**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and Nurse Practitioner (NP), Consulting Pharmacist and staff interviews, the facility failed to check finger-stick blood sugar (FSBS) for a resident that received insulin injections twice daily for 1 of 3 residents reviewed for unnecessary medications (Resident #40). The findings included: Resident #40 was admitted to the facility on [DATE] with multiple diagnoses which included, a right side below the knee amputation, type 2 diabetes mellitus and end stage renal disease. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was cognitively intact and required substantial to max assist for most Activities of Daily Living (ADLs). The MDS also revealed Resident #40 was coded that she received insulin injections. Documentation on the care plan last reviewed on 11/8/2024 revealed Resident #40 had type 2 diabetes mellitus with interventions that included: to assess for hyperglycemic episodes such as acetone breath, polyuria and flushed skin, during rounds and prn. Treat as per physician orders. Assess for hypoglycemic episodes such as sweating, chills, rapid weak pulse, tachycardia and tremors, during rounds and prn. Follow facility protocol for any acute signs and symptoms of hyper/hypoglycemic episodes. During an interview with Resident #40 on 11/28/2024 at 11:28am, Resident #40 voiced she was a diabetic and was concerned that her blood sugar was no longer being checked. Resident #40 stated that she received 14 units of insulin in the morning and 16 units in the evening, but the staff was no longer checking her blood sugar. Resident #40 stated she did not know why they were stopped. Resident #40 stated she had episodes of increased sleepiness since her blood sugars had stopped being checked. A review of Resident #40's Physicians' orders revealed Resident #40 had active orders for Levemir Insulin 100unit/ml Administer 16 units daily at 8pm with a start date of 6/3/2022, and Levemir Insulin 100unit/ml Administer 14 units daily at 8am with a start date of 4/8/2024. Review of the Nurse Practitioner (NP) note dated 9/25/2024 revealed Resident #40's lispro (short acting insulin) sliding scale order would be discontinued. Note also revealed that the NP educated Resident #40 on the importance of maintaining a balanced diet and monitoring blood sugar levels. Further review of Resident #40's Physicians orders revealed an order for insulin lispro (short acting insulin) with a sliding scale was discontinued on 9/25/2024. Review of the Point-of-Care Blood Sugar Summary report for Resident #40 revealed no FSBS had been recorded since the morning of 9/25/2024. Record review revealed Resident #40 had an order for HbA1c every 3 months. HbA1c completed on 4/16/2024 with results of 6.7, on 7/15/2024 with results of 6.6, and on 10/15/2024 with results of 6.5. (HbA1c Range 5.0-6.1) During an interview on 11/19/2024 at 12:52pm Nurse #2 stated the Nurse Practitioner (NP) wrote the order for Resident #40's lispro insulin sliding scale to be discontinued and that she (Nurse #2) verified the order. Nurse #2 stated that orders were verified by reviewing the order from the NP, and making sure the order in the computer electronic Medication Administration Record (eMAR) was entered into the system correctly. Nurse #2 stated that orders were normally verified by the charge nurse, but orders could also be verified by the hall nurse. Nurse #2 stated that FSBS are dependent on what is ordered by the provider. Nurse #2 stated that most of the time when a resident received insulin injections, the resident also has FSBS completed. Nurse #2 was not aware of any instances of Resident #40 having increased sleepiness reported, but stated Resident #40 did stay up late into the evening on her phone. During an interview on 11/19/2024 at 1:29pm the Nurse Practitioner (NP) verified she had entered the order to discontinue the lispro insulin sliding scale for Resident #40 into the computer. The NP stated she did not intend for the FSBS to be discontinued, only the sliding scale insulin and that she would fix it. The NP stated that FSBS can be tied into the order for a medication when entered into the system and that is probably why the FSBS was stopped when the sliding scale was discontinued. During an interview on 11/20/2024 at 8:56am Nurse #3, stated the Med Aide (MA) checked the FSBS and Nurse #3 saw the results on the computer and then administered insulin injections. Nurse #3 stated as far as she knew every resident that received insulin also had FSBS completed. Nurse #3 came back later that day at 2:18 pm and stated she was incorrect earlier and stated FSBS for residents are based on the order from the provider. During an interview on 11/20/2024 at 2:16pm Nurse #1 stated she checked her own FSBS on her hall because she did not normally have an MA assigned. Nurse #1 stated the residents who receive insulin also have FSBS completed. During an interview on 11/20/2024 at 2:20pm. Nursing Assistant (NA) #1 stated she checked the computer and completed the FSBS that were ordered, then documented them on the eMAR. NA #1 was not aware of all the residents that received insulin. During an interview on 11/19/2024 at 1:51pm the Consulting Pharmacist stated he was unaware that Resident #40 did not have a current order for FSBS. The Consulting Pharmacist stated anyone receiving insulin should have some FSBS completed. The Consulting Pharmacist would recommend at least once daily but knew some providers ordered FSBS for every other or every third day. The Consulting Pharmacist stated