focus area, revised 01/24/2024, that indicated the resident had an activities of daily living self-care performance limitation related to limited mobility from a left shoulder fracture and spinal stenosis. Resident #5's care plan did not address self-administration of any medications. Resident #5's physician's orders contained an order, dated 05/23/2024, for Flonase allergy relief nasal suspension, two puffs to each nostril every 12 hours as needed for allergies. The order indicated Resident #5 was able to keep the medication at their bedside. Nursing Progress Notes dated 05/23/2024 at 12:46 PM indicated the MDS Coordinator documented that a provider was at the facility for rounds and ordered Flonase to be kept at Resident #5's bedside. There was no documented evidence the facility determined whether self-administration of medications was clinically appropriate for Resident #5. Resident #5's electronic medical record Standard Assessments beginning 10/11/2023 revealed no documented evidence the facility assessed the resident for self-administration of medication. During an interview on 05/31/2024 at 11:24 AM. Resident #5 stated they had asked the physician to write an order that allowed them to keep their Flonase in their room to use when needed. Resident #5 stated they had used Flonase for years and administered two sprays into each nostril once a day; however, Resident #5 stated staff had not completed an assessment for self-administration and no staff had watched the resident self-administer their Flonase. A telephone interview on 05/31/2024 at 1:10 PM with the MDS Coordinator, the nurse who documented Flonase was ordered to be kept at the resident's bedside, revealed she believed the only thing required for a resident to keep a medication at the bedside was a physician's order. The MDS nurse confirmed an assessment for self-administration of medication was not completed for Resident #5. Registered Nurse (RN) #5 was interviewed on 05/31/2024 at 10:51 AM. RN #5 stated that prior to a resident self-administering medication, the physician had to write an order for the medication to be kept at bedside. RN #5 stated she was unaware residents needed to be assessed for self-administration of medications. The Director of Nursing Services (DNS) was interviewed on 05/31/2024 at 1:00 PM. The DNS stated that prior to a resident self-administering a medication, the staff had to make sure the resident was capable of self-administering the medication. The DNS stated if a resident was going to self-administer their medication, staff educated the resident and then observed a return demonstration of self-administration. The DNS stated documentation of the education and assessment findings should be found in the electronic medical record progress notes. An interview with the Administrator on 05/31/2024 at 1:22 PM revealed that before a resident could self-administer medication, she expected the resident to be assessed and the assessment documented in their progress notes.

Based on observation, interview, record review, and facility policy review, the facility failed to develop a care plan addressing the use of as needed, supplemental oxygen for 1 (Resident #3) of 3 sampled residents reviewed for respiratory care. Findings included: A facility policy titled, Oxygen Administration, revised in 10/2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. The policy further indicated, 2. Review the resident's care plan to assess for any special needs of the resident. An admission Record revealed the facility admitted Resident #3 on 06/19/2023. According to the admission Record, the resident had a medical history that included diagnoses of pneumonia and heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #3's Order Summary Report, listing active orders as of 05/31/2024, contained an order, started on 06/19/2023, for two liters of supplemental oxygen via nasal cannula as needed for shortness of air. The Order Summary Report also contained an order, started on 06/19/2023, for two liters of supplemental oxygen via NC at bedtime for hypoxia (low blood oxygen levels). Resident #3's care plan did not address the resident's supplemental oxygen usage prior to 05/31/2024 (during the survey). During an interview on 05/31/2024 at 9:20 AM, Registered Nurse (RN) #5 stated care plans should address a resident's use of oxygen. RN #5 said the care plan should reflect the ordered flow rate, whether the oxygen was used continuously or as needed, and any parameters set by the physician. During an interview on 05/31/2024 at 2:05 PM, the Administrator stated she expected care plans to address the use of oxygen.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure only licensed personnel adjusted the flow rate on an oxygen concentrator for 1 (Resident #45) of 3 residents reviewed for supplemental oxygen use. Findings included: A facility policy titled, Administering Medications, reviewed 05/12/2017, revealed, Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. An admission Record revealed the facility admitted Resident #45 on 03/19/2024. According to the admission record, Resident #45 had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/26/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #45 had an active diagnosis of asthma, COPD, or chronic lung disease. The MDS indicated Resident #45 received oxygen therapy while a resident. Resident #45's care plan revealed a focus area initiated 04/02/2024, that indicated Resident #45 had diagnoses of emphysema and COPD. Interventions directed staff to give oxygen therapy as ordered by the physician (initiated 04/02/2024). Resident #45's Order Summary Report, with active physician's orders as of 05/29/2024, revealed an order for supplemental oxygen to be delivered at 2 to 3 liters by nasal cannula (NC) to maintain blood oxygen saturation levels above 91 percent (%) each shift, with a start date of 03/19/2024. An observation on 05/29/2024 at 1:52 PM revealed Resident #45's oxygen concentrator was set to deliver 2.5 liters per minute by NC. During an interview at the time of the observation, Resident #45 stated they had just finished walking with therapy staff and was short of breath. Resident #45 activated their call light at 2:55 PM. At 3:05 PM Certified Nurse Aide (CNA) #1 entered the room and adjusted the resident's oxygen concentrator to deliver 3 liters of supplemental oxygen per minute. CNA #1 was interviewed on 05/30/2024 at 12:53 PM. CNA #1 stated she had not completed a Certified Medication Technician (CMT) course and was not allowed to administer medication. CNA #1 stated she had been taught that supplemental oxygen was a medication, and she was not allowed to change the setting on an oxygen concentrator. CNA #1 acknowledged she had adjusted Resident #45's supplemental oxygen on 05/29/2024 and stated she did not know why and added that she was not thinking and just wanted to give Resident #45 supplemental oxygen. CNA #1 sated she realized afterwards that she should not have altered the resident's oxygen concentrator and should have reported Resident #45's shortness of breath to the Director of Nursing Services (DNS). CMT #4 was interviewed on 05/31/2024 at 9:23 AM. CMT #4 stated either a nurse or a CMT could change the setting on an oxygen concentrator. CMT #4 stated supplemental oxygen was considered a medication and a CNA was not able to change an oxygen concentrator's setting. Registered Nurse (RN) #5 was interviewed on 05/31/2024 at 10:43 AM. RN #5 stated nurses were responsible for adjusting oxygen concentrators and added that she did not think the CMTs were allowed to adjust the oxygen concentrators and stated that CNAs were not allowed to adjust oxygen concentrators. RN #5 stated that she considered supplemental oxygen a medication and if a CNA adjusted an oxygen concentrator, it may cause under oxygenation or over oxygenation of a resident. The DNS was interviewed on 05/31/2024 at 12:55 PM. The DNS stated she did not consider supplemental oxygen a medication. The DNS stated the CNAs had completed an oxygen safety course that included instruction on setting up portable oxygen tanks and making sure the tanks had no oxygen leaks. The DNS stated the CNAs were shown how to know if a resident was receiving the correct dosage of supplemental oxygen. The DNS stated prior to adjusting the supplemental oxygen flow rate, she expected the CNAs to check with the nurse. The DNS stated she was the nurse on duty when CNA #1 adjusted the supplemental oxygen flow rate for Resident #45 and added that the CNA had not reported that Resident #45 was short of breath or that she had adjusted the resident's supplemental oxygen flow rate on the concentrator. The DNS stated it was not unusual for Resident #45 to become short of breath with activity, but the shortness of breath resolved when the resident rested. The Administrator was interviewed on 05/31/2024 at 1:22 PM. The Administrator stated a physician's order was needed for supplemental oxygen but added that she was not sure if supplemental oxygen was considered a medication but stated that it probably was. The Administrator stated the CNAs were not expected to adjust a resident's oxygen concentrator.

