**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to ensure two of fifteen sampled residents (4 and 24) professional standards of practice were followed for insulin administration and response to low blood glucose levels. 1. Review of resident 24's medical record revealed: *She had been admitted on [DATE]. *Her diagnoses included: type 2 diabetes mellitus with hyperglycemia, heart failure, chronic kidney disease, anemia, obesity, and long term use (current) of insulin. *Her 2/7/22 admission assessment showed a brief interview for mental status (BIMS) score of 14, indicating her cognition was intact. Interview on 3/24/22 at 11:25 a.m. with resident 24 revealed she: *Had some low blood sugars since being admitted . *Had been able to feel when her blood sugar was getting low and alert the staff. *Felt the staff responded quickly when she had a low blood glucose level by giving her some juice and something to eat. *Did have changes in her insulin dose since she was admitted . Review of resident 24's February 2022 medication administration record (MAR) revealed: *Her insulin detemir dose had been decreased three times. She had received: -38 units from 2/1/22 through 2/6/22. -36 units from 2/7/22 through 2/14/22. -32 units from 2/15/22 through 2/24/22. -18 units from 2/25/22 through 2/28/22. *Her scheduled Novolog insulin had been decreased two times. She had received: -7 units three times a day before meals from 2/1/22 through the morning dose on 2/3/22. -2 units three times a day from the evening dose on 2/3/22 through the noon dose on 2/7/22. *2 units daily prior to lunch from 2/8/22 through 2/26/22. *Another order for Novolog to be given per sliding scale [varies the dose of insulin based on blood glucose level] parameters. -The resident was to have her blood glucose level checked three times a day before meals and insulin administered as indicated by the scale. -On 2/6/22 at 11:00 a.m. her blood glucose level was 153 and she should have received Novolog 4 units per sliding scale. It was documented as Other/See Nurse Notes. -There was not a nurses note documented on 2/6/22. -On 2/18/22 at 4:00 p.m. her blood glucose level was 134 and she should have received Novolog 2 units per sliding scale. There was no documentation indicating it was administered. *She also had her blood glucose level done at bedtime. *An order for glucose gel to be administered for blood glucose level less than 70. -This was started on 2/9/22. -It had been administered on 2/23/22, 2/24/22, two times on 2/25/22, and on 2/28/22. *The scheduled Novolog was not administered on 2/8/22 or 2/22/22. The documentation indicated her blood glucose was within normal limits. *The scheduled Novolog was not administered on 2/5/22 at 11:00 a.m. and on 2/6/22 at 7:00 a.m. and at 11:00 a.m. The documentation indicated to see the nurses notes. -There were no nurses notes as to why these doses were not administered or notification of a physician. Review of resident 24's March 2022 MAR revealed on: *3/1/22 at 11:00 a.m. her blood glucose level was 291 and she should have received Novolog 12 units per sliding scale. It was documented as Hold/See Nurse Notes. *3/2/22 at 11:00 a.m. her blood glucose level was 130 and she should have received Novolog 2 units per sliding scale. It was documented as Other/See Nurse Notes. *3/4/22 at 4:00 p.m. there was no documentation of Novolog 6 units per sliding scale was administered for a blood glucose level of 206. *There had been no documentation in the nurses notes as to why these doses were not administered. *3/8/22 a list of blood sugars was to be faxed to physician C. It was documented as Other/See Nurse Notes. *There was not a nurses note regarding a fax to physician C. Review of resident 24's blood glucose levels revealed on: *2/2/22 at 7:00 a.m. it was 49. *2/3/22 at 7:00 a.m. it was 60, at 11:00 a.m. it was 49, and at 4:00 p.m. it was 64. *2/4/22 at 5:20 a.m. it was 43, at 5:48 a.m. it was 58, and at 7:00 a.m. it was 46. *2/5/22 at 11:00 a.m. it was 68. *2/6/22 at 7:00 a.m. it was 50. *2/8/22 at 7:00 a.m. it was 52. *2/9/22 at 7:00 a.m. it was 35. *2/12/22 at 7:00 a.m. it was 64. *2/13/22 at 7:00 a.m. it was 48. *2/14/22 at 2:53 a.m. it was 50. *2/15/22 at 7:00 a.m. it was 53. *2/17/22 at 4:19 a.m. it was 47. *2/20/22 at 7:00 a.m. it was 66. *2/22/22 at 11:00 am. it was 50. *2/23/22 at 7:00 a.m. it was 59. *2/24/22 at 4:00 p.m. it was 63. *2/25/22 at 3:10 a.m. it was 47, at 3:25 a.m. it was 46, and at 11:00 a.m. it was 65. *2/27/22 at 7:00 a.m. it was 62. Review of resident 24's nurses progress notes from 2/1/22 through 3/24/22 revealed on: *2/2/22 at: -12:30 a.m. she had a blood glucose level of 54 and was given 8 ounces of a breeze nutritional supplement and a peanut butter sandwich. -1:04 a.m. her blood glucose level was 112. --No documentation of physician notification. *2/3/22 at 12:26 a.m. she had been woken up to check her blood glucose level because it had been low at bedtime. *2/4/22 at 12:39 p.m. resident had refused her lunch. The nurse had offered substitutes and educated her on hypoglycemia. *2/8/22 at 4:43 p.m. physician C had made rounds and reviewed blood glucose levels with staff. *2/11/22 at 2:45 a.m. Her FSBS [fingerstick blood sugar] continue to run low especially in the mornings; discussed nutrition/blood sugar stabilization. She had an HS [hour of sleep] snack and is also agreeable to having a snack (prefers a PB&J [peanut butter and jelly] sandwich) after she uses the bathroom between 0200-0300 to see if this helps maintain her blood sugar until breakfast time. *2/12/22 at 9:14 a.m. her blood glucose had been 64 that morning and she did not eat well at breakfast. She was given an apple and a peanut butter and jelly sandwich. There was no physician notification or follow-up documentation. *2/13/22 at 7:36 a.m. her blood glucose had been 48 and was given an Ensure supplement. There was no physician notification or follow-up documentation. *2/14/22 3:14 a.m. her blood glucose level was 50 and was given a peanut butter sandwich and Breeze supplement. There was no physician notification or follow-up documentation. *2/14/22 at 7:33 a.m. indicated blood glucose levels had been faxed to physician C for review. There was not follow-up documentation. *2/15/22 at 12:18 a.m. indicated her FSBS remain unstable. Discussed nutrition, encouraged a heart healthy snack prior to bed; she voiced understanding. *2/15/22 at 9:18 a.m. her blood glucose level had been 53, she was given a cookie and Ensure supplement, then went to breakfast. There was no physician notification or follow-up documentation. *2/17/22 at 4:21 a.m. her blood