when he completed his review in October the September FSBS were reviewed. He stated the October MAR would be reviewed on his next visit in November 2024. The Consulting Pharmacist stated if he had seen during his review there were no FSBS, he would have questioned why they were stopped. A joint interview was conducted with the Administrator and the Director of Nursing (DON) on 11/20/2024 at 3:23pm. The DON and Administrator were unaware that Resident # 40 had not had FSBS from 9/25/2024, but the Administrator asked if Resident #40 had a HbA1c. The DON verified Resident #40 had a HbA1c of 6.5 on 10/15/2024. The DON verified that after orders are entered by the NP a nurse would verify the order before it was changed on the eMAR. The DON also verified that insulin and FSBS orders can be connected on the eMAR. The DON stated that it is up to the provider if a resident received FSBS while on insulin. The Administrator stated FSBS are looked at on a case-by-case basis determined by the provider. The Administrator stated the Medical Director had mentioned there were papers that suggested the use of HbA1c to monitor instead of FSBS would be considered. The DON stated they did not have a policy regarding FSBS use for diabetics. During a telephone interview on 11/21/23 at 8:10am the Medical Director stated residents were looked at on a case-by-case basis regarding orders for FSBS. The Medical Director stated there is talk starting, regarding using the HGBA1C for monitoring but did not mention any study or papers supporting this.

Based on observations, staff interviews, and record review the facility failed to record an open date on multi-dose insulin pens, failed to discard expired insulin pens, and failed to store an unopened insulin pen in the refrigerator for 1 of 2 medication carts reviewed for medication storage (Hall A medication cart). The findings included: Review of the manufacturer's package insert for Levemir (Insulin detemir) flexpen stated to store unopened Insulin detemir insulin pens in a refrigerator and in-use (opened) Insulin detemir pens at room temperature for 42 days and then discard. Review of the manufacturers' instructions for Glargine insulin pen, Novolog insulin pen, and Lispro insulin pen, stated the insulin pens may be used for 28 days after opening, then discard. An observation of the medication cart on Hall A was conducted on 11/20/2024 at 11:05 AM with Nurse #1. The observation revealed an opened Glargine insulin pen and an opened Novolog insulin pen that were not dated. The medication cart observation also revealed an opened insulin detemir flexpen with an open date of 08/23/2024 and an opened Lispro insulin pen with an open date of 09/24/2024. The observation further revealed an unopened insulin pen was stored in the right top drawer of the medication cart and was labeled as refrigerate until opened. An interview was conducted with Nurse #1 on 11/20/2024 at 11:11 AM who stated insulin should be stored in the refrigerator until ready to use and all insulin pens should have an open date with a 28-day expiration date. Nurse #1 further stated that she did not realize the insulin pens were not dated and that two insulin pens were expired. An interview was conducted with the Director of Nursing (DON) on 11/20/2024 at 11:50 AM. The DON revealed all insulin pens should have been labeled when opened for use with a 28-day expiration date sticker. The DON indicated that all nurses were responsible for checking medications in the medication carts for expired medications. She also stated that all unopened insulin pens should be stored in the refrigerator until ready for use and that no expired medications should be available for use in the medication carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interview, and staff interviews the facility failed to maintain a filled oxygen humidifier for 2 of 2 resident reviewed for oxygen therapy (Resident #14 and Resident #25). The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included asthma and heart failure. Resident #14 ' s admission Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact and received oxygen. Resident #14 ' s care plan revealed Resident #14 had impaired gas exchange due to chronic obstructive pulmonary disease (COPD). The goal for resident #14 was to have an effective gas exchange as evidenced by clear breath sounds, mental status within normal limits, and skin color within normal limits. Interventions included oxygen as ordered, administrator medications as ordered, encourage activities and self-care as tolerated, and assess and record signs of impaired gas exchange. A physician order dated 09/11/23 revealed Resident #14 received 2 liters (L) per minute of oxygen through the nasal cannula continuously. A physician order dated 09/30/23 revealed Resident #14 ' s oxygen concentrator filter to be cleaned with warm water, air dry, and replaced weekly. Observation conducted on 10/09/23 at 11:00 AM revealed Resident #14 ' s oxygen humidifier dated 10/05/23 was running low with little water in it. Observation and interview conducted with Resident #14 on 10/09/23 at 1:05 PM revealed Resident #14 ' s oxygen humidifier dated 10/05/23 had no water in it. Resident #14 further revealed staff was aware that it was low and should be back in the room later to change it out. Observation and interview conducted with Resident #14 on 10/10/23 at 11:05 AM revealed Resident #14 ' s oxygen humidifier dated 10/05/23 had no water in it. Resident #14 further revealed staff had not changed the humidifier and her oxygen