**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, the facility failed to ensure walls in a resident's room did not have stains (room [ROOM NUMBER]A) and failed to ensure a call light panel was securely attached to the wall behind a resident's bed (room [ROOM NUMBER]B) for 2 of 4 rooms on 1 of 3 halls (100 hall) reviewed for a safe, clean and homelike environment. Findings included: 1. On 2/23/2025 at 10:39 am the wall beside the bed in room [ROOM NUMBER]A had two 4-centimeters by 3-centimeters dried, dark brown stains. During observations on 2/24/2025 at 9:59 am and on 2/25/25 at 8:57 am the two 4-centimeters by 3-centimeters dried, dark brown stains remained on the wall beside the bed in room [ROOM NUMBER]A. On 2/25/2025 at 9:18 am Nurse Aide #2 was interviewed, and she stated she was assigned to room [ROOM NUMBER]A and housekeeping was responsible for cleaning the walls. Nurse #1 was interviewed on 2/25/2025 at 9:00 am and she stated room [ROOM NUMBER]A was on her assignment but had not noticed the two dried, dark brown stains to his wall. Nurse #1 stated housekeeping was responsible for cleaning the walls in the room. During an interview with Housekeeper #1 on 2/25/2025 at 9:12 am she stated the two 4- centimeters by 3-centimeters dried, dark brown stains on the wall beside the bed in room [ROOM NUMBER]A was dried stool. Housekeeper #1 stated she had the same assignment on 2/24/2025 and did not notice the stains on the wall beside the bed but housekeeping cleaned the walls twice a week in the residents' rooms. The Administrator was interviewed on 2/26/2025 at 9:15 am and she stated she was not aware of the two dried, dark brown stains on the wall beside his bed in room [ROOM NUMBER]A. She stated the walls should be washed daily when housekeeping completed the daily room cleaning and as needed. 2. On 2/23/2025 at 10:44 am an observation of room [ROOM NUMBER]B revealed the call light panel, which was above the head of the resident's bed, was detached from the wall and protruded 1 inch. The panel had a thick amount of caulk around the outer edges of the panel that was broken and the wiring to the panel was visible. On 2/25/2025 at 9:23 am an observation was made of room [ROOM NUMBER]B and the call light panel at the head of the bed continued to protrude from the wall 1-inch and the thick caulk around the edges of the call light panel and the caulk had broken away in areas. The wiring to the panel was visible. The resident in room [ROOM NUMBER]B stated she was afraid the panel would eventually fall out of the wall. During an interview with the Maintenance Director on 2/26/2025 at 8:59 am he stated he came to work at the facility about one month ago. He stated he had not been aware the call light panel in room [ROOM NUMBER]B was protruding from the wall, and it looked like someone had tried to repair around the panel by filling the area between the wall and the panel with caulk instead of fixing the panel flush with the wall. The Maintenance Director stated the protruded call light panel was not a danger to the resident. The Administrator was present during the observation and interview with the Maintenance Director on 2/26/2025 at 8:59 am and was then interviewed on 2/26/2025 at 9:02 am and stated they had fixed a lot of maintenance issues since she came to the facility a month ago and she was not aware the call light panel in room [ROOM NUMBER]B was protruding from the wall. The Administrator stated she was in room [ROOM NUMBER]B on 2/22/2025 and the call light panel was not protruding from the wall that day. The Administrator stated the call light panel should be attached to the wall and they would get it fixed immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to keep a urinary catheter bag and its tubing from touching the floor to reduce the risk of infection for 1 of 3 residents (Resident #55) reviewed with a urinary catheter. The findings included: Resident #55 was admitted to the facility on [DATE]. Her cumulative diagnoses included obstructive uropathy (a condition where the flow of urine is blocked, leading to a buildup of urine in the urinary tract). Resident #55's care plan included an area of focus related to the resident having an indwelling urinary catheter in place (Initiated on 2/6/25). An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #55 had moderately impaired cognition. No behaviors nor rejection of care were reported. The assessment indicated Resident #55 required supervision or touching assistance for eating and personal hygiene; partial to moderate assistance for sit to stand and chair/bed to chair transfers; and substantial to maximum assistance for toileting, bathing, dressing and bed mobility. The MDS reported Resident #55 had an indwelling urinary catheter. An observation was conducted on 2/24/25 at 10:20 AM as Resident #55 was sitting in her wheelchair with a urinary catheter collection bag hanging from her wheelchair. At the time of this observation, 1 inch of the bottom of Resident #55's urinary catheter bag and approximately 2 inches of the catheter tubing were lying on the floor. The resident appeared confused at the time of the observation and could not provide any information regarding her urinary catheter. Another observation was conducted of Resident #55 on 2/26/25 at 8:20 AM as she laid in her bed with the head of the bed raised and her breakfast meal placed on the bedside tray table in front of her. One-half (1/2) of the resident's urinary catheter bag and approximately four (4) inches of the catheter tubing was observed to be lying on the floor. On 2/26/25 at 8:25 AM, Nurse Aide (NA) #1 was identified as the NA who was assigned to care for Resident #55. Accompanied by the NA to Resident #55's room, another observation was made of the resident's catheter bag and tubing lying on the floor. When NA #1 was asked what her thoughts were with regards to the position of the catheter bag and tubing, the NA stated, It shouldn't be on the floor. The NA was observed to wash her hands and don gloves as she prepared to address the positioning of the catheter bag and tubing. Upon her request, an interview was conducted on 2/26/25 at 8:53 AM with the facility's Director of Nursing (DON). The DON stated she was made aware of the concerns related to Resident #55's urinary catheter bag and tubing having been on the floor. She reported that the entire catheter bag and tubing system was replaced this morning since they had been observed to be lying on the floor. An interview was conducted on 2/26/25 at 2:45 PM with the facility's Infection Preventionist. During the interview, the Infection Preventionist reported NA #1 told her about Resident #55's catheter bag and tubing found lying on the floor earlier that morning. The Infection Preventionist stated that because of this observation, she went ahead and changed the whole system. She stated that changing the system, brought it [the catheter bag] up and off the floor. When asked if the catheter bag and tubing should be on the floor, she reported they should not.