Based on observation, interview, record review, and facility policy review, the facility failed to specify dose parameters for 1 (Resident #7) of 3 residents reviewed for supplemental oxygen use. Specifically, the facility failed to ensure Resident #7's supplemental oxygen orders specified liters per minute (L/min) parameters. Findings included: A facility policy titled, Oxygen Administration, revised October 2010, indicated under the section titled Preparation to Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. The policy also indicated, Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Resident #7's admission Record revealed the facility admitted the resident on 09/15/2022. According to the admission Record, the resident had a medical history that included diagnoses of hypoxemia (low blood oxygen levels) dystonia (involuntary muscle movements causing twisting and contorting), torticollis (involuntary muscle movements causing twisting and contorting of the neck), and pneumonia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/13/2024, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident received oxygen therapy during the assessment period. Resident #7's Care Plan, included a focus area revised on 03/25/2024, that indicated the resident had oxygen therapy related to ineffective gas exchange from dystonia. Interventions directed staff to monitor for signs and symptoms of respiratory distress and report to the medical doctor as needed, humidified supplemental oxygen setting via nasal prongs at 2 liters continuously at night and as needed during the day, and to promote lung expansion and improve air exchange by positioning with proper body alignment and if tolerated, position the head of bed above 45 degrees. Resident #7's Order Summary Report revealed an order dated 12/24/2023 for supplemental oxygen by way of nasal cannula (NC) to maintain above 91 percent (%) blood oxygen saturation level every shift and to keep on at night. Resident #7's Treatment Administration Record [TAR], dated March 2024, April 2024, and for the timeframe from 05/01/2024 through 05/28/2024, revealed the staff had documented the resident had blood oxygen saturation levels over 90% every day on all three shifts. During an observation and interview on 05/28/2024 at 11:20 AM, Resident #7 was in their room. The resident's NC was askew on their nostrils and the supplemental oxygen concentrator was set at 2 L/min. Resident #7 stated they had no concerns about staff treatment or care provisions. During an interview on 05/30/2024 at 8:45 AM, Certified Nurse Aide (CNA) #1 stated she assisted residents with their supplemental oxygen. She stated she would enter the resident's room and make sure the supplemental oxygen was on. She stated supplemental oxygen use was in the resident's care plan. She stated she would make sure the cannula was correctly placed on the resident and would check the L/min, but she did not adjust the settings. She stated any concerns noticed were reported to the nurse and she would follow any directive given to assist the resident. She stated she would monitor the resident's blood oxygen saturation using the pulse oximeter. She stated the supplemental oxygen orders were relayed to her by the nurse. She stated Resident #7 was to have their supplemental oxygen on while in bed but could wear it while up at their discretion. She stated if the resident's blood oxygen saturation level was below 95%, she would reapply the NC for the resident. She stated the resident was compliant with their oxygen therapy when their blood oxygen saturation levels were outside the parameters. During an interview on 05/30/2024 at 12:41 PM, Registered Nurse (RN) #5 stated that as the RN she would check oxygen saturation readings for residents who required monitoring and make sure their blood oxygen saturation levels were good. She stated that when residents were in their rooms, they were connected to an oxygen concentrator and when they were out of bed they were connected to a portable tank, which was checked before application and refilled as needed. She stated supplemental oxygen orders should include as needed or continuous use, L/min, and any titration guidelines. She stated that when she received orders from physicians, she would review them and enter them into the resident's record, before placing them in the orders basket for the night nurses to verify. She stated if she found a discrepancy with the orders, she would call the Director of Nursing Services (DNS) and physician to verify. She stated if there was a supplemental oxygen order without parameters for L/min she would start off with 2 L/min and monitor per the resident's condition. RN #5 stated she worked with Resident #7 and double checked their NC placement frequently as it tended to become askew. She stated the resident's blood oxygen saturation levels were regularly between 90% and 92%. She stated she monitored the L/min setting and would reposition the resident if the resident's blood oxygen saturation levels were low. She stated Resident #7 was on 3 L/min supplemental oxygen flow. She stated if the resident's blood oxygen saturation levels read below 91%, she would call the physician. Review of Resident #7's medical record on 05/30/2024 at 12:56 PM with RN #7 revealed the resident's supplemental oxygen order indicated oxygen by way of NC to maintain above 91% sat [saturation] every shift keep on at night. After reviewing the order, RN #7 stated the only parameter was to maintain blood oxygen saturation levels above 91% and she did not see any L/min indication on the order to start from. She stated supplemental oxygen orders should be accompanied by L/min. During an interview on 05/30/2024 at 3:57 PM, Licensed Practical Nurse (LPN) #15 stated supplemental oxygen orders typically started at 2 L/min and titration was attempted from there to achieve blood oxygen saturation levels. She stated the resident's blood oxygen saturation levels were checked at least once a shift, so three times a day. She stated supplemental oxygen orders should be accompanied by L/min parameters, so the nurses had a starting point and was unsure why there was no L/min associated with the order. During an interview on 05/31/2024 at 1:06 PM the DNS stated any order for supplemental oxygen should be accompanied by L/min parameters. She stated she was made aware of the concern regarding Resident #7 on 05/30/2024 and the facility was awaiting a call back from the physician with L/min parameters to update the order. She stated the original order should have been accompanied by L/min parameters. During an interview on 05/31/2024 at 1:58 PM, the Administrator stated supplemental oxygen orders should be accompanied by L/min parameters, so the nurses knew where to start oxygen flow. During an interview on 05/31/2024 at 4:04 PM, Medical Doctor (MD) #17 stated supplemental oxygen orders should be accompanied by L/min parameters and there was no situation where that would not be the case. She stated the L/min was the dosage information.

Based on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #50) of 5 residents reviewed for unnecessary medications was free of significant medication errors. Specifically, staff administered metoprolol tartrate (a medication used for high blood pressure) to Resident #50 despite the resident's blood pressure being below the ordered parameters for administration and without monitoring the resident's pulse. Findings included: A facility policy titled, Administering Medications revised 12/2012, indicated, 3. Medications must be administered in accordance with orders, including any required time frame. The policy revealed, 8. The following information must be checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. An admission Record revealed the facility admitted Resident #50 on 04/24/2024. According to the admission Record, the resident had a medical history that included a diagnosis of essential (primary) hypertension. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/2024, revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS also indicated the resident had an active diagnosis of hypertension. Resident #50's 05/2024 Medication Administration Record [MAR] revealed a transcription of a physician's order dated 04/24/2024 for metoprolol tartrate 25 milligrams (mg) twice daily for hypertension, with instructions to hold the medication if the resident's systolic blood pressure (the top number of the blood pressure reading) was below 120 millimeters of mercury (mmHg), the diastolic blood pressure (the bottom number of the blood pressure reading) was less than 60 mmHg or if the resident's heart rate was less than 60 beats per minute. The 05/2024 MAR revealed no documented evidence staff checked the resident's heart rate prior to administering metoprolol tartrate. The MAR revealed staff documented that they administered metoprolol tartrate 25 mg to Resident #50 on the following dates and times despite the resident's blood pressure reading that required the medication be held: - 05/01/2024 at 5:00 PM with a blood pressure of 110/60 mmHg, - 05/02/2024 at 8:00 AM with a blood pressure of 110/60 mmHg, - 05/02/2024 at 5:00 PM with a blood pressure of 108/60 mmHg, - 05/03/2024 at 8:00 AM with a blood pressure of 108/60 mmHg, - 05/03/2024 at 5:00 PM with a blood pressure of 112/62 mmHg, - 05/06/2024 at 5:00 PM with a blood pressure of 159/51 mmHg, - 05/08/2024 at 5:00 PM with a blood pressure of 104/66 mmHg, - 05/12/2024 at 5:00 PM with a blood pressure of 112/67 mmHg, - 05/14/2024 at 8:00 AM with a blood pressure of 110/62 mmHg, - 05/14/2024 at 5:00 PM with a blood pressure of 96/64 mmHg, - 05/15/2024 at 8:00 AM with a blood pressure of 101/60 mmHg, - 05/15/2024 at 5:00 PM with a blood pressure of 106/59 mmHg, - 05/16/2024 at 8:00 AM with a blood pressure of 112/63 mmHg, - 05/16/2024 at 5:00 PM with a blood pressure of 124/58 mmHg, - 05/18/2024 at 8:00 AM with a blood pressure of 113/65 mmHg, - 05/19/2024 at 5:00 PM with a blood pressure of 110/70 mmHg, - 05/20/2024 at 8:00 AM with a blood pressure of 119/60 mmHg, - 05/21/2024 at 5:00 PM with a blood pressure of 110/60 mmHg, - 05/22/2024 at 5:00 PM with a blood pressure of 112/58 mmHg, - 05/23/2024 at 8:00 AM with a blood pressure of 110/64 mmHg, - 05/23/2024 at 5:00 PM with a blood pressure of 110/70 mmHg, - 05/26/2023 at 8:00 AM with a blood pressure of 116/64 mmHg, - 05/26/2023 at 5:00 PM with a blood pressure of 114/68 mmHg. Certified Medication Technician (CMT) #4 was interviewed on 05/31/2024 at 9:25 AM. CMT #4 stated if vital signs, such as a blood pressure or pulse, were required to meet certain parameters, then the vital signs were required to be recorded on the MAR. CMT #4 reviewed the 05/2024 MAR for Resident #50 and stated the resident's pulse was not documented on the MAR. She also reviewed Resident #50's recorded blood pressures and stated there were several that did not meet the physician's parameters and the medication should not have been given. CMT #10 was interviewed on 05/31/2024 at 9:50 AM. CMT #10 stated if a medication was not given due to not meeting vital sign parameters, she chose either a code 4 (indicating vitals outside of parameters) or code 9 (indicating other/see nurse notes) and entered the code on the MAR. CMT #10 reviewed the MAR for Resident #50 and identified her initials indicated she gave metoprolol to Resident #50 when the blood pressure parameters were not met for the blood pressure medication. CMT #10 reviewed the MAR and stated Resident #50's heart rate was not recorded daily as directed. CMT #10 stated she did not follow the physician's orders for administering Resident #50's blood pressure medication and gave the medication when it should have been held. During an interview on 05/31/2024 at 3:59 PM, CMT #11 stated she gave Resident #50 metoprolol when the resident's blood pressure did not meet the parameters and acknowledged she should have held the medication. CMT #11 stated she had not taken the resident's pulse and overlooked the blood pressure parameters. Registered Nurse (RN) #5 was interviewed on 05/31/2024 at 10:48 AM. RN #5 stated she had worked each Thursday in 05/2024 and no one had reported Resident #50's blood pressure had not met the parameters for giving metoprolol. RN #5 reviewed Resident #50's MAR and stated the days the systolic blood pressure was less than 120 mmHg the medication should not have been given and stated she would have liked for the CMT to have reported the low blood pressure to her. RN #5 reviewed the MAR and stated Resident #50's heart rate had not been documented and stated the CMTs that had given the medication to Resident #50 had not followed the physician's order. RN #5 stated the danger of giving the medication would be Resident #50's blood pressure drooping even lower, and the resident could faint. A telephone interview was held with the Consultant Pharmacist (CP) on 05/31/2024 at 11:29 AM. The CP stated giving metoprolol to Resident #50 when the resident's blood pressure had not met the physician's parameters would make the blood pressure drop even more. The CP stated the medication should have been held. The Director of Nursing Services (DNS) was interviewed on 05/31/2024 at 12:48 PM. The DNS stated if Resident #50 had parameters for blood pressure and heart rate they should have been documented on the MAR. The DNS stated if the resident's blood pressure had not met the parameters, then the metoprolol should have been held and if the medication was held frequently the staff should have notified the physician. The DNS stated she was unaware the mediation was administered even though the resident's blood pressure parameters were not met. The DNS stated she was also unaware that Resident #50's heart rate had not been added to the MAR. The DNS stated staff did not follow the physician's orders. The Administrator was interviewed on 05/31/2024 at 1:22 PM and stated she expected physician's orders to be followed, and if the order was not to give blood pressure medications if the parameters were not met, the medication should not have been administered and she expected the physician to be notified.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medication was safely stored for 1 (Resident #5) of 1 sampled resident reviewed for self-administration of medication. Specifically, Resident #5 had an order to keep their Flonase nasal spray at the bedside; however, the facility failed to ensure the medication was stored in a safe and secure place, not accessible to other residents, as directed by the facility's policy. Findings included: A facility policy titled, Self-Administration of Medications, revised in 12/2016, indicated 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. An admission Record revealed the facility admitted Resident #5 on 07/11/2022. According to the admission Record, Resident #5 had a medical history that included a diagnosis of chronic obstructive pulmonary disease (COPD). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 04/10/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS revealed the resident had an active diagnosis of non-Alzheimer's dementia. The MDS revealed the resident was independent with chair/bed to chair transfers and sitting to standing. Resident #5's physician's orders contained an order, dated 05/23/2024, for Flonase allergy relief nasal suspension, two puffs to each nostril every 12 hours as needed for allergies. The order indicated Resident #5 was able to keep the medication at their bedside. An observation and interview on 05/28/2024 at 9:49 AM, revealed a bottle of Flonase was on Resident #5's dresser. Resident #5 stated the physician told staff to leave the medication in the resident's room for the resident to use when needed. An observation on 05/29/2024 at 1:39 PM, revealed Resident #5 and the resident's roommate were in the room. The Flonase bottle remained on the resident's dresser and was visible from the open doorway. Resident #5 was interviewed on 05/31/2024 at 11:24 AM. Resident #5 stated they had asked the physician to write an order that allowed them to keep their Flonase in their room. Resident #5 stated that on 05/28/2024 and 05/29/2024 the resident kept the Flonase on top of the dresser. Afterward, the resident's family member put the medication in a dresser drawer so no other resident could get the medication. Resident #5 stated facility staff had not provided any instructions on how to store their Flonase. Certified Nurse Aide (CNA) #1 was interviewed on 05/30/2024 at 12:48 PM. CNA #1 stated Resident #5 had nasal spray in their room that was kept on top of their dresser. CNA #1 stated the medication had been in the resident's room for the last couple of months and the CNA had been told the resident was able to have the medication at bedside. Certified Medication Technician (CMT) #3 was interviewed on 05/30/2024 at 2:01 PM. CMT #3 stated Resident #5 had an order to keep their Flonase at bedside. CMT #3 stated she thought Resident #5 left the Flonase on the table. Registered Nurse (RN) #5 was interviewed on 05/31/2024 at 10:51 AM. RN #5 stated medications kept at bedside were kept on top of the resident's bedside table or in the bedside table drawer. The Director of Nursing Services (DNS) was interviewed on 05/31/2024 at 1:00 PM. The DNS stated medications that were kept in a resident's room were expected to be stored in a bathroom cabinet. The Administrator was interviewed on 5/31/2024 at 1:22 PM. The Administrator stated she expected medications to be stored out of sight.