glucose level was 47 and she was given a nutritional supplement and a peanut butter sandwich. There was no physician notification or follow-up documentation. *2/21/22 at 3:20 p.m. her blood glucose level was 65 and she was given a sandwich and milk. There was no physician notification or follow-up documentation. *2/22/22 at 12:21 p.m. her blood glucose levels for a week had been faxed to physician C. He reviewed the levels and made no changes to her medication. *2/25/22 at 7:38 a.m. her blood glucose levels from 2/11/22 through 2/25/22 had been faxed to physician C. There was no follow-up documentation. *2/28/22 at 1:57 p.m. her blood glucose level was 48 and she told the nurse she felt like it was low. She had been given a dose of glucose gel. *2/28/22 at 2:430 p.m. she was feeling better. Her blood glucose level was 92 and she had been given a snack. *3/1/22 at 10:59 a.m. education was provided to her about her blood glucose levels by director of nursing A. She had agreed to not throw her food away until nursing could look and see what she had eaten. *3/1/22 at 5:52 p.m. she had been refusing to eat supper and her insulin was held. There was no physician notification or follow-up documentation. Review of faxed communications for resident 49 between the provider and physician C revealed on: *2/3/22 a note was sent to notify him of low blood glucose levels that day along with a list of blood glucose levels. -He had returned the note with new orders to decrease her insulin and to fax her blood glucose levels again the following Monday. *2/9/22 to let him know of a blood glucose level of 35 and that they had administered glucose gel from their emergency kit. Had also asked for an order for the glucose gel. -He returned the fax with an order for the glucose gel as needed for a blood glucose level less than 70. *2/15/22 a list of blood glucose levels had been faxed to him. He returned the fax with new order to decrease the Levemir and fax blood sugars again, in one week. *2/25/22 a note indicated that her blood glucose levels continued to run low and a list of her blood glucose levels had been sent along with the note. -He faxed back with an order to decrease the Levemir and stop the scheduled dose of Novolog. *3/4/22 a list of blood glucose levels had been sent with no medication changes. Review of resident 49's Patient Visit Notes revealed: *Physician C had seen her on 2/8/22 and on 3/8/22. *He did discuss and review blood glucose levels and medications during each visit. Review of resident 49's 3/1/22 Care Conference Summary revealed: *She had been invited but chose not to attend. *Dietary, MDS (Minimum Data Set) nurse, activities, and social services had attended the conference. *Her blood glucose levels had not been addressed. *Her behavior to throwing food away before nursing could monitor what she had eaten had not been discussed. Review of resident 49's revised 3/16/22 care plan revealed: *[Resident's name] has potential to refuse to eat meals without reasoning given. She will indicate to nurse she is going to eat, insulin will be administered, and then refusal will occur. Education had been provided. *The goal was she would be free from complications related to refusing food . *Interventions included: -Explain importance of consuming prescribed diet and/or risks of taking insulin and then refusing to eat, to [resident's name]. Educate on need for adequate nutritional intake. -[Resident's name] triggers for refusing to eat are unclear at this time, will continue to monitor. [Resident's name] may indicate to staff she is upset, however does not provide reasoning/rationale. [Resident's name] behaviors are de-escalated by allowing time to self-calm, providing comfort and support. *It did not indicate what her blood glucose levels should be or what to do if they were low. 2. Review of resident 4's medical record revealed: *She was admitted on [DATE]. *Her diagnoses included: chronic kidney disease, essential hypertension, dementia without behavioral disturbance, long-term (current) use of insulin, and type 2 diabetes mellitus with hypoglycemia without coma. *Her 1/24/22 quarterly assessment showed a BIMS of 4, indicating severe cognitive impairment. Review of resident 4's January 2022 MAR revealed on: *1/6/22 at 7:00 a.m. she was to have Novolog 5 units and it had been documented Other/See Nurse Notes. *1/8/21 at 4:00 p.m. her blood glucose level was 59. *1/12/22 at 4:00 p.m. her blood glucose level was 62. *1/17/22 at 9:00 p.m. her blood glucose level was 62. *1/21/22 at 7:00 a.m. she was to have Novolog 5 units and it had been documented that her blood glucose level was within normal limits, so she did not need the scheduled dose. *1/23/22 at 4:00 p.m. her blood glucose level was 49. *1/25/22 at 7:40 p.m. her blood glucose level was 60. *1/26/22 at 12:00 p.m. she was to have Novolog 3 units and it had been documented Other/See Nurse Notes. Review of resident 4's February 2022 MAR revealed on: *2/2/22 at: -7:00 a.m. her schedule Novolog 5 units was not given and it had been documented that her blood glucose level was within normal limits. -4:00 p.m. she had a blood sugar of 66. *2/16/21 at 8:17 p.m. she had a blood glucose level of 44. Review of resident 4's March 2022 MAR revealed on: *3/13/22 at 5:00 p.m. her blood glucose level was 54. *3/18/22 at 12:00 p.m. her blood glucose level was 61. Review of resident 4's nurses progress notes revealed on: *1/10/22 at 3:11 p.m. her blood glucose level was 66 and she was given a peanut butter sandwich. There was no physician notification or follow-up documentation. *2/17/22 at 9:34 p.m. resident had a blood glucose level of 44 so a list of blood glucose levels had been faxed to physician's office. *2/18/22 at 1:30 p.m. physician had reviewed the blood glucose levels and gave no new orders. *3/13/22 at 4:39 p.m. her blood glucose level was 54 and she had been given peanut butter toast. Her blood glucose level was 99 within 20 minutes. 