Based on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 9 of 91 days reviewed for sufficient nurse staffing (September 2024, October 2024, November 2024). Findings included: Review of the facility's Posted Nurse Staffing for September of 2024 revealed there was not a Registered Nurse scheduled for at least 8 hours a day on September 6, 2024, September 7, 2024, September 21, 2024, and September 22, 2024. The Posted Nurse Staffing for October 2024 was reviewed and there was not a Registered Nurse scheduled for at least 8 hours a day on October 6, 2024 and October 20, 2024. The November Posted Nurse Staffing was also reviewed and there was not a Registered Nurse scheduled for at least 8 hours daily for November 3, 2024, November 16, 2024, and November 17, 2024. During an interview with the Director of Nursing on 2/25/2025 at 1:19 pm she stated she was responsible for the nurse staffing schedule in September 2024, October 2024, and November 2024. The Director of Nursing stated there was a staffing issue during those months and she was aware there was not a Registered Nurse in the facility for 8 hours on the dates in September 2024, October 2024, and November 2024. The Director of Nursing stated they had initiated a plan of correction for the scheduling of a Registered Nurse for 8 hours daily. The Administrator was interviewed on 2/26/2025 at 3:19 pm and she stated she expected nursing to have a Registered Nurse in the building 8 hours a day every day. The Administrator stated she was not the Administrator during September 2024, October 2024, and November 2024 but had reviewed the Plan of Correction initiated during that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews, staff interviews and observations, the facility failed to provide a room free of a strong smell of urine. This was evident in 1 of 5 rooms reviewed for clean, homelike environment (room [ROOM NUMBER]). Findings included: Resident #10 was admitted in the facility on 12/13/13 with the most recent readmission on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 was independent with toilet use and required oversight, encouragement or cueing with personal hygiene with one-person physical assist. Resident #10 required one-person physical assist with bathing with physical help limited to transfer only. A review of Resident #10's care plan dated 4/20/23 revealed Resident #10 Resident sometimes resisted/refused care which may compromise health/ safety/ well-being. Often refused baths and personal hygiene care. Also sometimes refused to allow laundry to wash dirty clothes or allow staff to move dirty clothes piled on the floor. Refused to be evaluated by psych services and medical MD's multiple times. Interventions included to approach resident warmly and positively to convey acceptance, warmth, and welcome and speak in a calm, gentle manner, to provide positive feedback for demonstrating desired behaviors/cooperation with staff and assess for uncommunicated/unmet needs when behaviors occur such as hunger, thirst, pain, and toileting needs and provide appropriate interventions. Interventions also included to be aware resident sometimes refused room rounds to ensure cleanliness of room, identify unsafe situations of presence of inappropriate items. Explain this is for their well-being/comfort and safety and encourage compliance. In addition. resident was very reclusive and didn't want anyone to handle her things. The care plan addressed Resident #10 had occasional bladder incontinence due to her impaired mobility, dependence on staff, increased weakness, and decreased endurance presented a barrier to independent toileting activities. An intervention for bladder incontinence included to utilize disposable briefs to prevent soiling of clothing/ bed linens and reduce risk for skin issues. An observation on 9/25/23 at 2:20 PM of room [ROOM NUMBER] was conducted in conjunction with an interview with Resident #10 who resided in the room. The observation revealed the room smelled strongly of urine from the doorway into the hallway. The bathroom door was open, and the bathroom was observed to be neat and clean. The resident in the bed closest to the window (Resident #10) stated she was continent of bladder but wore a pull up for incontinent episodes. The odor of urine was pungent on Resident #10's side of the room. She said she tried to make it to the bathroom when she needed to urinate but had been incontinent at times. An observation on 9/26/23 at 11:44 AM of room [ROOM NUMBER] was conducted in conjunction with an interview with Resident #10 who resided in the room. The observation revealed the room smelled strongly of urine from the doorway into the hallway. Resident #10 stated housekeeping cleaned the room once a day and the facility did her laundry. She stated she wore pull ups for incontinence episodes. On 9/26/23 at 12:00 PM an interview with the Laundry and Housekeeping Manager revealed housekeeping deep cleaned room [ROOM NUMBER] bimonthly. Resident rooms were swept and mopped daily, and hard surfaces were disinfected daily. She stated, to her knowledge, Resident #10 had not refused to have her room cleaned. On 9/26/23 at 12:03 PM an interview with Housekeepers #1 and #2 revealed Resident #10 did not refuse to allow room to be cleaned. They stated that they cleaned and mopped the room daily, but it still smelled of urine due to Resident #10's incontinence episodes. On 9/26/23 at 12:08 PM an interview with Nurse Aide #3 (NA) revealed she had worked at the facility for 18 years and was usually assigned to Resident #10. She stated Resident #10 would not allow staff to assist her with care because she wanted to be independent. She further stated Resident #10 refused showers because she was very private and preferred to bathe herself in the bathroom sink. She added Resident #10 would not give staff the soiled pad from