Based on interview, record review, and review of the Facility Assessment Tool, the facility failed to ensure nurse aides received 12 hours of required in-service training per year for 2 (Certified Medication Technician [CMT] #3 and CMT #10) of 5 nurse aide employee files reviewed. Findings included: The Facility Assessment Tool, reviewed by the Quality Assurance and Performance Improvement (QAPI) Committee on 08/23/2023, revealed, Required in-service training for nurse aides. In-service training must: - Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. - Include dementia management training and resident abuse prevention training. CMT #3's Orientation Checklist revealed she was hired as a CMT on 06/28/2018. CMT #3's Employee Inservice Attendance Record revealed that for the timeframe from 06/18/2022 to 06/18/2023 (most recent full year based on her hire date of 06/28/2018), CMT #3 attended only four in-services, none of which pertained to dementia management. The Employee Inservice Attendance Record did not reflect the number of in-service hours awarded for each in-service CMT #10 attended. CMT #10's Orientation Checklist revealed she was hired as a CMT on 12/03/2019. CMT #10's Employee Inservice Attendance Record revealed that for the timeframe from 12/03/2022 to 12/03/2023 (most recent full year based on her hire date of 12/03/2019), CMT #10 attended only four in-services, none of which pertained to dementia management. The Employee Inservice Attendance Record did not reflect the number of in-service hours awarded for each in-service CMT #10 attended. The Administrator (ADM) was interviewed on 05/30/2024 at 12:05 PM. The ADM acknowledged that there may have been missing in-service training records and stated that the facility recently hired a full-time Staff Development Director (DSD); however, per the ADM, the DSD had not yet started working at the facility.

2. A facility policy titled, Oxygen Administration, revised in 10/2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration; however, the policy did not address infection control measures for labeling or storage of oxygen equipment/supplies. During an interview on 05/31/2024 at 12:20 PM, the Director of Nursing Services (DNS) stated that night shift staff should change oxygen tubing once per week. The DNS stated the tubing should be labeled and stored in a blue bag. An admission Record revealed the facility admitted Resident #3 on 06/19/2023. According to the admission Record, the resident had a medical history that included diagnoses of pneumonia and heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #3's Order Summary Report, listing active orders as of 05/31/2024, contained an order, started on 06/19/2023, for two liters of supplemental oxygen via nasal cannula as needed for shortness of air. The Order Summary Report also contained an order, started on 06/19/2023, for two liters of supplemental oxygen via NC at bedtime for hypoxia (low blood oxygen levels). On 05/28/2024 at 8:34 AM, an observation of Resident #3 revealed the resident's oxygen tubing and nasal cannula were lying on the resident's bed. The nasal cannula was not stored in a bag and the tubing was not dated. During an interview on 05/28/2024 at 8:35 AM, Resident #3 stated that they had been utilizing supplemental oxygen since returning from the hospital. Resident #3 stated they only used supplemental oxygen at night. An observation on 05/29/2024 at 2:12 PM, revealed Resident #3's nasal cannula and oxygen tubing were hanging on the resident's bed rail. The tubing was dated 05/29/2024 but was not stored in a bag. During an interview on 05/29/2024 at 2:12 PM, Resident #3 stated staff put a date on the tubing during the morning on 05/29/2024. An observation on 05/30/2204 at 9:45 AM, revealed Resident #3's nasal cannula and oxygen tubing were hanging on the resident's bed rail, and the tubing was not dated and was not stored in a bag. During an interview on 05/30/2024 at 2:02 PM, Certified Nurse Aide (CNA) #1 revealed Resident #3 only used oxygen at night when in bed and staff shut off the oxygen machine during the day. CNA #1 stated that the oxygen tubing normally just hung on the bed rail, and no one really put it in a bag. During an interview on 05/31/2024 at 8:54 AM, Certified Medication Technician (CMT) #14 stated night shift staff was responsible for changing oxygen tubing every week, and the day shift staff were responsible for monitoring to ensure the tubing stayed clean. The CMT stated Resident #3 only utilized oxygen at night, and when not in use, the tubing should be stored in a bag and dated. During an interview on 05/31/2024 at 9:20 AM, Registered Nurse (RN) #5 stated night shift staff were responsible for changing and dating oxygen tubing. During an interview on 05/31/2024 at 11:32 AM, the MDS Coordinator stated Resident #3 only used oxygen at night. She stated typically, the night shift charge nurse dated and stored the tubing when the tubing was changed. An interview with the Administrator on 05/31/2024 at 2:05 PM revealed their expectation was for oxygen tubing to be dated and stored in a bag. Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Certified Medication Technicians [CMT] #4) of 4 staff observed during medication administration wore gloves while performing fingerstick blood sugar checks and washed hands between residents for 2 (Resident #47 and Resident #41) of 6 residents observed during medication pass observations. In addition, the facility failed to ensure oxygen supplies were labeled and stored in a manner to prevent the development or spread of infection for 1 (Resident #3) of 3 residents reviewed for respiratory care. Findings included: 1. A facility policy titled, Obtaining a Fingerstick Glucose Level, revised 06/26/2017, indicated, The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level. The policy The policy revealed the Steps in the Procedure included, 6. Wear clean gloves and 19. Wash hands or hand sanitize. A facility policy titled, Personal Protective Equipment - Gloves, reviewed on 05/30/2024, revealed Gloves must be worn when handling blood, body fluids, secretions, mucous membranes, and/or non-intact skin. The policy further revealed, 8. Wash your hands after removing gloves. An admission Record revealed the facility admitted Resident #47 on 11/21/2023. According to the admission Record, Resident #47 had a medical history that included a diagnosis of type one diabetes mellitus without complications. Resident #47's Order Summary Report, listing active orders as of 05/31/2024, contained an order, dated 01/24/2024, to complete fingerstick blood sugar checks four times a day. An admission Record revealed the facility admitted Resident #41 on 06/29/2022. According to the admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus with unspecified complications. Resident #41's Order Summary Report, listing active orders as of 05/31/2024, contained an order, dated 12/21/2023, to complete fingerstick blood sugar checks three times a day before meals. During medication pass observations on 05/30/2024 at 11:36 AM, CMT #4 entered Resident #47's room and completed a fingerstick blood sugar check without donning gloves. After completing Resident #47's fingerstick blood sugar check, CMT #4 did not wash her hands, and proceeded to complete a fingerstick blood sugar check for Resident #41 at 11:45 AM, again without donning gloves. CMT #4 was interviewed on 05/30/2024 at 11:59 AM. CMT #4 stated she had no explanation for not washing her hands between the residents. CMT #4 further stated it was the facility's policy to wear gloves when there was a potential for contact with blood, such as fingerstick blood sugar checks. Per CMT #4, she forgot to wear gloves when completing the residents' blood sugar checks. The Director of Nursing Services (DNS) was interviewed on 05/31/2024 at 1:32 PM. The DNS stated staff were expected to wash or sanitize their hands after patient care, any time the hands were soiled, and after completing a fingerstick blood sugar check. The DNS stated staff were also expected to wear gloves when performing blood sugar checks. The Administrator was interviewed on 05/31/2024 at 1:22 PM. The Administrator stated she expected staff to wash or sanitize their hands between resident care, including fingerstick blood sugar checks. She further stated she expected staff to use gloves when performing blood sugar checks due to potential contact with blood.