7:00 a.m. There had been no documentation the physician had been notified. *There were no other notes indicating the physician had been notified of low blood glucose readings. *There were no notes indicating to hold scheduled Novolog doses. Review of resident 4's revised 3/16/22 care plan revealed: *Her hospitalization prior to admission to the facility had been for severe hypoglycemia. *The goals included: -[Resident's name] will have no complications related to diabetes . -[Resident's name] will be free from any s/sx [signs or symptoms] of hypoglycemia or hyperglycemia . *Interventions included: -Observe [resident's name] and document/report PRN [as needed] any s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. *It did not indicate what her blood glucose levels should be or what to do if they were low. 3. Interview on 3/24/22 at 1:26 p.m. with director of nursing B revealed: *She had considered a blood glucose level low if it was below 60. *If the resident had a blood glucose level below 60 and was alert she expected the nurse to give them juice or milk. *If the resident was not alert she would have expected the nurse to administer glucose gel or glucagon injection. *She did not expect the nurses to call a physician for a low blood glucose, just would expect them to give them some milk or juice. *If a resident was on scheduled insulin and sliding scale insulin even if the sliding scale insulin was not indicated she would expect the nurse to still administer the scheduled dose. *A nurse needed a physician's order to hold the insulin. *She had not reviewed the provider's policy for management of hypoglycemia and had not expected the nurses to follow it. *There was always a physician or nurse practitioner on-call. Interview on 3/24/22 at 4:00 p.m. with physician C revealed: *He does not have parameters set for blood glucose levels. *If a resident had a blood glucose level less than 80 he would expect a nurse to call and update him. *He expected nurses to treat a low blood glucose level with juice or crackers. *He was aware resident 24 had been refusing to eat at times. *He felt like the provider was good at keeping him updated when a resident had a low blood glucose level. On 3/24/22 at 4:10 p.m. surveyors had requested documentation of education provided to nurses on diabetes and blood glucose levels and a physician notification policy from the administrator and director of nursing. They did not have any documentation of education or the policy. Interview on 3/24/22 at 4:20 p.m. regarding residents 4 and 24 with administrator A and director of nursing B revealed: *They did not have a standard of practice for guiding policy development. *They used policies written for them by Med Pass. *They used nursing judgement and if they had questions they would call a nurse consultant. Review of the provider's November 2020 Management of Hypoglycemia policy revealed for a blood sugar less than: *70 the nurse should have: -Given oral glucose. -Notified the doctor immediately. -Stayed with the resident. -Rechecked the blood sugar in fifteen minutes. *54 the nurse should have: -Given glucagon. -Notified the doctor immediately. -Stayed with the resident. -Make the resident comfortable. -Monitor vital signs. -Rechecked the blood sugar in fifteen minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure two of two residents had: *Received risks versus benefits education for side rail use. *Obtained signed informed consent forms for side rail use. *Quarterly assistive device assessments completed. *Routine inspections of side rails. Findings include: 1. Observation and interview on 3/22/22 at 9:04 a.m. with resident 38 revealed: *He had been in his room, sitting in a wheelchair and watching television. *He thought he was here to see patients. *His bed had a side rail attached on the right side. -This side rail was in the up position. *He stated he used the side rail to help him turn over in bed. Review of resident 38's medical record revealed: *He had been admitted on [DATE]. *His diagnosis included: Fracture of his left femur and dementia. *There was no documentation that a safety assessment had been completed for use of a side rail. *There was no documentation that education of risks versus benefits had been completed. *There was no documentation that informed consent had been given. Interview on 3/23/22 at 2:45 p.m. with director of nursing (DON) B revealed: *She thought a therapist completed safety assessments for side rails. *Resident 38 used the right side-rail as a grab bar. Interview on 3/23/22 at 2:48 p.m. with DON B and director of therapy-physical therapist (PT) K revealed: *The process for use of side rails was: *PT K would complete an informal assessment when a resident is admitted . -If she thought the resident would participate better in transferring with a side rail, she would recommend the use of it. *PT K stated resident 38 needed physical assistance of two people and a side rail for positioning while in bed. -The side rail should be used only for bed positioning. Observation and interview on 3/22/22 at 4:10 p.m. of resident 21 sitting on the edge of the bed with her daughter revealed: *The daughter had indicated that her mother's memory was not good and she could not remember things. *The bed had a side rail attached to the right side in the up position. *The daughter did not know why she had it, and had not been told why she needed it. Review of resident 21's 8/17/21, 11/8/21, and 1/31/22 Positioning Device/Restraint Assessments revealed they had not: *Included the side rail. *Included consent or education of the side rail. *Addressed the risk for entrapment. Review of resident 21's medical record did not include a signed consent for use of a side rail. Review of resident 21's 3/16/22 care plan revealed the side rail had not been part of the care plan. Interview on 3/23/22 at 5:03 p.m. with maintenance director D revealed: *He did not have documentation that the side rails are inspected regularly. *He had planned to start documenting when he inspected the rails. Interview on 3/24/22 at 1:20 p.m. with director of nursing B regarding use of side rails revealed: *Therapy did the assessment for use of the side rails. They did not document that assessment. *She had been aware of what was required for use of the side rails. *They had contacted families and had started to get consents signed for use of the side rails. Review of the provider's December 2016 Proper Use of Side Rails policy revealed: *3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: -a. Bed Mobility; -b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet' -c. Risk of entrapment from the use of side rails; and -d. That the bed's dimensions are appropriate for the resident's size and weight. *4. The use of side rails as an assistive device will be addressed in the resident care plan. *5. Consent for using restrictive devises will be obtained from the resident or legal representative per facility protocol. *8. The risks and benefits of side rails will be considered for each resident. *There was a hand written statement on the bottom of the policy that stated The [name of facility] does not use bed rails. Grab bars are used to promote resident independence with rolling, scooting, and sit to/from lying transfers when needed.