her bed unless staff had a clean one to provide her. NA #1 added when Resident #10 refused to shower this morning she got NA #4 to try but Resident #10 still refused. An interview with NA #4 on 9/26/23 at 12:12 PM revealed she had worked at the facility for two years and was familiar with Resident #10. She stated that NA #3 had asked her to try to convince Resident #10 to shower but she had refused. Resident #10 was offered a bed bath and she refused. On 9/28/23 at 10:45 AM an observation of room [ROOM NUMBER] was conducted in conjunction with an interview with the Staff Development Coordinator (SDC). Upon entering the room there was no odor of urine noted. The SDC and housekeeping staff were observed in the process of cleaning Resident #10's room. Staff moved furniture and boxes and swept and mopped under them. The waste basket next to Resident #10's bed was clean with a fresh liner. The SDC stated Resident #10 often refused to leave her room so that staff could clean but had agreed to attend activities and allow staff to clean the room this day. She explained Resident #10 was very independent and preferred to bathe herself in the sink rather than shower. On 9/28/23 at 10:46 AM an interview was conducted with the Director of Nursing (DON). The DON stated Resident #10 was adamant she could care for herself and had a right to refuse up to a point. She explained Resident #10 had agreed to palliative care because of her refusal of care and refusal to allow staff to clean her room and linens. She stated she expected Resident #10's room to be clean and free of odors. She explained she expected staff to reapproach Resident #10 often to see if she would allow more assistance with her care and cleanliness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #85 was admitted to the facility on [DATE]. A review of the electronic record for Resident #85 documented he was discharged on 7/26/2023 to a non-Medicare/Medicaid bed at the facility. A review of the discharge MDS assessment, dated 7/26/2023, documented Resident #85 was discharged to an acute care hospital. An interview was conducted with the MDS Coordinator on 9/28/2023 at 3:06 p.m. and she reviewed the MDS discharge assessment, dated 7/26/2023, for Resident #85. She revealed the Resident had been discharged to a non-Medicare/Medicaid bed at the facility and the discharge to the hospital was not accurate. An interview was conducted with the Administrator on 9/28/2023 at 3:18 p.m. and he revealed it was his expectation that all MDS assessments be completed accurately. Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Hospice/End of life care (Resident #74) and discharge location (Resident #85). This occurred for 2 of 23 residents reviewed for accuracy of assessments. The findings included: 1. Resident #74 was admitted to the facility on [DATE] with a cumulative diagnosis which included heart failure and a history of a cerebrovascular accident (stroke). The resident's admission Minimum Data Set (MDS) was dated 5/3/23. A review of the resident's electronic medical record (EMR) revealed her physician orders included a Hospice consult on 5/9/23. A significant change MDS assessment dated [DATE] was completed for resident #74. However, review of this MDS revealed the section on Health Conditions did not indicate the resident had a life expectancy of less than 6 months. Also, the MDS section on Special Treatments, Procedures and Programs did not indicate Resident #74 was receiving Hospice services. An interview was conducted on 9/28/23 at 4:03 PM with the facility's MDS Nurse. When asked what prompted the significant change MDS to be completed for Resident #74 on 5/9/23, the nurse reported it was completed due to the resident's admission to Hospice on 5/9/23. Upon further inquiry, the MDS Nurse reviewed the Section J and Section O of the resident's MDS assessment. At that time, the MDS Nurse reported Section J should have indicated Resident #74's life expectancy was less than 6 months and Section O should have indicated the resident was on Hospice. The MDS Nurse acknowledged these two pieces of information had been miscoded and reported she would submit a correction for them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to implement a comprehensive fall prevention care plan for a resident (Resident #67) with a history of falling. This occurred for 1 of 2 residents reviewed for falls. The findings included: Resident #67 was admitted to the facility on [DATE] with diagnoses that included hemiplegia, cerebral infarction, and convulsions. A review of the annual comprehensive Minimum Data Set (MDS) assessment, dated 6/27/2023, revealed Resident #67 had severe cognitive impairment, required extensive assistance of one staff member for bed mobility, and total assistance of two staff members for transferring. She had no documented falls since the prior assessment. A review of the comprehensive care plan, dated 6/27/2023, identified a focus area that read; Resident #67 was at risk for falls related to multiple factors including her cerebral vascular accident, hemiplegia, increased weakness, decreased endurance, decreased safety awareness, lack of coordination, and cognitive deficits. The interventions included: 1. A fall mat beside the bedside that was started on 6/2/2021. 2. Do not leave the Resident in the room unattended when up in the wheelchair and was started on 1/9/2021. 