felt dry in her nose. Observation and interview conducted with Nurse #1 on 10/10/23 at 11:15 AM revealed Resident #14 ' s oxygen humidifier was empty and needed to be changed. Nurse #1 further revealed all staff were responsible for checking humidifiers and reporting to the assigned Nurse if it is empty. Nurse #1 indicated she was not aware that it was empty. Interview conducted with Nurse Aide (NA) #1 on 10/11/23 at 10:00 AM revealed she observed Resident #14 ' s oxygen humidifier was empty after breakfast on 10/10/23 and notified Nurse #1 it needed to be changed. NA #1 further revealed NAs are unable to change residents ' oxygen humidifier and educated to notify assigned Nurse. Interview conducted with the Director of Nursing (DON) on 10/11/23 at 1:50 PM revealed she was not aware Resident #14 ' s oxygen humidifier was empty. The DON further revealed nursing staff has been educated to check oxygen humidifiers every shift and change if low. The DON stated Resident #14 ' s humidifier should have been changed. Interview conducted with the Administrator on 10/11/23 at 2:55 PM revealed she expected nursing staff to check residents ' oxygen humidifier daily and to be changed if low or empty. The Administrator indicated Resident #14 ' w oxygen humidifier should have been changed. 2. Resident #25 was admitted to the facility on [DATE] with diagnoses that included asthma and congestive heart failure. Resident #25's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and received oxygen. A review of Resident #25's physician orders revealed: *An active order dated 07/16/21 to change oxygen tubing and set up weekly on Wednesday. *An active order dated 06/19/23 for oxygen at 3 liters per minute via nasal cannula as needed. A review Resident #25's Medication Administration Record (MAR) for 10/2023 revealed the oxygen tubing and set up was changed on Wednesday 10/04/23. A review of Resident #25's vital signs revealed the following: *10/09/23 at 5:10 PM submitted by Nurse #2 read, oxygen saturation level 95% on 3 liters per minute via nasal cannula. *10/11/23 at 9:49 AM submitted by Nurse #1 read, oxygen saturation level 95% on 3 liters per minute via nasal cannula. On 10/09/23 at 11:22 AM an observation and interview were made of Resident #25 who was lying in bed with oxygen being delivered via nasal cannula by the bedside concentrator at a setting of 3 liters per minute. The oxygen tubing was dated 10/04/23 with no water observed in the humidification container located on the oxygen concentrator. Resident #25 explained she preferred humidified oxygen, so her nose did not become dry and itchy. She stated at the time of the interview she was not experiencing any dryness or itching but staff were not good about changing her water container. The interview revealed in the past she had gone days without the water container being changed. She stated she felt more comfortable wearing oxygen because she sometimes became short of breath. The interview revealed she had told staff she wanted humidified oxygen but it had been a few months prior and she could not remember who she told. On 10/10/23 at 11:13 AM an observation was made of Resident #25's oxygen concentrator revealed the humidification container remained in the same condition with no water. Resident #25 was lying in bed with oxygen being delivered via nasal cannula by the bedside concentrator at a setting of 3 liters per minute. Resident #25 stated her nose was becoming dry and itching. She stated she did not know the humidification container was empty because it was located at the foot of her bed, and she couldn't see it. An interview was conducted with Nurse #1 on 10/10/23 at 11:19 AM. Nurse #1 stated she was responsible for Resident #25. She stated Resident #25 had an order to change the oxygen tubing and equipment weekly on Wednesdays. She stated the humidification containers were supposed to be checked each shift and changed when empty. The interview revealed Resident #25 did not have orders for the humidified oxygen because it was based on resident preference. She stated Resident #25 had complained of dryness in the past and humidification was added to her concentrator. Nurse #1 stated she had been in Resident #25's room but had not looked at her concentrator. She stated any staff member could look at the oxygen concentrator and notify her if it was empty. An interview was conducted with Nurse Aide (NA) #1 on 10/11/23 at 9:06 AM. NA #1 stated she had worked with Resident #25 on 10/10/23 and 10/11/23 and did not see the humidification container on the resident's oxygen was empty. She stated normally if she saw a container empty, she would let a nurse know. An interview was conducted with Nurse Aide (NA) #2 on 10/11/23 at 11:32 AM. NA #2 stated she had worked with Resident #25 on 10/10/23 with NA #1. She stated she had been working in the facility for one month and was told she wasn't allowed to change the humidification containers, so she did not look at the oxygen concentrator when she was in the room. An interview was conducted with Director of Nursing (DON) on 10/11/23 at 1:48 PM who stated it should be the responsibility of the nurse on the hall to ensure the oxygen humidification container was not empty. She stated the container should have been replaced. On 10/11/23 at 2:52 PM an interview was conducted with the Administrator. During the interview she stated Resident #25 wore her supplemental oxygen on an as needed basis and it was her preference to have humidified oxygen. She stated she did not think the oxygen had to be humidified