Based on observation, interview, and policy review, the provider failed to ensure: *One of one registered nurse (RN) F had completed appropriate hand hygiene (HH) during wound care for one of one sampled resident (32). *One of one certified nursing assistant (CNA) had completed appropriate HH when doffing an N95 and donning a face mask for one of one random observation. 1. Observation and interview on 03/23/22 at 11:35 a.m. of licensed practical nurse (LPN) E and registered nurse (RN) F completing resident 32's wound care revealed: *A physician order for wound care was in the electronic medical record. -Twice a day remove packing, rinse with half strength H2O2 [hydrogen peroxide]. Rinse with saline. Use 2 inch Kling roll and pack wound with dry dressing pack under all skin flaps and in abscess cavity. When Kling is in place, sprinkle with betadine. Cover with dry sterile dressings after that. Two times a day for wound care. *Nursing had followed the wound care procedure per physician order correctly. *RN F missed one of three opportunities' for handwashing during the wound care. -She had removed her gloves after she completed cleansing the wound and had not washed her hands or used hand sanitizer before she had applied clean gloves to place a new dressing. Interview on 3/23/22 at 2:20 p.m. with RN F regarding resident 32's wound care and infection control revealed; *Hand hygiene and glove changes should have occurred when moving from dirty to clean during wound care. *RN F agreed she had missed an opportunity for hand hygiene prior to putting on clean gloves to place a clean dressing. Review of the facility's August 2019 Handwashing/Hand Hygiene policy revealed; *2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before moving from a contaminated body site to a clean body site during resident care. *Procedure -Applying and Removing Gloves --1. Perform hand hygiene before applying non-sterile gloves. 2. Interview and observation on 3/23/22 at 8:40 a.m. with CNA L revealed she: *Had come from a resident room after performing personal cares. *Had an N95 mask on, which would have been contaminated. *Removed the contaminated N95 mask and discarded it in a trash can. *Obtained a new surgical mask from a personal protective equipment cart and put it on. *Did not complete HH when she removed the contaminated N95 and before obtaining the new surgical mask. *Agreed she had not completed HH and should have. -Had training in the last year regarding proper HH. Interview on 3/23/22 at 9:45 a.m. with administrator A and director of nursing B revealed: *Administrator A agreed HH should have been completed when removing an N95 as it would have been contaminated. *Administrator A and director of nursing B both would have expected to have HH completed each time gloves were removed. Interview on 3/23/22 at 2:58 p.m. with director of nursing B regarding HH revealed: *Her expectation was for staff to complete HH between: -Removing contaminated gloves and donning new gloves. -After removing gloves. -Removing a contaminated mask and a new mask. *Training had been for HH had been provided annually and upon hire. -Reminders of proper HH had been provided during stand-up meetings each day. *The infection control nurse and director of nursing completed random audits for HH on a continual basis. Review of provider's undated validation checklist for donning/removing personal protective equipment (PPE) revealed: *11. Goggles/face shield are removed from the sides or front . 12. Hand hygiene performed with alcohol-based hand sanitizer. 13. Mask/respirator is removed . 14. Hand hygiene performed with alcohol-based sanitizer paying attention to hands and forearms. Review of provider's April 2020 general procedure for donning and doffing masks revealed: *1. To put on a mask: a. When donning the face mask, do so immediately after hand hygiene. -d. After touching a facemask or before changing a face mask, perform hand hygiene. *2. To remove mask: a. Front of mask is contaminated-DO NOT TOUCH. If your hands get contaminated during mask/respirator removal, immediately wash your hands or use an alcohol-based hand sanitizer.