3. Provide a scoop mattress for the bed and was started on 1/29/2021. A review of the most recent fall incident report history for Resident #67 revealed she experienced an unwitnessed fall from the bed on 7/18/2023. An observation was conducted of Resident #67 on 9/25/2023 at 3:14 p.m. sitting in her wheelchair and the bed did not have a scoop mattress. She was alone in the room. An observation was conducted of Resident #67 on 9/26/2023 at 10:50 a.m. sitting in her wheelchair and a scoop mattress was not on the bed. She was alone in the room. An observation was conducted of Nursing Assistant (NA) #1 and #2 on 9/27/2023 at 3:06 p.m. as they provided assistance, using a mechanical lift, to transfer Resident #67 from the wheelchair to the bed. The Resident was placed onto a non-scooped mattress with no positioning devices. The two NA's then asked the resident if they could assist her anymore and went to exit the room. An interview was conducted with NA #1 and NA #2 on 9/27/2023 at 3:10 p.m. and they stated they were finished conducting care. They both were asked if the Resident was on a scoop mattress and they replied, No. The two stated they did not place a fall mat at the bedside and did not realize she should have one. NA#2 stated he would review the care plan and get a fall mat as needed. An interview was conducted with Nurse #1 on 9/27/2023 at 3:13 p.m. and she stated she had been employed at the facility for approximately 6 months. She added Resident #67 was on her assignment regularly. She revealed she was not familiar with the Resident's plan of care and did not recall seeing a fall mat placed beside the bed. She stated Resident #67 had not had a scoop mattress during her employment. An interview was conducted with the Director of Nursing on 9/17/2023 at 3:20 p.m. and she observed the room for Resident #67. She revealed the Resident did not have a fall mat and did not have a scoop mattress. She stated the two interventions were on the care plan and should be in use. She felt the issue occurred when a room change had to occur last December of 2022 and then the Resident was moved back to the current location after room renovations were completed, in March 2023. She added, at that time, the intervention items must have been misplaced and this was not picked up on during regular Administrative rounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with staff and the consultant pharmacist, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.6% for 2 of 5 residents (Resident #72 and Resident #61) observed during the medication administration observation. The findings included: 1. Resident #72 was admitted to the facility on [DATE]. His cumulative diagnoses included diabetes. On 9/27/23 at 11:30 AM, Nurse #1 was observed as she checked Resident #72's blood glucose (sugar) with the result noted to be 337 milligram (mg) / deciliter (dl). The nurse was then observed as she returned to the medication cart and prepared to administer Novolog insulin in accordance with his sliding scale insulin orders (where the dose of insulin administered would be dependent on the resident's current blood glucose level). Based on Resident #72's blood glucose result, Nurse #1 reported she needed to administer 9 units of Novolog insulin to the resident. The nurse was observed as she primed the insulin pen. Priming an insulin pen before each injection is recommended by the manufacturer to remove air from the insulin cartridge and needle; priming the pen ensures a full dose is administered. After the insulin pen was primed, Nurse #1 dialed the pen to indicate a dose of 9 units of Novolog insulin would be administered to the resident. Nurse #1 was observed as she injected the 9 units of insulin subcutaneously (under the skin) to Resident #72 on 9/27/23 at 11:37 AM. A review of the resident's electronic medical record (EMR) included physician orders dated 8/16/23 for insulin coverage scheduled at 11:30 AM daily. The order indicated Novolog insulin was to be injected subcutaneously according to the following sliding scale: If the resident's blood glucose (BG) = 70 - 120, cover with 0 units of insulin; If BG = 121 - 150, administer 1 unit of insulin; If BG = 151 - 200, administer 2 units of insulin; If BG = 201 - 250, administer 3 units of insulin; If BG = 251 - 300, administer 5 units of insulin; If BG = 301 - 350, administer 7 units of insulin; If BG = 351 - 400, administer 9 units of insulin; If BG is greater than 400, call Medical Doctor (MD). Based on Resident #72's current sliding scale insulin orders, 7 units of Novolog insulin should be administered for a BG of 337 mg/dl. An interview was conducted with Nurse #1 on 9/27/23 at 1:07 PM. During the interview, the nurse was asked about the discrepancy of the insulin dose administered to Resident #72 (9 units) versus 7 units of sliding scale insulin ordered for a blood glucose of 337. The nurse reported she was taught to always double prime an insulin pen. When asked for further clarification, the nurse stated she always primed an insulin pen with 2 units of insulin. After the initial priming, she would then dial the insulin pen to add 2 more units of insulin to the actual dosage ordered for administration. She reported this would double prime the pen. Upon inquiry, Nurse #1 acknowledged she always added 2 units to the prescribed insulin dose administered to a resident. An interview was conducted on 9/27/23 at 4:07 PM with the facility's consultant pharmacist. During the interview, the pharmacist was asked what her thoughts were with regards to the double priming of an insulin pen. The pharmacist responded by stating the initial priming of the pen was done to ensure accuracy of the insulin dose administered to the resident. Additional insulin should not be added to the insulin dose administered to a resident. An interview was conducted on 9/28/23 at 10:02 AM with the facility's Director of Nursing (DON). During the interview, the DON reported education had already been provided to Nurse #1 on correct insulin dosing and administration with a return demonstration. 