Based on observation, interview, and facility policy review, the facility failed to maintain professional standards in the kitchen. Specifically, the facility failed to ensure dented canned foods were not in circulation in 1 of 1 dry storage area observed. This had the potential to affect all 55 residents who resided in the facility and received meals from the kitchen. Findings included: A facility policy titled, Food Receiving and Storage, revised 05/29/2024, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. The policy also indicated, When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. During an interview on 05/29/2024 at 2:56 PM, the Administrator stated the facility had no specific policy regarding dented canned food. Observations of the facility's dry storage area on 05/28/2024 at 10:08 AM revealed compromised canned foods in the facility storage rack, specifically: - One unlabeled 6-pound can of food had dents along the rim, - One dented 46 ounce (oz.) can of V8, - One unlabeled 3-pound can was in with other 3 pound cans of cream of mushroom soup, and - One dented rim of a 55 oz can of olives. Further observation revealed no designated dented can area was seen in the dry storage area. During an interview on 05/29/2024 at 10:29 AM, the Certified Dietary Manager (CDM) stated canned foods could be put away by anyone, but she preferred to put away the deliveries. She stated some of the dietary staff would take initiative and put things away on their own. She stated she would come in to find things everywhere at times. During an interview on 05/29/2024 at 11:38 AM, [NAME] #8 stated that when putting deliveries away she would make sure items received were not open or dented. She stated damaged items were put aside so the facility could get credit from the distributor. She stated that when she found damaged items she took a picture and sent it to the CDM. She stated she would then remove the damaged item and write on it that it was damaged and to not be used. Follow-up observations of the facility's dry storage area on 05/29/2024 at 11:44 AM revealed compromised canned goods in the facility storage rack, specifically: - Two dented 6-pound cans of sweet potatoes, both had dented rims, and - One dented 6.5-pound can of pinto beans. During an interview on 05/29/2024 at 11:55 AM, the CDM stated dented cans could allow oxygen into the canned food, causing microbe and bacteria growth and making the food unsafe and could cause illness. During an interview on 05/29/2024 at 12:22 PM, Dietary Aide (DA) #7 stated all dietary staff were to help unload the deliveries. He stated he would put deliveries away, and canned goods that were damaged or unlabeled should be thrown away. He stated if the distributor was alerted of the damaged product in the allotted timeframe the facility would get a credit. During an interview on 05/29/2024 at 12:30 PM, [NAME] #9 stated she had worked in the facility kitchen for a year and a half. She stated she was told by the CDM that they were going to be putting away the deliveries. She stated she had not help put away dry goods recently. She stated canned goods should be inspected for dents around the lid to make sure the food was not open and possibly contaminated. She stated if a can was dented it should be removed to the CMD's office. Observations in the CDM's office on 05/29/2024 at 12:40 PM after the CDM had gone through the dry storage can rack revealed that 36 compromised cans of food had been removed in total from the dry storage can rack, this included the compromised cans observed on 05/28/2024 at 10:08 AM and 05/29/2024 at 11:44 AM. Two cans were unlabeled and the other 34 were dented. The removed cans were all either 6-pounds or 46 oz of various foods. During an interview on 05/29/2024 at 1:00 PM, the Administrator stated if canned goods were delivered dented, they should be sent back and not used. She stated if dented cans of food were found after delivery they should be labeled and removed from storage. During an interview on 05/31/2024 at 1:06 PM, the Director of Nursing Services (DNS) stated dented cans of food should not be on the rack in dry storage. She stated she was unaware of the risks regarding compromised canned foods.

Based on interview and record review, the facility staff failed to report to Department of Health and Senior Services (DHSS) an injury of unknown origin when the facility staff became aware on 12/14/23 that one resident (Resident #1) had a broken femur and did not know the source of the fracture. The facility census was 54. Review of facility policy, Abuse and Neglect Protocol, dated 2/15/22, showed: -Response and Reporting: It is the purpose of this facility to report to the state agency and appropriate law enforcement entity, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility. The facility shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours. Serious bodily injury would be classified as a fracture. The facility will report the results of all investigations to the Administrator or designee, DHSS and to other officials in accordance with State law, and within five working days of the incident, and if the alleged violation is verified, appropriate corrective action will be taken. -Indicators of abuse, neglect, or misappropriation of resident's property to be investigated include, but not limited to the following: injuries of unknown origin. 1. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/25/23, showed: -A Brief Interview Mental Status (BIMS), an assessment tool used in long term care facilities to monitor cognition, score of 14, showed cognitively intact; -He/She used a manual wheelchair and mechanical lift; -He/She was dependent for mobility in sitting to lying, chair to bed transfers, toilet transfers, lower body dressing, showers, and toileting hygiene; -He/She required substantial/maximal assistance for upper body dressing and rolling left to right; -Diagnoses included: Dystonia (a condition causing involuntary muscle contractions that cause repetitive or twisting movements), edema, torticollis (rare condition in which neck muscles contract, causing the head to twist to one side), low back pain, and a fracture. Review of care plan, dated 12/18/23, showed: -He/She was at risk for falls due to gait and balance problems and disease process of dystonia; -He/She had pain due to dystonia, osteoarthritis, and right femur fracture; -He/She required two staff participation with transfers using the mechanical lift; -He/She required leg brace to right leg when transferred; Review of electronic medical record, dated 12/13/24 to 12/18/23, showed: -12/13/23 at 11:00 P.M., Licensed Practical Nurse (LPN) A wrote Resident complained of right knee pain. He/She did not rate pain but stated it hurt really bad. The resident's knee appeared to be swollen. He/She told the nurse he/she did not know what happened but his/her knee started hurting during the night. -12/14/23 at 9:09 A.M., MDS Coordinator wrote the nurse practitioner was in the facility for rounds. The resident was complaining of pain in right knee, hurts worse with movement. Magnetic resonance imaging (MRI) scheduled at the hospital. Will send to hospital today and the hospital will give resident Toradol (pain medication) intramuscularly (IM) injection. -12/14/23 at 1:50 P.M., Call received from nurse practitioner stating resident being sent to emergency room for further evaluation due to imaging showed a fracture of the femur; -12/14/23 at 2:43 P.M. Resident had dystonia and was chair bound and transferred with a sit to stand lift. -12/18/23 at 7:04 P.M., LPN B wrote the resident arrived back to facility at 3:22 P.M. with diagnosis of femur fracture. Resident was supposed to be transferred by the mechanical lift. Review of facility investigation showed investigation was started on 12/14/23 by the Administrator. During an interview on 1/29/24 at 9:01 A.M., the Administrator said: -On 12/14/23 discovered Resident #1 had a broken femur; -He/She completed investigation and interviews with staff; -Resident was seen by the nurse practitioner and was sent to the hospital to have a MRI done to rule out blood clots; -Daughter was notified of the fracture; -She did not know how the fracture occurred; -Resident was not dropped, never screamed out in pain; -Resident was using sit to stand which required two people for all his/her transfers; -Resident did not want to start using the mechanical lift, he/she was assessed by therapy that he/she was still appropriate to use sit to stand lift a few weeks prior. During an interview on 1/29/24 at 10:53 A.M., the Administrator said she did not report the resident's fractured femur to DHSS because it was an injury of an unknown origin. During an interview on 1/29/24 at 11:37 A.M., the Administrator said: -He/She reviewed emails and he/she had not contacted DHSS; -He/She never suspected abuse of the injury of unknown origin. -He/She was responsible for reporting and should have reported the injury of unknown origin. MO228795

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to develop and implement a comprehensive person-centered plan of care which included measurable objectives and timeframe's to meet each resident's medical, nursing, and mental psychosocial needs identified in the comprehensive assessment for of three of 13 sampled residents (Residents #2, #22 and #30). The facility census was 51. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, showed the following: - A comprehensive, person-centered care plan that includes measurable objectives to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. - The compressive, person-centered care plan will (included): o Include measurable objectives and timeframes; o Describe the serves that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; o Describes the services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; o Incorporate identified problem areas; o Incorporate risk factors associated with identified problems - Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan; - Identifying problem areas and their causes, and developing interventions that are targets and meaningful to the resident, are the endpoint of an interdisciplinary process; - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; - The IDT must review and update the care plan when there has been a significant change in the resident's condition; At least quartering, in conjunction with the required quarterly assessment. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/24/22, showed the following: - Date admitted [DATE]; - Severe cognitive impairment; - Had one fall with injury since the previous assessment and two or more non-injury falls; - Received antipsychotic (used to treat mental disorders) and antianxiety medications in the last seven days of the assessment. Review of the resident's care plan dated 6/3/22 showed the following: - The resident was at risk for falls. The interventions included: o Conduct fall assessment on admit and every quarter and as needed; o Ensure that the resident has his/her call light close at hand and remind him/her to use it for needs; o Frequently check in on the resident to ensure he/she is safe; o The resident required a two-person assist with all transfers; - It did not include fall mats or the use of bolster sides; - The care plan did not include information regarding the use of psychotropic medications. Review of the resident's physician orders sheet (POS), dated 6/8/22, showed the following: - Haloperidol lactate concentrate (an anti-psychotic, used to treat mental/mood disorders), give 0.5 milliliter (mL) by mouth three times a day for restlessness, start date 5/19/22; - Lorazepam concentrate (psychotropic, used to treat anxiety), give 0.5 milliliters (mL) by mouth every two hours as needed (PRN) for anxiety/restlessness. Start date 5/7/22; - Lorazepam intensol concentrate, give 0.5 mL mouth four times per day for anxiety. Start date 4/29/22; - Seroquel (antipsychotic, used to treat mental/mood conditions) 25 milligrams (mg), give half a tablet by mouth one time per day for anxiety. Start date 2/8/22; - Seroquel 25 mg, give 1.5 tablet by mouth at bedtime for anxiety. Start date 2/8/22. Review of the resident's medical records showed the following: - A nurse note, dated 4/5/22, showed the staff heard a thump and found the resident on the fall mat next to his/her bed. The resident complained of hitting his/her right eye. Noted a red spot above the right eye and light redness on his/her back; - Fall assessment dated [DATE] showed the resident was a moderate fall risk. During an interview on 6/8/22 at 2:34 P.M., the resident's spouse said: - Facility staff used fall mats during evenings for safety and they also used bolster sides. Observation on 6/6/22 at 3:29 P.M. showed the resident had fall mats stacked against the wall behind the resident's bed and bolster sides were on the resident's bed. Observation on 6/9/22 at 12:41 P.M. showed: - Fall mats were placed next to the resident's floor and the resident was laying in bed. During an interview on 6/08/22 at 2:36 P.M. Licensed Practical Nurse (LPN) A said: - Fall preventions for the resident included bolsters on the side of the resident's bed and they moved him/her to a room closer to the nurse station. 2. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/13/22, showed the following: - Date admitted [DATE]; - Cognitively intact; - Was independent with bed mobility; - Was independent with transfers including to and from bed, chair, wheelchair, and standing position (excluding to and from the bath/toilet); - Bed rail was not indicated as used. Review of the resident's care plan dated 4/21/22 did not show any information about the use of rails. Observation on 6/7/22 at 9:28 A.M., showed the resident had grab bars During an interview on 6/7/22 at 9:28 A.M. the resident said the bars were for positioning in bed. 3. Review of Resident #30's MDS dated [DATE], showed: - A Brief Interview of Mental Status (BIMS) of 15 which indicated no cognitive impairment; - Diagnoses of : unsteadiness on feet, overactive bladder (a sudden uncontrolled need or urge to urinate), hypertension, diabetes mellitus (a long-lasting health condition that affects how your body turns food into energy), personality with behavior disorder and nocturia (a condition that causes you to wake at night to urinate). -Has had two falls with no injuries; -Requires limited assistance of one staff member for Activities of Daily Living (ADL's); -Is not steady with walking or movements; -Impairment on one side of the body; -Uses a wheelchair or walker for mobility. Review of resident's electronic health record showed fall events on : - 1/1/2022 at 6:04 P.M. - 1/22/2022 at 1:00 P.M. - 2/3/2022 at 5:10 P.M. - 2/10/2022 at 1:19 P.M. - 2/18/2022 at 11:22 P.M. - 4/28/2022 at 1:00 P.M. - 5/6/2022 at 11:51 P.M. - 5/8/2022 at 2:14 P.M. - 5/17/2022 at 9 :15 P.M. - 6/1/2022 at 4:30 A.M. - 6/4/2022 at 11:06 P.M. Review of a radiology report dated 5/18/22 showed: -2nd proximal phalanx shaft fracture without malalignment. (the small bone closest to the hand in the pointer finger has a fracture); - Soft tissues (tendons,ligaments, and blood vessels) appear swollen. Review of the resident's undated care plan showed: - He/she participates in restorative therapy. - Physical therapy to evaluate and treat as needed. - Heavy duty grab bar in bathroom and outside bathroom. - He/she needs assist of one staff with a gait belt for transfers. - He/she will transfer him/herself independently at times. -The care plan did not address the history of falls, cause of the falls or interventions to prevent further falls. -No care plan to address behaviors. During an interview on 6/9/22 at 9:48 A.M., the resident said: - He/she falls a lot. - He/she does not want to fall. - He/she turns on the call light , staff do not always come so he/she tries to get up him/herself. - He/she broke this finger (indicating left first finger) when he/she fell. During an interview on 6/9/22 at 9:16 A.M., Certified Nurse Aide (CNA) A said: - He/she believes the resident places him/herself on the floor for attention. - He/she has not seen the resident place him/herself on the floor. - Fall interventions should be in the care plan. During an interview on 6/9/22 at 9:23 A.M., Registered Nurse (RN) A said: - Every fall is written on the care plan. - New interventions are put in place with each fall. During an interview on 6/9/22 at 9:55 A.M., Licensed Practical Nurse (LPN) A said: - Each fall is not care planned unless there are changes in approach. - New approaches should be tried with each fall. During an interview on 6/9/22 at 12:20 P.M., the Administrator said: - He/she expected fall interventions to be care planned. - He/she believes Resident #30's falls are behavioral. 4. During an interview on 6/09/22 at 12:35 P.M. Certified Nurse Aide (CNA) A said: - Care plans were kept behind nurse station. CNA's have access to them to review; - The more falls a resident has, the more interventions were in the care plans; - Wounds were addressed that they are at risk for the wounds; - Grab bars were addressed on the care plan. During an interview on 6/9/22 at 11:19 A.M., the MDS Coordinator said: - She was responsible for updating care plans. Care plans were updated quarterly on the computer and hand written updates were made as needed; - Changes were discussed during weekly risk meetings; - Fall mats, and bolster sides should be addressed on the care plan; - If a resident is prescribed psychotropic medication, it should be addressed on the care plan; - If a resident comes in and the bed had grab bars on them and the resident does not need them, it would not necessarily be on the care plan and they do not take them off the bed because they were not a restraint. During an interview on 6/09/22 at 12:41 P.M. the Director of Nursing (DON) said: - The use of grab bars should be on the care plan; - The use of fall mats and bolster sides should be on the care plan. 6. During an interview on 6/9/22 at 12:41 P.M., the Administrator said: - Anyone could update the care plan. The MDS Coordinator was responsible to make sure updates are accurate. Risk management met weekly for needed updates. - The use of grab bars should be on the care plan.

Based on interviews and record review, the facility failed to develop and implement a fall plan for one of 13 sampled residents who was at risk for falls, had multiple falls and a recent fall with an injury (Residents #30). The facility census was 51. Review of the facility policy Fall Protocol and Management dated 4/15/22 showed: -The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall and implementing interventions to prevent falls. 1. Review of Resident #30's Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff) dated 4/27/22, showed: - A Brief Interview of Mental Status (BIMS) of 15 which indicated no cognitive impairment; - Diagnoses of : unsteadiness on feet, overactive bladder (a sudden uncontrolled need or urge to urinate), hypertension (high blood pressure), diabetes mellitus (a long-lasting health condition that affects how your body turns food into energy), personality with behavior disorder and nocturia (a condition that causes you to wake at night to urinate); -Has had two falls with no injuries; -Requires limited assistance of one staff member for Activities of Daily Living (ADL's); -Is not steady with walking or movements; -Impairment on one side of the body; -Uses a wheelchair or walker for mobility. Review of the resident's undated care plan showed: - He/she participates in restorative therapy. - Physical therapy to evaluate and treat as needed. - Heavy duty grab bar in bathroom and outside bathroom. - He/she needs assist of one staff with a gait belt for transfers. - He/she will transfer him/herself independently at times. -The care plan did not address the history of falls, the cause of the falls or interventions put into place after each fall. Review of resident's electronic health record showed on : - 1/1/22 at 6:04 P.M. Resident was found by staff on the floor in between the wheelchair and recliner chair. Resident reports that he/she was trying to make his/her bed. - 1/22/22 at 1:00 P.M. Resident was found sitting in front of his/her recliner holding on to the grab bar on the wall. When asked how he/she fell, the resident states he/she was holding onto the grab bar on the wall and lost his/her balance. Resident states he/she was trying to go to bed. - 2/3/22 at 5:10 P.M., He/she was found on the floor, stating he/she was trying to get a ring off the antlers above his/her head and the wheelchair moved. - 2/10/22 at 1:19 P.M., Resident found by staff on the floor. He/she reports he/she could not wait to use the bathroom, and reports he/she slid from recliner to floor. - 2/18/2022 at 11:22 P.M., A staff member answered his/her call light to find the resident on the floor beside his/her bed. Resident said he/she was getting him/herself up to the bathroom. - 4/28/22 at 1:00 P.M., Resident had a fall in the bathroom, found lying on the floor. He/she stated he/she was trying to clean him/herself up and fell. - 5/6/22 at 11:51 P.M., Staff found resident on the floor, yelling for help. He/she states he/she was leaning for the remote and fell out of bed. - 5/8/22 at 2:14 P.M., He/she states he/she fell from reaching over his/her bed for the remote; falling onto his/her side. Review of the undated care plan for at risk for falls related to gait/balance did not show any documentation for the falls or interventions to prevent further falls. Review of resident's fall risk assessment showed: - 5/9/22 Resident score is 16. Indicates high risk for falls. Review of resident's electronic health record showed on: - 5/17/22 at 9 :15 P.M., Resident had the light on and was found sitting on the floor with right hand hanging on to grab bar in bathroom. He/she complains of hitting left hand on toilet, complaining of discomfort in left hand. His/her knuckles are red but no bruises at this time. His/her floor was wet. - 5/18/22 at 9:39 A.M., Staff noted Resident's left hand knuckles were bruised and swollen with normal range of motion (normal range of movement of a joint). Review of radiology report dated 5/18/22 showed: -2nd proximal phalanx shaft fracture without malalignment. Soft tissues appear swollen. Review of resident's electronic health record showed on: - 5/19/22 at 3:16 A.M., He/she has a splint to the index finger on his/her left hand due to fracture. Review of resident's fall risk assessment showed: - 5/31/22 Resident score is 12. Indicates moderate risk for falls. Review of resident's electronic health record showed on: - 6/1/22 at 4:30 A.M., Staff answered resident's call light to find resident on the floor on his/her knees with his/her bedspread underneath him/her. Resident stated he/she leaned over to get his/her call light. The call light was observed clipped to his/her pillow. - 6/4/22 at 11:06 P.M., he/she was found sitting upright on the floor in the bathroom with urine on the floor. During an interview on 6/7/22 at 10:54 A.M., the resident said he/she had several falls lately. During an interview on 6/9/22 at 9:16 A.M., Certified Nurse Aide (CNA) A said: - He/she is aware Resident #30 falls but does not believe he/she falls a lot. - He/she believes the resident places him/herself on the floor for attention. - He/she has not seen the resident place him/herself on the floor. During an interview on 6/9/22 at 9:23 A.M., Registered Nurse (RN) A said: - Every fall is written on the care plan. - New interventions are put in place with each fall. During an interview on 6/9/22 at 9:48 A.M., the resident said: - He/she falls a lot. - He/she does not want to fall. - He/she turns on the call light; staff do not always come so he/she tries to get up by him/herself. - He/she broke this finger (indicating his/her left first finger) when he/she fell. During an interview on 6/9/22 at 9:55 A.M., Licensed Practical Nurse (LPN) A said: - Each fall is not care planned unless there are changes in approach. - New approaches should be tried with each fall. During an interview on 6/9/22 at 12:20 P.M., the Therapy Supervisor said: - Resident #30 was non-complaint with therapy. - Therapy recommended grab bars inside and outside the bathroom. - He/she attends risk meetings every week where falls are discussed and makes recommendations as needed. During an interview on 6/9/22 at 12:20 P.M., the Administrator said: - He/she would expect fall interventions to be care planned. - Grab bars were moved when Resident #30 moved rooms. - Incentive programs have been discussed and Resident #30 chose to go on a drive. - He/she believes Resident #30 's falls are behavioral.