Based on observation and interview, the provider failed to ensure homelike noise levels were maintained during observations in one of two resident units (100 hallway). Findings include: 1. Observation and interview on 11/19/19 from 9:05 a.m. through 9:20 a.m. with resident 195 in his room on the 100 unit revealed: *He had been admitted the week before and had lived in his own home prior to that. *He was working with therapy and hoping to get back home again soon. *During the interview the door to his room was nearly closed but was not shut all the way. *There was a significant amount of noise coming from the hallway at times including: -A cognitively impaired resident yelling out frequently. -Staff voices in the hallway including over the walkie-talkies they used to communicate to each other throughout the building. --The walkie-talkie volumes consistently seemed loud. *When the noise level outside the room increased the resident would stop talking for a bit. -When the noise level went back down he would start talking again. *He commented it was noisy in the building, and he was not used to that. *He wore hearing aides and stated sometimes he just took those out when he wanted quiet. Observation on 11/19/19 from 9:45 a.m. through 10:30 a.m. in the lounge area on the 100 unit revealed: *The lounge area was near the connecting point of the 100 hallway, main hallway, and a hallway to administrative offices including an exit door. *Also near that area was a small dining room, a staff break area, the beauty shop, and the therapy gym. *The lounge space had a couch and three recliners that residents, staff, and visitors used frequently. *There were two cognitively impaired residents sitting in the lounge area at the above time. -Resident 6 was resting in a recliner in front of the television, and resident 39 was sitting on the couch. *A few other residents stopped at the area to rest for a few minutes and then continued on to their destinations. *During the above time frame the noise level in that area was elevated, distracting, and included: -Several staff near or walking past the area talking to each other. -Call lights were dinging. -Door alarms were sounding when visitors went through them without de-activating them. -Staff voices were heard over the walkie-talkies frequently that were kept at a loud volume. -Housekeeping staff were vacuuming near the area. -The television was on with the volume at a moderate level. -Staff were frequently opening and closing the medication cart drawers near that area. -There were staff, visitors, and other residents in the beauty shop and therapy areas nearby that were adding to increased noise. *Resident 32 came to talk with resident 39 for a few minutes and held her hand. -She stated they were friends, and she liked to visit her at times. --During that visit she also talked to the surveyor and indicated she had a hard time hearing the surveyor's voice due to the noise level in the area. Random observations of the 100 unit lounge area throughout the rest of that day until 6:00 p.m. revealed: *The noise level had lessened some compared to the time frame above. *The staff walkie-talkies remained at a very loud volume. -Frequently it was clear what the speaker was saying even though the staff member carrying the walkie-talkie was halfway down the hallway or more. *Resident 39 spent a lot of time in that lounge area, and her mood fluctuated. Observation and interview on 11/20/19 at 11:19 a.m. with certified medication assistant/certified nursing assistant (CMA/CNA) C regarding the above observation revealed: *The lounge area again had a large amount of noise including the walkie-talkies, doors opening and closing, staff voices nearby including the beauty shop and therapy areas, call lights sounding, the television, and door alarms. *There were five residents sitting in the lounge area with a visitor trying to speak with one of them. *CMA/CNA C confirmed the noise in the area was distracting and loud. -That could have affected the residents who were sitting in that area. *She had not thought before about the impact the noise could have on the residents. *She stated the staff were just busy working and probably had not noticed the noise. *During our interview her walkie-talkie volume was at a loud level that interrupted the conversation a few times. *She confirmed most walkie-talkies staff carried were turned up loud, so they could hear them easily. -There was a way to adjust the volume, and they could have been adjusted down a little and still been heard. *She stated the loud noises could have been distracting and disruptive especially to the residents with cognitive impairment. Interview on 11/20/19 at 11:28 a.m. with the Minimum Data Set assessment nurse revealed: *Her office was close to the 100 unit lounge area and next to the therapy gym and beauty shop. *She confirmed that area of the building had increased activity, and the noise level was higher at times. *She agreed when the noise level was too loud it could have impacted the residents. -The noise level could have been lessened making it a more homelike atmosphere. *She indicated she had talked to staff in the past about lowering the volume of their voices including the volume of their walkie-talkies, because she felt they were too loud. Interview on 11/20/19 at 1:25 p.m. with the social services designee regarding the noise levels in the building revealed she: *Indicated she had a hearing impairment herself. *Stated most of the time she did not wear her hearing aides while she worked since it was loud enough for her to hear. *Confirmed the 100 unit lounge area and hallways were noisy at times. *Felt the lounge area should have been a calm and quiet environment for the residents to have a more homelike atmosphere. *Indicated resident 39 spent a lot of time in that lounge area, and her mood/behavior could have been affected by the surrounding environment. Interview on 11/20/19 at 1:43 p.m. with the director of nursing (DON) and administrator regarding the above revealed: *They had not heard any residents complaining of the noise level in the facility before. *They confirmed the lounge area and hallways had times throughout the day where the noise level might have been worse than others. *Increased noise levels could have been disruptive to the residents especially residents with cognitive impairment or mood and behavior concerns. -The atmosphere should have been less noisy and more homelike. *The walkie-talkie volumes had been discussed in the past, and they had confirmed they were too loud at times. -The volume should have been maintained at a reasonable level. A policy on homelike environment and sound levels had been requested from the DON on 11/20/19 at 1:50 p.m. and again at 5:25 p.m. and was not received by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure a summary of stay was completed for one of one sampled discharged resident (45). Findings include: 1. Review of resident 45's medical record revealed she had been admitted on [DATE] for rehabilitation services. She had been discharged to an assisted living center on 11/6/19. Review of resident 45's discharge summary form revealed it did not include the following: *Health conditions that impacted the resident's functional status and quality of life. *Nutrition and hydration conditions. *Treatments, programs, or therapy received during her stay. *Laboratory results. Interview on 11/20/19 at 5:20 p.m. with the director of nursing revealed she was not sure what a summary of stay was. She agreed the discharge summary was not complete. Review of the provider's 1/22/19 Transfer or Discharge Documentation policy revealed: *When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: -The basis for the transfer or discharge; -If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: --the specific resident needs that cannot be met; --this facility's attempt to meet those needs; and --the receiving facility's service(s) that are available to meet those needs. -That an appropriate notice was provided to the resident and/or legal representative; -The date and time of the transfer or discharge; -The new location of the resident; -The mode of transportation; -A summary of the resident's overall medical, physical, and mental condition. -Disposition of personal effects; -Disposition of medications; -Others as appropriate or as necessary; and -The signature of the person recording the data in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (22) had: *Appropriate assessments of pain. *Appropriate use of as needed (PRN) pain medication and non-pharmacological interventions for pain. *Followed the care plan interventions. *Obtained a physician's order for the discontinuation of scheduled acetaminophen. *Received hot pack therapy from restorative therapy as ordered. Findings Include: 1. Review of resident 22's medical record revealed: *He had been admitted on [DATE]. *His diagnoses included: -Pain. -Cervicalgia. -Spondylosis with radiculopathy, cervical region. -Primary generalized (osteo)arthritis. Review of resident 22's 9/23/19 quarterly Minimum Data Set (MDS) assessment revealed his Brief Interview for Mental Status (BIMS) score was nine indicating moderate cognitive impairment. Observation on 11/18/19 of resident 22 at 4:25 p.m. revealed he: *Was in his room seated in his wheelchair (w/c). He was facing the window. *Stated he could not turn his neck. *Stated he had pain in his neck. *Had a grimace on his face and furrowed eyebrows when he tried to turn his head. Observation on 11/18/19 at 5:09 p.m. revealed he was seated in his w/c in front of a dining table. His head was lowered onto the table with his hands folded in front of him supporting his head. Observation and interview on 11/19/19 at 9:01 a.m. with certified nursing assistant (CNA) (I) during personal care for resident 22 revealed: *He was transferred from his w/c to his bed using a full body lift. *He was turned from side-to-side when his personal care was performed and when removing the full body lift sling from underneath him. -He grimaced, tightened his jaw, and closed his eyes when he was being turned. *They positioned him on his left side with the pillow under his right side for support. *When CNA I was asked if the resident had pain she stated: He has a lot of pain, to my knowledge he has PRN Tramadol. *The resident was asked if he was in pain, and he said yes. He rated it a fifty on a number scale of one to ten with ten being the worst pain level. His eyes were closed and jaws clenched. Interview on 11/20/19 at 8:20 a.m. with CNA/unlicensed assistive personnel (UAP) G revealed: *Resident 22 received scheduled Voltaren gel 1 percent (%) to his neck two times a day for pain. *He also had physician's orders for PRN Tramadol and acetaminophen. *The CNAs would tell her when he was having pain. *She would then notify the nurse to see what intervention was to have been used. Review of resident 22's physician's orders revealed: *A 10/29/19 order for Tramadol 50 milligrams (mg) give 50 mg by mouth every eight hours as needed for pain. *A 10/31/19 order for acetaminophen liquid 160 mg per 5 milliliters (ml) give 26.5 ml by mouth every eight hours as needed. *A 7/22/19 order for Voltaren Gel 1% apply one application transdermally two times a day for neck pain. *A 10/25/18 order for hot packs to back of neck in restorative every day for fifteen minutes. Review of resident 22's November 2019 medication administration record (MAR) revealed: *Tramadol had been used once 11/13/19 at 11:13 a.m. for a pain rating of seven. *Acetaminophen had not been given so far in November. *Pain was assessed and recorded on the MAR with the Voltaren gel administration at 8:00 a.m. and 8:00 p.m. *A pain assessment on 11/19/19 by CNA/UAP G at 8:00 a.m. revealed he had stated his pain was a zero. *A pain assessment on 11/20/19 by CNA/UAP G at 8:00 a.m. had been recorded as a six. No other pain medications had been given other than the scheduled Volarten gel. *Review of his pain ratings for 11/1/19 through 11/20/19 at 8:00 a.m. revealed he had rated his pain at zero eighteen times out of twenty days. *Review of his pain ratings for 11/1/19 through 11/20/19 at 8:00 p.m. revealed he had rated his pain at zero, six times; at one, once; at two, twice; at three, five times; at four, three times; at five, one time out of twenty days. Review of resident 22's last revised 9/13/19 care plan revealed: *A focus area of: -[Resident name] has arthritis and history of Gout r/t [related to] immobility and pain. He is on scheduled pain medication. *Goals included: -[Resident name] will be/remain free of complications related to arthritis with less joint stiffness, swelling, or decline in mobility through review date. -[Resident name] will maintain acceptable level of comfort by describing level of pain at level 4 or less or mild pain through review date. He does not always admit to pain. *Interventions included: -Pain: Attempt non-pharmacological interventions with [resident name]. Hot packs in Restorative give him comfort to his neck and upper shoulders. *A focus area of: -[Resident name] has a potential for communication problem R/T Hearing deficit and wears hearing aid only in left ear. *A goal of: -[Resident name] will be able to hear adequately with use of hearing aid in left ear in 1:1 [one-to-one] environment through the review date. *Intervention included: -Monitor and observe [resident name] for physical/nonverbal indicators of discomfort or distress, and follow up as needed. He has a history of stiffness to neck r/t cervical spondylosis. He has limited ROM [range of motion] to head and neck. *A Focus area included: -[Resident name] has a need for restorative intervention due to ADL [activities of daily living] self-care performance deficit/limited physical mobility and activity intolerance. He has diagnosis of depression and history of poor motivation. * A goal included: -[Resident name] will maintain current level of function with eating/dining and maintain adequate caloric intake. *Interventions included: -NURSING REHAB [rehabilitation] WARM PACK: Apply warm packs to back of [resident name] neck to promote comfort and lessen stiffness for 15 minutes per day up to 7 days a week. Surveyor: 26632 Interview on 11/20/19 at 1:00 p.m. with the MDS assessment coordinator regarding resident 22 revealed: *The resident had not received the hot packs during his restorative therapy. *She had not added the restorative therapy aide for the hot pack intervention to his care plan. *If the discipline was not added it did not show up for restorative to complete. Surveyor: 42478 Review of resident 22's primary care provider's orders for pain medication revealed: *On 10/29/19: Change Tramadol to 50 mg every 8 hours PRN. Discontinue the scheduled tramadol. *On 10/29/19: Tylenol 850 mg by mouth every eight hours PRN. *There was no nurse's signature to indicate those orders had been verified. *There was no order to have discontinued the scheduled Tylenol. Interview on 11/20/19 at 1:25 p.m. with the assistant director of nursing (ADON) revealed: *In October 2019 he had received scheduled Tramadol and acetaminophen. *He started to lose weight and complain of stomach pain, so his Tramodol was changed to PRN. *She was not aware he had stated his pain was a zero for eighteen of twenty times each morning. *She was not aware he had only received the PRN Tramadol one time in November 2019. *She agreed he should have been offered PRN pain medication when he was grimacing or rated his pain at a four or higher. *He would rate his pain between fifty and one-hundred. *She had tried to get a physician's order for a soft neck brace. -There was no documentation to support that. *She could not find any physician's order to have discontinued the scheduled Tylenol. *She agreed that orders should have been double-checked by the night nurse and should have been noted by nurse. *She agreed it might have been assumed the scheduled Tylenol had been discontinued. *She could not find any order to discontinue the scheduled Tylenol. Review of the provider's revised March 2018 Pain - Clinical Protocol policy revealed: *With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment. *The physician will order appropriate non-pharmacologic and medication interventions to address the individual's [resident] pain. *The staff will reassess the individual's [resident] pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. *The staff will evaluate and report the resident/patient's use of standing and PRN analgesics. Review of the provider's revised July 2016 Medication and Treatment Orders policy revealed: *Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart. *Such orders are reviewed by the consultant pharmacist on a monthly basis.