2. Resident #61 was admitted to the facility on [DATE]. Her cumulative diagnoses included diabetes and heart failure. On 9/27/23 at 8:15 AM, Medication (Med) Aide #2 was observed as she prepared and administered 11 oral medications to Resident #61. At that time, the med aide reported this resident's calcium and vitamin D combination tablet was not available on the med cart for administration because it had not been delivered by the pharmacy. A review of Resident #61's EMR included her current physician's orders and revealed an active medication order (dated 4/12/23) was written for 315 milligrams (mg) calcium with 250 International Units (IU) vitamin D3 (the natural form of vitamin D produced by the body from sunlight) to be given as one tablet by mouth every day. This medication was not administered to Resident #61 as ordered on 9/27/23. An interview was conducted on 9/28/23 at 10:02 AM with the facility's Director of Nursing (DON). During the interview, results of the medication administration observations were discussed. The DON reported she had been made aware that Resident #61's calcium and vitamin D supplement was not available for administration. She stated this medication has since come in from the pharmacy and the resident received a dose of it on 9/28/23.

Based on observations, record review, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on 7/14/22. This was for 1 deficiency that was cited in the area of Free of Medication Error Rate of 5 Percent or More (F759). The continued failure of the facility during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program (QA). The findings included: This citation is cross referred to: F759: During the facility's recertification survey on 9/28/23, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.6% for 2 of 5 residents (Resident #72 and Resident #61) observed during the medication administration observation. During the facility's recertification survey of 7/14/22, the facility's medication error rate was greater than 5% as evidenced by 2 medication errors out of 33 opportunities. There were medication errors for 1 of 4 residents during medication pass observations. The medication error rate was 6.06%. The Administrator was interviewed on 9/28/23 at 2:40 pm. He stated that the QA members were made up of Administrator, the Director of Nursing, Dietary Manager, Business office manager, Maintenance Director, Social Worker, Activities Director, and Housekeeping Director. The Nurse Practitioner and the Medical Director were always invited to attend. He also stated that the QA committee usually meets quarterly but they have met monthly this year due to new staff. He also added that the facility has to utilize a lot of agency staff since Covid began and they have recently been able to decrease the amount of agency staff needed. He stated the facility nursing staff meet to discuss this issue and investigate new ways to achieve compliance.

Based on observations, staff interviews, and record review, the facility staff failed to clean and disinfect a blood glucose meter (glucometer) dedicated for individual-resident use in a manner that would protect against the cross-contamination from contact with other meters or equipment. This was observed for 2 out of 8 sample residents (Residents #64 and #17) who were observed to have a blood glucose (sugar) check. The findings included: A review of the facility policy entitled Glucometer Disinfection (Date Implemented: January 2018; Date Reviewed / Revised: December 2019) included the following Policy Explanation and Compliance Guidelines related to the disinfection of glucometers, in part: Policy Explanation and Compliance Guidelines: 1. The facility will ensure blood glucometers will be cleaned, disinfected, and air-dried after each use and according to manufacturer's instructions for multi-resident use 2. The glucometers should be disinfected with a wipe pre-saturated with an EPA [Environmental Protection Agency] registered healthcare disinfectant that is effective against HIV, Hepatitis C and Hepatitis B virus. 3. Glucometers should be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 4. Procedure [designated with the letters a. through n.] . i. Retrieve (2) disinfectant wipes from container. j. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. k. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions The manufacturer's Guidelines for Cleaning and Disinfecting the [Brand Name of Meter] used at the facility were also reviewed. The Cleaning and Disinfecting Procedures read, in part: Step 6 (of 7) Treated surface must remain wet for recommended contact time. Please refer to wipe manufacturer's instructions. Do not wrap the meter in a wipe. A review of the manufacturer instructions for the disinfectant wipes used to disinfect individual-resident glucometers at the facility included read in part, Allow treated surface to remain wet for two (2) minutes. Let air dry. The manufacturer of the disinfectant wipes provided additional clarification regarding the product's wet contact time under the topic of Most Frequently Asked Questions. The response read, The contact time listed on the product label is the total amount of time that it takes to inactivate all of the microorganisms listed on the product label. This time is typically referred to in minutes, and should be communicated to staff members that are utilizing the disinfectant. In certain geographies and also in settings where temperature, relative humidity, and air changes may vary, it is possible that the surface may not remain visibly wet for the designated contact time. Current EPA [Environmental Protection Agency] guidance requires that the treated environmental surface or equipment remains wet for the contact time stated on product label. Additional wipes may be needed in order to comply with the EPA guidance, however the overall contact time does not change . An observation was conducted of Nurse #2 on 9/27/23 at 11:41 AM as she prepared to do a blood glucose check for Resident #64. The nurse pulled Resident #64's glucometer stored in the manufacturer's box from the medication (med) cart. Both the meter and the box were labeled with Resident #64's name. The nurse removed the glucometer from the box and collected the supplies needed for a blood glucose check (test strips, two alcohol prep pads, a lancet, and gloves). She wiped the glucometer with an alcohol wipe for 3 seconds, placed the meter directly on top of the med cart, then inserted a test strip. The nurse picked up the glucometer with supplies and entered the resident's room on 9/27/23 at 11:45 AM. After the blood glucose check, the nurse exited the room at 11:47 AM and returned to the med cart. Nurse #2 was observed as she wiped the glucometer with a disinfectant wipe for two (2) seconds, then immediately returned the meter to the box before storing it in the med cart. The meter did not appear to be visibly wet when placed in the box for storage. On 9/27/23 at 11:53 AM, Nurse #2 was observed as she removed a new glucometer from its box and prepared to do a blood glucose check for Resident #17. The nurse placed the meter on top of her closed laptop computer, donned gloves, and used an alcohol wipe to wipe the glucometer for 2-3 seconds prior to using it. The nurse discarded her gloves and performed hand hygiene. Nurse #2 then gowned and gloved at the entrance of Resident #17's room (the resident was on Enhanced Contact Precautions). On 9/27/23 at 11:57 AM, the nurse placed the glucometer on the resident's bedside tray table. She used the meter to test Resident #17's blood glucose before placing the meter back on the bedside tray table. Nurse #2 was observed as she slid the glucometer across the table's surface, then picked it up and returned to the med cart. On 9/27/23 at 12:00 PM, the nurse used an alcohol wipe to wipe the glucometer for 2-3 seconds before returning it to the box for storage in the med cart. When finished, the nurse was observed to pull a disinfectant wipe from the container placed on top of the med cart to wipe off the top of the med cart. An interview was conducted on 9/28/23 at 9:03 AM with Nurse #2. During the interview, the concerns regarding the glucometer disinfection observed were discussed. The nurse reported either an alcohol wipe or disinfectant wipe could be used to disinfect a glucometer. Nurse #2 stated she typically used a disinfectant wipe to disinfect the residents' glucometers at the beginning and end of each day. An interview was conducted on 9/28/23 at 10:02 AM with the facility's Director of Nursing (DON). During the interview, the DON reported the facility's nurses were educated to disinfect the individual-resident use meters after each use in accordance with the manufacturer's directions. She stated the disinfectant used at the facility required a 2-minute wet contact time. On 9/28/23 at 11:35 AM, a follow-up interview was conducted with the Directors and the DON. At that time, the Directors confirmed that wiping the glucometer with a disinfectant wipe only kept the meter wet for 50 seconds and would require a meter to be re-wiped after a minute or so to keep the surface wet for recommended contact time indicated by the manufacturer of the disinfectant wipes. Upon request, an interview was conducted on 9/28/23 at 11:20 AM with the facility's corporate Director of Operations and Director of Clinical Operations. During the interview, the Directors expressed concern regarding possible discrepancies between the glucometer instructions for disinfection (indicating the glucometer should not be wrapped in a wipe) and the disinfectant wipe instructions for disinfecting the machine. At that time, the Directors were informed the observations conducted of glucometer disinfection included use of an alcohol pad or a 2-3 second wipe of glucometers with a disinfectant wipe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with the staff and consultant pharmacist, and record reviews, the facility failed to acquire a medication (a combination calcium and vitamin D supplement) ordered for administration resulting in multiple doses of the prescribed medication being missed for 1 of 5 residents (Resident #61) observed for medication administration. The findings included: Resident #61 was admitted to the facility on [DATE]. Her cumulative diagnoses included diabetes and heart failure. On 9/27/23 at 8:15 AM, Medication (Med) Aide #2 was observed as she prepared and administered 11 oral medications to Resident #61. At that time, the med aide reported this resident's calcium and vitamin D combination tablet was not available on the med cart for administration because it had not been delivered by the pharmacy. A follow-up interview was conducted on 9/27/23 at 11:28 AM with Med Aide #2. During the interview, the med aide confirmed Resident #61's calcium / vitamin D tablets had been previously supplied by the pharmacy. When the process of acquiring medications from the pharmacy was discussed, Med Aide #2 reported the calcium / vitamin D had been ordered from the pharmacy but had not come in. Med Aide #2 reported she did not know why it hadn't been delivered by the pharmacy. A review of Resident #61's electronic medical record (EMR) included her current physician's orders and revealed an active medication order (dated 4/12/23) was written for 315 milligrams (mg) calcium with 250 International Units (IU) vitamin D3 to be given as one tablet by mouth every day. This medication was not administered to Resident #61 as ordered on 9/27/23. A review of the documentation on Resident #61's September 2023 Medication Administration Record (MAR) revealed the resident did not receive the calcium / vitamin D tablet as ordered on 17 of 26 days during the month. The MAR indicated a dose of the calcium / vitamin D supplement was previously missed on each of the following dates: 9/1/23, 9/7/23, 9/8/23, 9/9/23, 9/11/23 - 9/18/23, 9/20/23 - 9/22/23, 9/25/23 and 9/26/23. Seventeen (17) notations were