as the facility had no physician order for it or standing physician order. The Administrator stated she did want staff to follow the physician order to change the equipment weekly or if the humidification container became empty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure a resident had been assessed to self-administer medications when the Nurse #1 gave the resident his medications to self-administer (Resident #63). This occurred for 1 out of 3 residents reviewed for medication administration. The findings included: Resident #63 was admitted to the facility on [DATE] with diagnoses which included hypertension and Parkinson's disease. Resident #63's quarterly Minimum Data Set (MDS) dated [DATE] revealed he was alert and oriented requiring was he cognitively intact extensive assistance of one staff member for most activities of daily living (ADL). On 04/04/23 at 4:32 PM an observation was conducted of Nurse #1 removing Resident #63's medication from the medication cart and placing the pills into a cup. Nurse #1 then obtained Resident #63's roommate's medication located in a clear cup and Resident #63's medication and entered the resident's room. Nurse #1 handed the cup of pills to Resident #63 and proceeded to turn her back to him while she sat his roommate up and administered his medication. Resident #63 was then observed picking through the cup of pills and swallowing each one, while Nurse #1 remained with her back to the resident. Nurse #1 then walked by Resident #63 and obtained the empty pill cup and exited the room. Resident #63's physician orders since his admission on [DATE] were reviewed and did not reveal an order to self-administer medication. An interview was conducted on 4/4/23 at 5:15 PM with Nurse #1. During the interview she stated she thought Resident #63 could self-administer his medication. Nurse #1 stated she did not feel like it was an issue to turn her back to Resident #63 or to take two residents' medications into the room at the same time. An interview was conducted on 4/5/23 at 10:23 AM with Resident #63. During the interview he stated Nurse #1 was the only nurse that handed him a cup of medication and left him to take it alone. He stated most nurses would stand with him while he swallowed the medication. Resident #63 stated he did not want to self-administer his medication further stating, there is no way I could keep up with my medication. An interview conducted on 04/05/23 at 12:42 PM with the Director of Nursing (DON) revealed no residents in the facility had orders to self-administer their medication. She stated she expected nurses to administer the resident's medication and remain in the room with the resident until they took all of the medication that was ordered. The DON stated if a resident were to request to self-administer their medication, they would need to sign a form prior to doing so and be assessed as safe to self-administer their medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, staff and family interviews the facility failed to allow unrestricted visitation by limiting visitation for 1 of 1 resident (Resident #51) reviewed for visitation. The findings included: Resident #51 was admitted to the facility on [DATE]. Review of Resident #51's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #51 was cognitively intact and able to make her needs known. An interview conducted with Resident #51 and a family member on 04/03/23 at 11:55 AM revealed on Saturday 04/01/23 Resident #51's family member was asked to leave the facility. Resident #51 further revealed she had called her family member late that evening due to not feeling well and wanted company. Resident #51 stated her family member visited around 11:30 PM and was there for an hour in a private room and was asked to leave by Nurse #1 around 12:30 AM. Resident #51's family member stated Nurse #1 was rude and stated it was facility policy that the family member had to leave the facility. An interview conducted with Nurse #1 on 04/05/23 at 10:15 AM revealed she was an agency staff and had been working in the facility for a short period of time. Nurse #1 further revealed Resident #51's family member had visited late on 04/01/23. Nurse #1 stated Resident #51 was in a private room and Resident #51's family member had not caused any issues. Nurse #1 indicated Nurse #2 expressed concerns to her that Resident #51's family members were not supposed to visit late at night. Nurse #1 revealed she was unsure how long Resident #51's family member was going to visit but stated to the family member that she had been told by other nursing staff that they were not allowed to stay. Nurse #1 indicated Resident #51's family member got up and left the facility. An interview conducted with Nurse #2 on 04/05/23 at 2:05 PM revealed Nurse #1 had come to her and told her Resident #51's family member was there late visiting. Nurse #2 further revealed she had advised Nurse #1 that family members were not allowed to visit late in the facility unless the resident was on hospice. An interview conducted with the Director of Nursing and Administrator on 04/05/23 at 3:40 PM revealed they were not made aware that Resident #51's family member had visited late on 04/01/23. The Administrator further revealed the facility had no policy or rules that family members could not visit late at night. The DON and Administrator both stated Resident #51's family member should have not been asked to leave and all resident families were welcome at anytime as long as they do not disrupt nursing staff or other residents.