Based on observation, record review, interview, and policy review, the provider failed to ensure medication had been administered according to their policy and procedure by one of one licensed practical nurse (LPN) (B) causing a medication error rate of 7.41% for: *One of two observed residents (10) who had almost received insulin from another resident's (44) insulin pen. *One of one randomly observed residents (42) intravenous (IV) pump that had been set at the incorrect rate for administration. Findings include: 1. Observation and interview on 11/19/19 at 11:40 a.m. of LPN B regarding resident 10 revealed: *She removed a Novolog insulin flex-pen out of the medication cart. *She removed the cover from the pen that had the label attached to it. *She dialed two units of the insulin to prime the pen, and then dialed five units to give to the resident.*While she primed the insulin pen the cover dropped on the floor. *This surveyor picked the cover up and the label indicated it was resident 44's insulin pen. *LPN B went into resident 10's room and was about to inject the insulin. *This surveyor stopped her, asked her to come into the hall, and showed her the label of the insulin pen. *She stated the insulin pen for resident 44 had been put into resident 10's insulin supply container in the medication cart. *She agreed she had not read the label to ensure it was resident 10's insulin pen. 2. Observation and interview on 11/19/19 at 4:00 p.m. of LPN B during an intravenous medication administration for resident 42 revealed: *After she had attached and primed the IV tubing to the first bag of fluconazole 200 milligram in 100 milliliter (ml) of sodium chloride she: -Set the IV machine at a rate of 200 ml per hour and the volume to be infused of 100 ml. -Review of the medication label for the fluconazole revealed it should have been infused at 100 ml per hour. -The rate it was set at would have had it infused in one-half hour instead of one hour. *LPN B was questioned about the rate and stated it was correct. This surveyor explained it did not match the indicated rate of the medication label. *LPN B reset the rate to 100 ml per hour. 3. Interview on 11/20/19 at 2:30 p.m. with the assistant director of nursing agreed the above medication administration observations would have potentially caused harm to the residents. She agreed they should be considered medication errors. Review of the provider's revised July 2016 Medication and Treatment Orders policy did not have any information about checking the medication labels for the resident's name, medication name, and dose of medication to have been given.

Based on observation, interview, record review, and guideline review, the provider failed to ensure the correct diet had been followed for one of one sampled resident (6) who was on a mechanically altered diet. Findings include: 1. Review of resident 6's medical record revealed: *An admission date of 11/18/15. *He was unable to complete the Brief Interview for Mental Status assessment. *A physician diet order dated 4/13/18 for, Regular diet Level 1-Puree texture, Regular fluid consistency, special occasions permitted. *Diagnosis of dementia with behavioral disturbance. Observation on 11/19/19 of resident 6 revealed: *At 8:13 a.m.: -He was sitting at an assisted table in the dining room. -There was an unidentified staff member sitting next to him. -He was holding a whole peeled banana in his left hand eating it independently. *Between 9:04 a.m. to 9:30 a.m.: -He had been sitting in the 100 unit sitting area and was coughing. *At 11:03 a.m. he was coughing while being assisted to the bathroom. *At 12:16 p.m. he was given a pureed meal on a divided plate. Interview on 11/20/19 at 10:20 a.m. with certified nursing assistant A regarding resident 6 revealed: *He was to have food that had been blended. *She could not remember what the diet was called. Interview on 11/20/19 at 10:35 a.m. with licensed practical nurse B regarding resident 6 revealed: *He was on a pureed diet. *He had refused to let the staff mash up the banana in the past, so they gave him whole bananas. *His wife was aware they let him have whole bananas. *She was going to call a physician about an order. *She did not know if he had been evaluated by a speech therapist. Interview on 11/20/19 at 1:21 p.m. with the Minimum Data Set assessment coordinator regarding resident 6 revealed: *He had been put on a pureed diet, because he was pocketing food in his mouth. *They let him have bananas as they were soft enough, and he had not pocketed the banana in his mouth. *The only non-pureed food he was given was bananas. Interview on 11/20/19 at 1:58 p.m. with the director of rehabilitation revealed resident 6 had not been seen by a speech therapist. Interview on 11/20/19 at 2:11 p.m. with the director of dining services regarding resident 6 revealed: *He had been pocketing food, so they had asked the physician for an order for a pureed diet. -She could not remember how long ago he had been changed to a pureed diet. *When they had a resident who was having problems with eating they discussed it with the interdisciplinary team. -Then the team decided what should be done to help the resident. *He had not been referred to speech therapy. *No attempt had been made to upgrade his diet. *It was his regular routine to have a banana while he was waiting for his meal. *Family was aware of the resident eating whole bananas. *He had no trouble swallowing the banana. Interview on 11/20/19 at 4:11 p.m. with the director of nursing regarding resident 6 revealed: *She had given him the banana. *She did not know he could not have a whole banana with a pureed diet. *She agreed he should not have had a whole banana. *She did not know why he was on a pureed diet. Review of resident 6's 10/1/18 care plan revealed: *He required supervision to extensive assistance with meals. *He was on a pureed diet. *Family was aware and agrees with the appropriate diet. *It had not addressed the resident eating a whole banana. Review of the provider's undated Dysphagia Level 1/Pureed Diet guideline revealed fresh bananas were to be well-mashed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to accurately document the effectiveness of psychotropic medications for one of one sampled resident (14). Findings include: 1. Review of resident 14's medical record revealed: *He was admitted on [DATE]. *His diagnoses included: -Alzheimer's