made within the electronic MAR notes which indicated the medication was unavailable and had not been delivered by the pharmacy. An interview was conducted on 9/27/23 at 3:27 PM with Nurse #1. Nurse #1 was identified as the hall nurse assigned to care for Resident #61. During the interview, the nurse reported she was unaware Resident #61's calcium and vitamin D supplement was not available because she typically did not work on that medication cart (the 200 Hall Med Aide's Med Cart). When asked what the process was for ordering refills of medications from the pharmacy, Nurse #1 reported she could call the pharmacy to check on an order to see if it was already ordered and scheduled for delivery. An interview was conducted on 9/27/23 at 4:07 PM with the facility's consultant pharmacist. During the interview, the pharmacist was asked what the process was for ordering refill medications from the dispensing pharmacy. The pharmacist reported that staff should typically be requesting medication refills electronically. If that didn't work for some reason, staff could manually fax a refill request to the pharmacy. A follow-up interview was conducted on 9/28/23 at 9:25 AM with the consultant pharmacist. The pharmacist reported that Resident #61's calcium and vitamin D supplement had been previously dispensed by the pharmacy on 4/22/23, 5/19/23, 6/29/23 and 7/28/23. She stated the dispensing pharmacy reported they had notified the facility this supplement was available as an over-the-counter (OTC) house stock. The pharmacist indicated the failure to have Resident #61's calcium / vitamin D available for administration appeared to be a miscommunication between the facility and dispensing pharmacy as to which OTC products would be supplied by the pharmacy and which ones would be obtained by the facility as house stock. An interview was conducted on 9/28/23 at 10:02 AM with the facility's Director of Nursing (DON). During the interview, concerns identified during the medication administration observations were discussed. The DON reported she was made aware that Resident #61's calcium and vitamin D supplement had not been available for administration. She stated that since the med administration observation, the medication was delivered by the pharmacy and the resident received a dose as ordered on 9/28/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with staff and the consultant pharmacist, and record reviews, the facility failed to: 1) Label medications with the minimum information required, including the first and last name of the resident on 3 of 3 medication (med) carts observed (the 300 Hall Nurse's Med Cart, the 100 Hall Nurse's Med Cart, and the 300 Hall Med Aide's Med Cart); 2) Store medications in accordance with the manufacturer's storage instructions on 2 of 3 med carts (300 Hall Nurse's Med Cart and the 300 Hall Med Aide Med Cart); and 3) Discard an expired medication on 1 of 3 med carts observed (the 300 Hall Med Aide's Med Cart). The findings included: 1-a. An observation was conducted on [DATE] at 3:58 PM of the 300 Hall Nurse's medication (med) cart in the presence of Nurse #3. The observation revealed the following medications stored on the med cart failed to be labeled with the minimum information required: --An opened, manufacturer's bottle of 0.4 milligrams (mg) nitroglycerin tablets (a medication used to treat angina or chest pain) was stored on the med cart. A hand-written notation on the top of the cap only read, 305B 7/26. The bottle of tablets did not include the minimum required information, including the resident's first and last name. --One Lantus Solostar insulin pen with a handwritten notation on the pen read, 9/24 and [a last name only]. The medication label did not include the minimum information required, including both the first and last name of the resident. 1-b. An observation was conducted on [DATE] at 3:58 PM of the 300 Hall Nurse's med cart in the presence of Nurse #3. The observation revealed two vials of 0.5 mg/3 mg per 3 milliliters (ml) of ipratropium/albuterol inhalation solution (an inhaled medication delivered via a nebulizer to treat asthma or chronic obstructive lung disease) dispensed for Resident #74 were stored outside of the manufacturer's foil pouch. There was no notation of when the vials had been removed from the foil pouch. Storage Conditions printed on the foil pouches read: Protect from light. Unit dose vials should remain stored in the protective foil pouch at all times. Once removed from the foil pouch, the individual vials should be used within two weeks. An interview was conducted with Nurse #3 on [DATE] at 4:15 PM. During the interview, the findings of the med cart observation were discussed. The nurse confirmed the vials of inhalation solution should have been dated as to when they were removed from the pouch. Upon review of the insulin pen, the nurse stated the pen may have been obtained from the facility's emergency medication stock. 2-a. An observation was conducted on [DATE] at 4:22 PM of the 100 Hall Nurse's medication cart in the presence of Nurse #4. The observation revealed the following medications stored on the med cart failed to be labeled with the minimum information required: --One Lantus Solostar insulin pen with a handwritten notation on the pen read, [an initial for the first name and a last name]. A pharmacy auxiliary sticker placed on the pen indicated the Date opened was [DATE]. The medication label did not include the minimum information required, including both the first and last name of the resident. --One Humalog insulin Kwikpen with a handwritten notation on the pen read, [last name only]. A pharmacy auxiliary sticker placed on the pen indicated the Date opened was [DATE]. The medication label did not include the minimum information required, including both the first and last name of the resident. --One Basaglar insulin pen with a handwritten notation on the pen read, [DATE] and [a last name only]. The medication label did not include the minimum information required, including both the first and last name of the resident. An interview was conducted with Nurse #4 on [DATE] at 4:30 PM. Upon review of the insulin pens identified without the minimum required labeling information, the nurse reported she thought sometimes the pharmacy delivered multiple insulin pens at a time with only one label provided. 