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation, and failed to review the risks and benefits with the resident or resident representative and failed to obtain informed consent from resident or resident representative. This affected three of 13 sampled residents (Residents #22, #47, and #50). The facility census was 51. Review of the pamphlet titled A Guide to Bed Safety, dated October 2000, included: - Which ways of reducing risk are best: o A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety. Many patients go through a period of adjustment to become comfortable with new options. Patients and their families should talk to their health care planning team to find out which options are best for them; - Patient or family concerns about bed rail use: o Encourage patients or family to talk to their health care planning team to determine whether or not bed areas are indicated; o Reassure patients and their families that in many cases that patient can sleep safely without bed rails; o Reassess the need for using bed rails on a frequent, regular, basis. 1. Review of Resident #22's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 4/13/22, included the following: - Date admitted [DATE]; - Cognitively intact; - Was independent with bed mobility; - Was independent with transfers including to and from bed, chair, wheelchair, and standing position (excluding to and from the bath/toilet); - Bed rail was not indicated as used. Review of the resident's care plan dated 4/21/22 did not show any information about the use of rails. Review of the resident's medical records showed: - There were no orders or assessments for the use of bed rails; - No records of informed consent received from the resident or his/her representative. Observation on 6/7/22 at 9:28 A.M. showed the resident had grab bars on both sides of his/her bed. During an interview on 6/7/22 at 9:28 A.M., the resident said the bars were for positioning in bed. 2. Review of Resident #47's quarterly MDS dated [DATE], included the following: - Date admitted [DATE]; - Cognitively intact; - Required limited assistance with bed mobility and transfers; - Bed rails were not indicated as used. Review of the resident's care plan dated 6/3/22 showed the resident used grab bars for repositioning in bed. Review of the resident's medical records showed: - There were no orders, or assessments for the use of rails; - There were no records of informed consent received from the resident or his/her representative. Observation on 6/6/22 at 11:40 A.M., showed the resident had grab bars on both sides of his/her bed. During an interview on 6/6/22 at 11:40 A.M., the resident said he/she used the rails a little for positioning in bed. 3. Review of Resident #50's comprehensive MDS dated [DATE] included the following: - Date admitted [DATE]; - Cognitively intact; - Required extensive assistance with bed mobility and transfers; - Bed rails were not indicated as used on the assessment. Review of the resident's care plan dated 6/3/22 showed used grab bars for bed mobility. Observation on 6/6/22 at 2:15 P.M., showed the resident's bed had grab bars on both sides of his/her bed. During an interview on 6/6/22 at 2:15 P.M. the resident said he/she used the grab bars for positioning. Review of the resident's medical records showed: - There were no orders, or assessments for the use of rails; - There were no records of informed consent received from the resident or his/her representative. 4. During an interview on 6/09/22 at 12:41 P.M. the Director of Nursing (DON) said: - She did not know assist grab bars had the same requirements as bed rails. - She did not think of them rails because they were so small and tight fitting to the mattress. During an interview on 6/8/22 at 3:02 P.M., the Administrator said: - The facility did not utilize side rails, only grab bars. - The grab bars were only used for positioning; - They did not use them to keep residents from falling out of bed; - They have used grab bars for years for positioning. - She believed most residents who use them are cognitively intact. - They would not have orders or assessments for the grab bars because they did not consider them bed rails.

Based on observation, interview, and record review, the facility failed to ensure staff labeled lorazepam liquid (an anti-anxiety medication) with an opening date which affected one resident (Resident #26) and failed to label liquid morphine sulfate (narcotic pain medication) with an opening date for one resident (Resident #35). The facility census was 53. Review of the facility's Administering Medications Policy, revised December 2012, showed: - When opening a multi-dose container, the date opened shall be recorded on the container. Review of the lorazepam liquid manufacturer's guidelines, updated October 2012, showed: - Discard opened bottle after 90 days. 1. Observation and interview on 6/5/19, at 9:36 A.M., of the medication room refrigerator, with Registered Nurse (RN) A showed: - Resident #26's lorazepam bottle was not labeled with an open or discard date; the narcotic sheet indicated staff opened the lorazepam on 3/6/19. - RN A said lorazepam should be labeled upon opening. 2. Observation and interview on 6/5/19, at 9:50 A.M., of the medication cart, with Certified Medication Technician (CMT) A showed: - Resident #35's morphine sulfate bottle not labeled with an open or discard date; - The narcotic sheet indicated staff opened the bottle on 8/25/18, and manufacturer's expiration date of February 2020. - CMT A said morphine should be labeled upon opening. 3. During an interview on 6/6/19, at 3:00 P.M., the Director of Nursing (DON) said: - Staff should label all multi-dose medications upon opening, including lorazepam and morphine. - Liquid lorazepam is good for 90 days upon opening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Review of the facility's Weight Monitoring policy, dated 9/21/16, showed: - In recognition of the fact that large weight variances, particularly weight loss trends, are significant risk factors for the ill and debilitated elderly, this facility will closely monitor weight changes in each resident for each month. - The Restorative Assistant or designee will complete monthly weights for each resident on or around the first Monday of each month. - The Restorative Aide or designee will give the report of weights to the charge nurse who will sign acknowledging receiving the weights. - The charge nurse will address any concerns and then file it in the weight book that will be kept at the nurse's station. 9. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment, a federally mandated assessment completed by facility staff, dated 3/13/19, showed: - No cognitive issues. - Required limited assistance with one person physical assistance for ADLs. - Diagnoses included: atrial fibrillation and heart failure. Review of the resident's June, 2019 physician's order sheet (POS) showed: - An order for the resident to be weighed weekly, with a start date of 12/4/18. - An order for Ensure, a liquid nutritional supplement, taken twice a day. - An order for high fiber diet, regular texture, regular/thin consistency. Review of the resident's care plan, revised on 3/14/19, showed: - Resident on regular diet. - Weigh the resident weekly, monthly or as the physician orders. Review of the resident's medical record showed staff did not document a weight for the resident for the weeks of: - 1/22/19 1/28/19, 3/11/19, 4/1/19, 4/29/19, and 5/21/19. 10. Review of Resident #25's quarterly MDS assessment, dated 5/15/19, showed: - No cognitive issues. - Required extensive assistance with one to two person physical assistance with ADLs, - Diagnoses included: diabetes. - Weight loss of 5% or more in the last month or loss of 10% or more in the last six months; - Therapeutic diet. Review of the resident's current POS showed: -Weekly weights, if weight above 3 pounds, give Lasix (a medication used to reduce fluid retention), start date of 3/28/19. - An order for Med Pass 60 milliters (ml) three times a day, with a start date of 4/2/19. Review of the resident's revised care plan, dated 3/15/19, showed: - Monitor nutritional status, serve diet as ordered. Review of the resident's medical record showed staff did not document the a weekly weight for the resident on the follow weeks: - 4/8/19, 4/15/19, 4/22/19 and 4/29/19, and 5/13/19. 11. During an interview on 6/6/19, at 4:00 P.M., the DON said nursing staff are responsible for obtaining the resident's weights, she was not sure why the resident's weight were not obtained as ordered, all residents' weights should be taken and documented at least monthly or as ordered by the resident's physician. Based on observation, interview, and record review, the facility failed to ensure staff provided services that meet professional standards of quality of care when staff failed to use the medication administration record (MAR) and follow the 5 Rights of medication administration (right patient, right drug, right dose, right route, and right time) when staff performed accuchecks, administered insulin, and documented administration of insulin for six out of 14 sampled residents (Resident #2, #4, #6, #9, #12, and #51) and failed to obtain weekly weights, as ordered by the residents' physicians, to monitor for weight variances. This affected two of sixteen sampled residents (Residents #17 and #25). The facility census was 53. 1. Review of the facility's Administering Medications Policy, revised December 2012, showed: - Medications shall be administered in a safe and timely manner, and as prescribed. - The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. - The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. - As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: the date and time the medication was administered, the dosage, route of administration, the injection site, and signature and title of the person administering the drug. Review of the facility's Insulin Administration Policy, revised September 2014, showed: - To provide guidelines for the safe administration of insulin to residents with diabetes. - The type of insulin, dosage requirements, strength, and method of administration must be verified before administration , to assure that it corresponds with the order on the medication sheet and the physicians order. 