3-a. Accompanied by Med Aide #1, an observation was made on [DATE] at 4:33 PM of the 300 Hall Med Aide's medication cart. The observation revealed one packet of 0.8 grams (g) sevelamer carbonate for oral suspension (a phosphate binder) was not labeled with the minimum required information, including the resident's name. 3-b. Accompanied by Med Aide #1, an observation was made on [DATE] at 4:33 PM of the 300 Hall Med Aide's medication cart. The observation revealed an opened bottle of neomycin / polymyxin B / dexamethasone 0.1% ophthalmic suspension (a combination antibiotic and corticosteroid eye drop) dispensed for Resident #47 was stored lying on its side in the med cart. Storage instructions on the manufacturer's labeling of the bottle read in part, Store upright. 3-c. Accompanied by Med Aide #1, an observation was made on [DATE] at 4:33 PM of the 300 Hall Med Aide's medication cart. The observation revealed an opened bottle of 1% prednisolone ophthalmic suspension (a steroid eye drop medication) dispensed for Resident #74 was stored lying on its side in the medication cart. The manufacturer's storage instructions printed on the label of the eye drops provided instructions to store the bottle in an upright position. 3-d. Accompanied by Med Aide #1, an observation was made on [DATE] at 4:33 PM of the 300 Hall Med Aide's medication cart. The observation revealed an opened manufacturer's box of Dulcolax suppositories (a stimulant laxative) containing 6 suppositories and labeled for Resident #74 was stored on the med cart. The suppositories had a manufacturer's expiration date of [DATE] printed on its label. An interview was conducted with Med Aide #1 on [DATE] at 4:33 PM as the concerns regarding the med cart observations were identified. At that time, Med Aide #1 confirmed the manufacturer's labeling on the eye drop bottles indicated they should be stored in the upright position. She also confirmed the suppositories were past their expiration date. An interview was conducted on [DATE] at 4:07 PM with the facility's consultant pharmacist. During the interview, an inquiry was made as to what information she would expect to be included on the label of a medication dispensed from the pharmacy. The pharmacist reported that she would certainly expect the full name of the resident that the medication belonged to be on the medication. During a follow-up interview conducted with the pharmacist on [DATE] at 9:25 AM, the pharmacist reported only one insulin pen had been pulled from the emergency drug kit for resident use within the last 3 months. She stated that upon review of the extra insulin pens stored in the med room refrigerator, all pens were being sent out from the pharmacy with a mini-sticker which included all of the minimum required information. It was not known why the mini-sticker labels were missing from several insulin pens stored on the med carts. An interview was conducted on [DATE] at 4:53 PM with the facility's Director of Nursing (DON) to discuss the findings of the medication storage observations. During the interview, the DON stated she would expect medications to be stored in accordance with the manufacturer's instructions.

Based on observation, record review and staff interviews, the facility's medication error rate was greater than 5% as evidenced by 2 medication errors out of 33 opportunities. There were medication errors for 1 of 4 residents (Resident # 42) during medication pass observations. The medication error rate was 6.06%. Review of current physician orders for Resident # 42 indicated the following medications were due to administer during the morning medication pass: Carbidopa-Levodopa 25-100 tab let via gastric tube three times a day. Ezetimibe 10 mg tablet via gastric tube once daily. Review of records revealed there were no physician orders or progress notes to indicate Resident #42 could have medications crushed and administered at the same time via gastric tube. During observations of a medication pass on 7/13/22 at 8:58 am, Nurse #1 indicated Resident # 42 had a gastric tube and her medications were to be administrated via this route. Nurse #1 crushed 2 pills and mixed with 10 milliliters (mL) water in the same medication cup. After checking placement of the gastric tube per facility policy, Nurse # 1 administered the crushed medications via gastric tube. This writer asked Nurse # 1 if there was a physician's order to administer medications at the same time without a specified amount of water flush in between, in which she responded, I don't think so. This writer and Nurse # 1 checked the physician's orders together outside of Resident # 42's room, and no orders were found to indicate the medications could be crushed and administered at the same time. Nurse #1 explained at that time that she was aware she was supposed to administer pill medications separately with a specified water flush in between medications. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) together on 7/13/22 at 2:00 pm. The NHA and the DON both indicated all medications intended for gastric tube administration should be prepared and given separately according to their facility policy and procedures. The NHA further indicated the manner in which Nurse # 1 administered medication on 7/13/22 to Resident # 42 was a medication error due to improper administration via gastric tube.