2. Review of Resident #6's quarterly MDS, dated [DATE], showed: - Moderately cognitive impaired; - Limited assist of one staff for activities of daily living (ADLs); - Diagnoses included: DM and depression; - Daily insulin injections. Observation and interview on 6/5/19, at 11:46 A.M., showed: - Certified medication technician (CMT) B performed an accucheck on the resident without a MAR or recording the blood sugar of 144; - CMT B said the resident did not receive insulin. - CMT B did not have a MAR or electronic medical record (EMAR) to verify insulin dosage or documented the resident's blood sugar. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Extensive assist of two staff for ADLs; - Diagnoses included: DM, dementia, anxiety, and depression; - Daily insulin injections. Observation on 6/5/19, at 11:53 A.M., showed: - CMT B performed an accucheck without a MAR/EMAR or recording the blood sugar of 229. - CMT B administered Humalog insulin pen (rapid acting insulin) 8 units (U) to the left abdomen per the directions on the insulin pen without consulting the MAR/EMAR or utilizing the 5 Rights of medication administration. - He/she did not document on the MAR/EMAR the insulin given or the location. 4. Review of Resident #4's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Limited assist of one staff for ADLs; - Diagnoses included: DM, high blood pressure, pneumonia, depression, and lung disease; - Daily insulin injections. Observation on 6/5/19, at 11:59 A.M., showed: - CMT B performed an accucheck without consulting the MAR/EMAR or recording the blood sugar of 186; - CMT B said the resident only receives sliding scale insulin if his/her blood sugar is above 250; - He/she did not have a MAR/EMAR to verify insulin dosage or documented the resident's blood sugar. 5. Review of Resident #12's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Limited assist of one staff for ADLs; - Diagnoses included: DM, anxiety, depression, and lung disease; - Daily insulin injections. Observation on 6/5/19, at 12:08 P.M., showed: - CMT B performed an accucheck without consulting the MAR/EMAR and without recording the blood sugar of 226. - CMT B said to the resident, he/she would be back; he/she had to go find a computer to look up sliding scale insulin. - CMT B came back to resident and said he/she would receive Novolog insulin pen (rapid acting insulin) 6Us scheduled and 6Us sliding scale for a total of 12U. - CMT B did not have a MAR/EMAR or computer with him/her to confirm dosage prior to administering. - CMT B administered Novolog insulin pen 12 U to the right abdomen. - CMT B did not document insulin administered or location of injection. 6. Review of Resident #9's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/1/19, showed: - Cognitively intact; - Extensive one assist of staff for ADLs; - Diagnoses included: diabetes mellitus (DM), stroke, heart disease, and depression; - Daily insulin injections. Observation on 6/5/19, at 12:14 P.M., showed: - CMT B performed an accucheck without a MAR and without recording the blood sugar of 208; - CMT B said the resident did not get any insulin based on the label on the insulin pen. - CMT B did not have a MAR to verify insulin dosage or documented the resident's blood sugar. 7. Review of Resident #51's quarterly MDS, dated [DATE], showed: - Cognitive intact; - Extensive assist of one to two staff for ADLs; - Diagnoses included: DM, high blood pressure, and depression; - Daily insulin injections. Observation on 6/5/19, at 12:17 P.M., showed: - CMT B performed an accucheck without consulting the MAR and without recording the blood sugar of 210; - He/she administered Novolog insulin pen 30U to the left abdomen per the directions on the insulin pen without consulting the MAR/EMAR and without utilizing the 5 Rights of medication administration. - CMT B did not document on the MAR/EMAR the insulin given and location. 6. During an interview 6/6/19, at 1:20 P.M., CMT B said: - He/she did not have a computer or MAR/EMAR to verify accucheck or insulin administration. - He/she said there was not enough room for the computer and MAR/EMAR on top of the insulin medication cart. - He/she relies on memory and the resident's label on the insulin pen. - Staff should verify accucheck and insulin dosage with the MAR/EMAR prior to administering and follow the 5 Rights of medication administration. - He/she charts the accuchecks, location of injection, and insulin administered after he/she done with insulin administration. 7. During an interview on 6/6/19, at 3:00 P.M., the Director of Nursing (DON) said: - Staff should always use the MAR/EMAR and the 5 Rights of medication administration with every medication. - Staff should verify the accucheck and insulin orders with the MAR/EMAR prior to administering. - Staff should document the blood sugar on the MAR/EMAR upon obtaining it. - Staff should document on the MAR/EMAR insulin administration and location upon receiving the insulin. - Staff should follow the facility's policy and procedures with medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made four medication errors out of 27 opportunities for error, resulting in a medication error rate of 14.8%. This affected four of 14 sampled residents (Resident #2, #12, #33, and #51). The facility census was 53. Review of the facility's Administrating Medication Policy, dated 2001, showed: - Medications must be administered in accordance with the orders; - Staff administering the medication must initial the resident's medication administration record (MAR) on the appropriate line after giving each medication and before administering the next ones. Review of the facility's Insulin Administration Policy, dated 2001, showed: - The type of insulin, dosage requirements, strength, and method of administration must be verified before administering, to assure that it corresponds with the order on the medication sheet and the physician's order. - When injecting the insulin pen needle under the skin, press the button all the way returning to zero, and keep pressing for 6 to 10 seconds and withdrawal from the skin. Review of the Humalog Insulin KwikPen manufacturer's insert, dated 1/6/17, showed: - Insert the needle into the skin, push the dose down all the way and continue to hold the dose knob in and slowly count to 5 before removing the needle. Review of the Novolog Insulin Flexpen manufacturer's insert, dated 2017, showed: - Insert the needle into the skin, press push-button all the way in until 0 lines up with the pointer. - The needle must remain in the skin for at least 6 seconds to ensure that the full dose has been injected. Review of the dosage and administration instructions for Miralax (laxative) manufactures website showed: - Measure the dose with the medicine cap on the bottle. The cap contains dose marks on the inside. - Pour the powder into 4 to 8 ounces of of a cold or hot beverage. - Stir the mixture until dissolved. 1. Review of Resident #33's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 4/13/19, showed: - Cognitively intact; - Independent with activities of daily living (ADLs); - Diagnoses included: anxiety, depression, dementia, lung disease, and dementia. Review of the resident's June 2019 physician's order sheet (POS) showed: - Miralax powder (treats constipation) 17 grams (gm) by mouth one time a day, mix with 4-8 ounces (oz). Observation on 6/5/19, at 9:17 A.M., showed the following as Certified Medication Technician (CMT) B passed medications: - He/she measured the resident's Miralax in a 30 milliliter (ml) measuring cup, filled to the top, and did not use the measuring lid provided with the Miralax bottle. - He/she walked in the resident's room, poured the Miralax into a plastic cup, added water without measuring, then handed the cup to the resident to stir. - The resident stirred the contents a few times, then drank the Miralax not fully dissolved and the incorrect dosage of Miralax. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Extensive two assist with ADLS; - Diagnoses included: diabetes mellitus (DM), anxiety, dementia, and depression; - Daily insulin injections. Review of the resident's POS, dated June 2019, showed: - Humalog (rapid acting insulin) 100 units (U)/ml, inject 8U subcutaneous (beneath the skin) before meals for diabetes. Observation on 6/5/19, at 11:53 A.M., showed: - CMT B did not have a MAR to check the insulin orders prior to administering. - He/she looked at the directions on the Humalog insulin pen and did not verify the medication or dosage with a MAR. - CMT B dialed the Humalog insulin pen to 2U and disposed of them. - He/she then dialed 8U Humalog, administered the insulin to the left abdomen and did not keep the needle held against the skin for 5 seconds. - Insulin rolled down the resident's abdomen when CMT B removed the needle. - He/she did not document the dosage given, time, or location of injection. 3. Review of Resident #12's quarterly MDS, dated [DATE], showed: - Cognitively intact. - Limited one staff assist with ADLs. - Diagnoses included: DM, lung disease, anxiety, and depression. - Daily insulin injections. Review of the resident's POS, dated June 2019, showed: - Novolog Flexpen 100 U/ml, inject 6U subcutaneous before meals for diabetes. - Novolog Flexpen 100 U/ml, inject 6U sliding scale for blood sugar 201-250. Observation on 6/5/19, at 12:08 P.M., showed: - CMT B did not have the MAR to check the insulin orders prior to administering. - He/she performed an accucheck with a blood sugar of 226. - He/she looked at the directions on the Novolog Flexpen and said the resident would receive 6U scheduled but would have to go locate a computer to look at the MAR to find out sliding scale dosage. - CMT B left the resident in the side room off the dining room and went to locate a computer. - CMT B dialed the Novolog Flexpen to 2U and disposed of them. - He/she then returned without a computer and MAR and said the resident would receive an additional 6 Us. - He/she then dialed 12U Novolog Flexpen, administered to the right abdomen and did not keep the needle held against the skin for 6-8 seconds. - He/she did not document the dosage given, time, or location of injection. 4. Review of Resident #51's quarterly MDS, dated [DATE], showed: - Cognitively intact. - Extensive one to two staff with ADLs. - Diagnoses included: DM, high blood pressure, and depression. - Daily insulin injections. Review of the resident's POS, dated June 2019, showed: - Novolog (rapid acting insulin) 100 U/ml, inject 30U subcutaneous before meals for diabetes. Observation on 6/5/19, at 12:20 P.M., showed: - CMT B did not have the MAR to check the insulin orders prior to administering. - He/she looked at the directions on the Novolog insulin pen and did not verify the medication or dosage with a MAR. - CMT B dialed the Novolog Flexpen to 2U and disposed of them. - He/she then dialed 30U Novolog Flexpen, administered to the left abdomen and did not keep the needle held against the skin for 6-8 seconds. - Insulin rolled down the resident's abdomen when CMT B removed the needle. - He/she did not document the dosage given, time, or location of injection. 5. Review of Resident #12's quarterly MDS, dated [DATE], showed: - Cognitively intact. - Limited one staff assist with ADLs. - Diagnoses included: DM, lung disease, anxiety, and depression. - Daily insulin injections. Review of the resident's POS, dated June 2019, showed: - Novolog Flexpen 100 U/ml, inject 6U subcutaneous before meals for diabetes. - Novolog Flexpen 100 U/ml, inject 6U sliding scale for blood sugar 201-250. Observation on 6/5/19, at 12:08 P.M., showed: - CMT B performed an accucheck without consulting the MAR/EMAR and without recording the blood sugar of 226. - CMT B said to the resident, he/she would be back; he/she had to go find a computer to look up sliding scale insulin. - CMT B came back to resident and said he/she would receive Novolog insulin pen (rapid acting insulin) 6Us scheduled and 6Us sliding scale for a total of 12U. - CMT B did not have a MAR/EMAR or computer with him/her to confirm dosage prior to administering. - CMT B administered Novolog insulin pen 12 U to the right abdomen. - CMT B did not document insulin administered or location of injection. 6. During an interview on 6/6/19, at 1:20 P.M., CMT B said: - He/she measured Miralax and poured it in a 30 ml measuring cup since the measuring tool provided appeared too big of a dose. - He/she should measure the Miralax with the measuring lid provided, measure 4 to 8 oz of water, and stir until dissolved. - He/she should use the resident's MAR to administer medications to ensure proper medication and dosage per physician orders and document when medications are administered. - He/she stated insulin pens should only be held against the skin until a click is heard, maybe one second, and then remove the pen from the skin. During an interview on 6/6/19, at 3:00 P.M., the Director of Nursing (DON) said: - Staff should follow the resident's MAR to administer medications and should document when the medication is given. - Staff should measure Miralax with the measuring lid provided, add 4 to 8 oz of water, and completely dissolve before administering. - Staff should follow the resident's MAR when administering insulin to ensure the right medication, dosage, injection site, and document upon administering. - Staff should hold insulin pens against the resident's skin for at least 5 to 6 seconds to ensure all medication is administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff provided care in a manner to prevent infections or the possibility of infection when staff did not appropriate clean glucometers between residents; failed to provide a clean field for the glucometer and supplies on the medication cart and in the resident's room; failed to removed gloves and wash their hands between dirty and clean tasks and in between resident care; and failed to clean the tip of the insulin pen prior to applying the needle. This affected six out of 14 sampled residents (Resident #2, #4, #6, #9, #12, and #51). The facility census was 53. Review of the facility's Obtaining a Fingerstick Glucose Level Policy, revised October 2011, showed: - Always ensure that the blood glucose meters intended for reuse are cleaned and disinfected between resident uses. - Clean and disinfect reusable equipment between each resident's use with a disinfecting wipe and allow time for glucometer to dry. - Remove gloves and discard into designated container. - Wash hands or hand sanitize. Review of the facility's Personal Protective Equipment - Using Gloves Policy, revised September 2010, showed: - To prevent the spread of infections; wounds from contamination; hands from potentially infectious material; and to prevent exposure to HIV (AIDS) and hepatitis B (HBV) viruses from blood or body fluids. - Wash hands or hand sanitize after removing gloves; gloves do not replace hand washing. Review of the facility's Hand washing/Hand Hygiene Policy, revised August 2015, showed: - All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. - Use an alcohol-based hand rub or soap and water for the following situations: before and after direct contact with residents, before preparing and handling medications, before performing any non-surgical invasive procedures, after contact with blood or bodily fluids, and after removing gloves. Review of the facility's Insulin Administration Policy for Insulin Injections via Pens, revised September 2014, showed: - Wash hands. - Wipe the tip of the pen where the needle will be attached with an alcohol wipe and then screw on the needle. - After administering the insulin, wash hands. Review of the undated Evencare G3 glucometer operator's manual showed: - Should be cleaned and disinfected between each patient; - Clean the meter surface with one of the approved disinfected wipes; - Wipe all external areas of the meter including both front and back surfaces until visibly wet; - Wipe meter dry or allow to air dry. 1. Review of Resident #6's quarterly MDS, dated [DATE], showed: - Moderately cognitive impaired; - Limited assist of one staff for ADLs; - Diagnoses included: DM and depression; - Daily insulin injections. Observation on 6/5/19, at 11:46 A.M., showed Certified Medication Technician (CMT) B performed an accucheck on Resident #6 as follows: - He/she hand sanitized and applied gloves. - Cleansed the glucometer with micro-kill one germicidal alcohol wipes, did not let the machine dry and completed the accucheck. - Cleansed the glucometer and placed on the medication cart without a clean field. - Removed gloves and hand sanitized then went immediately to provide care for Resident #2. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Extensive assist of two staff for ADLs; - Diagnoses included: DM, dementia, anxiety, and depression; - Daily insulin injections. Observation on 6/5/19, at 11:53 A.M., showed CMT B did the follow after providing care for Resident #6: - CMT B pushed the medication cart to the resident's room and applied gloves without hand sanitizing or washing his/her hands. - He/she took the glucometer from on top of the medication cart with no barrier and placed on the resident's bedside table without a barrier. - He/she performed the accucheck and placed the glucometer back on top of the medication cart without cleansing or placing on a barrier. - With the same gloves, he/she retrieved the insulin pen, did not clean the tip of the pen with an alcohol wipe prior to applying the needle. - After administering the insulin and still wearing the same gloves, he/she cleaned the glucometer at 11:59 A.M. - Removed his/her gloves and reapplied new gloves without washing his/her hands or hand sanitized, then moved on to provide care for Resident #4. 3. Review of Resident #4's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Limited assist of one staff for ADLs; - Diagnoses included: DM, high blood pressure, pneumonia, depression, and lung disease; - Daily insulin injections. Observation on 6/5/19, at 11:59 A.M., showed: - CMT B left Resident #2's room, removed gloves, reapplied gloves without washing his/her hands or sanitizing, cleansed glucometer with micro-kill one germicidal alcohol wipe and immediate walked into Resident #4's room without letting the glucometer dry. - He/she performed accucheck, walked out of the resident's room and placed glucometer on top of the medication cart without cleaning or barrier. - Removed his/her gloves and did not wash or sanitize his/her hands then moved on to provide care to Resident #12. 4. Review of Resident #12's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Limited assist of one staff for ADLs; - Diagnoses included: DM, anxiety, depression, and lung disease; - Daily insulin injections. Observation on 6/5/19, at 12:08 P.M., showed: - CMT B left Resident #4's room, removed his/her gloves, did not his/her wash or hand sanitize his/her hands and pushed the medication cart to the dining room. - He/she took the resident to the dining side room to perform an accucheck and pushed the wheelchair. - He/she applied gloves without washing or sanitizing his/her hands and cleansed the glucometer with with micro-kill one germicidal alcohol wipe then immediately performed the accucheck without letting the glucometer dry. - CMT B placed the glucometer back on the medication cart without cleaning or a barrier. - With the same gloves, he/she retrieved the insulin pen and did not clean the tip of the pen with an alcohol wipe prior to applying the needle. - He/she returned the insulin pen to the medication cart, removed his/her gloves, and did not wash or hand sanitize hands before moving on to provide care for Resident #9. 5. Review of Resident #9's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/1/19, showed: - Cognitively intact; - Extensive one assist of staff for activities of daily living (ADLs); - Diagnoses included: diabetes mellitus (DM), stroke, heart disease, and depression; - Daily insulin injections. Observation on 6/5/19, at 12:14 P.M., showed: - He/she applied new gloves without washing or hand sanitizing his/her hands from previous insulin administration with Resident #12. - CMT B cleansed the glucometer with micro-kill one germicidal alcohol wipe and immediately performed the accucheck without letting the glucometer dry and placed on the table in the dining side room. - Removed his/her gloves and placed glucometer on the medication cart without cleaning or a barrier then moved on to provide care for Resident #51. 6. Review of Resident #51's quarterly MDS, dated [DATE], showed: - Cognitive intact; - Extensive assist of one to two staff for ADLs; - Diagnoses included: DM, high blood pressure, and depression; - Daily insulin injections. Observation on 6/5/19,at 12:17 P.M., showed: - CMT B applied new gloves without washing or hand sanitizing his/her hands from previous accucheck with Resident #9. - He/she cleansed the glucometer with micro-kill one germicidal alcohol wipe and immediately performed the accucheck without letting the glucometer dry then placed it on the table in the dining side room. - With the same gloves, he/she retrieved the insulin pen and did not clean the tip of the pen with an alcohol wipe prior to applying the needle. - He/she returned the insulin pen to the medication cart, removed his/her gloves, placed the uncleansed glucometer back in the medication cart, and did not wash or hand sanitize hands. 7. During an interview on 6/6/19, at 1:20 P.M., CMT B said: - Staff do not need to removed gloves and wash their hands in between cleansing the glucometer, completing the accucheck, retrieving the medication, and administering the medication. - He/she should have removed his/her gloves and wash his/her hands or use hand sanitizer in between residents. - The glucometer does not need but a few seconds to dry and use on the next resident. - The insulin pen does not need the tip cleansed with an alcohol wipe prior to applying the needle. - A barrier is not needed when placing the glucometer on the bedside table or top of medication cart. - Staff should follow manufacturer's guidelines and facility policies when completing accuchecks, cleansing glucometers, and administering insulin. During an interview on 6/6/19, at 3:00 P.M.,the Director of Nursing (DON) said: - Staff should wash or sanitize hands and apply new gloves before completing an accucheck, insulin, and cleaning the glucometer. - Staff should removed their gloves and wash their hands from dirty to clean tasks. - Staff should wash or sanitize their hands in between providing resident care. - Staff should use a barrier when placing the glucometer on the resident's bedside table and on top of the medication cart. - Staff should clean the glucometer with the micro-kill one germicidal alcohol wipe and allow it to completely dry around 3 to 5 minutes. - Staff should cleanse the tip of the insulin pen with alcohol prior to applying the needle. - Staff should follow all facility policies and manufacturer's guidelines.