disease with late onset. -Altered mental status, unspecified. -Cerebral cysts. -Dementia in other diseases classified elsewhere with behavioral disturbance. -Major depressive disorder, single episode, unspecified. -Anxiety disorder, unspecified. -Insomnia, unspecified. -Benign prostatic hyperplasia with lower urinary tract symptoms. *He had been admitted to a behavioral health hospital on 5/6/19 and returned on 5/8/19. *He returned with new medications of Lexapro 10 milligrams (mg) every day, lorazepam 0.5 mg every evening, and Trazodone HCL 50 mg at bedtime. *Trazodone HCL 50 mg at bedtime had been discontinued on 6/14/19. Review of resident 14's 8/29/19 Minimum Data Set assessment revealed: *His Brief Interview for Mental Status assessment score was thirteen indicating his cognition was intact. *He was not depressed. *He had no hallucinations, delusions, or behaviors. *He had no change in behavior compared to the prior assessment on 6/5/2019. *He rejected care one to three days during the assessment period. *He required limited assistance of one staff member for dressing, toileting, and bed mobility. -He required limited assistance of two staff members for transferring. *He was occasionally incontinent of bladder. *He was continent of bowel. Review of resident 14's current undated care plan revealed: *He took the anti-anxiety medication lorazepam related to anxiety disorder. *Administer Lorazepam as ordered by physician. Monitor for side effects and effectiveness as needed per protocol. *Monitor [resident name] per shift and as needed for safety. [Resident name] is taking Lorazepam which is associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. Monitor [resident name] sleep pattern since Trazodone discontinued 6/14/19. *Monitor/document/report PRN [as necessary] any adverse reactions [resident name] may exhibit of ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Pharmacy review 8/25/19. *Monitor/record [resident name] with occurrence of for target behavior symptoms of inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. *He took an anti-depressant medication Lexapro related to depression and behavior. *Administer Lexapro as ordered by physician. Monitor/document side effects and effectiveness with clinical charting. Monitor sleep pattern since Trazodone discontinued 6/14/19. *Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition [resident name] may exhibit; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL [activities of daily living] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v [nausea/vomiting], dry mouth, etc. Pharmacy review 8/25/19. Review of resident 14's nurses' notes from 5/7/19 through 6/18/19 revealed: *There was no documentation of mood and behaviors after he returned from the hospital on 5/8/19. *There was no documentation on 5/9/19 regarding his mood and behavior. *On 5/10/19 they had documented no behaviors. *The next mood and behavior note was written on 5/17/19. *They had documented on mood and behaviors only fifteen out of forty-one opportunities. *There was no documentation of his sleep patterns. Interview on 11/19/19 at 11:32 a.m. with resident 14 revealed he was: *Angry, and stated he was being held captive at the facility. *Upset he no longer had a phone in his room. *Upset that his son, power of attorney, was selling all my stuff. Interview on 11/20/19 at 4:30 p.m. and again at 6:02 p.m. with the director of nurses (DON) and the assistant director of nurses (ADON) revealed: *Any documentation regarding monitoring for effectiveness of medications should have been documented in the nurses notes. *Asked for specific monitoring for the lorazepam and Lexapro started after he had returned from the hospital on 5/8/19. *At 6:02 p.m. the ADON stated they were unable to locate any documentation on effectiveness or behavior monitoring regarding the above medications. Review of the provider's April 2018 Medication Utilization and Prescribing - Clinical Protocol policy revealed: *The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications. *The staff and physician will monitor the progress of anyone with a probable adverse drug reaction and anyone for whom medications have been adjusted because of the possibility of an adverse drug reaction. *If the physician has stopped, tapered, or changed an existing medication, the staff will monitor for, document, and report any return of symptoms.

Based on observation, interview, and policy review, the provider failed to ensure appropriate hand hygiene, glove use, and disinfection of the glucometer had been used by: *Two of two certified nursing assistants (CNA) (H and I) during personal care for one of one sampled resident (22). *One of one CNA/unlicensed assistive personnel (UAP) (G) for two of two sampled residents (10 and 36) during checking their blood glucose levels. Findings include: 1. Observation on 11/19/19 at 9:01 a.m. of CNAs H and I during personal care for resident 22 revealed: *CNA H did not complete any hand hygiene prior to putting on gloves. *CNA I did not complete any hand hygiene prior to assisting with resident 22's transfer. *Both CNAs used the full body lift to transfer resident 22 from his wheelchair to his bed. *CNA I then put on gloves with no hand hygiene completed. *Both CNAs assisted to reposition resident 22 onto his side on the bed. *CNA H removed the resident's incontinent brief, provided perineal care, and placed a new incontinent brief on him without changing her gloves. She then put barrier cream on his perineal area. *CNA I had assisted with the repositioning him from side-to-side removing the soiled brief, placed a new brief on him, and rearranged his clothing. *No glove change was completed when they also placed a pillow behind his back to position him on his left side. *Both CNAs H and I disposed of their gloves. CNA I applied soap to her hands then she washed and rinsed her hands under the running water. *CNA I opened the drapes and placed a fall mat on the floor. She then washed her hands for six to ten seconds before leaving his room. Interview on 10/20/19 at 2:00 p.m. with CNA I confirmed she had not changed her gloves or washed her hands at the appropriate times when she had assisted resident 22. 2. Observation on 11/19/19 at 11:32 a.m. of CNA/UAP G during the blood glucose checks for residents 10 and 36 revealed: *For both residents she removed the glucometer from the top of the medication cart. *She set the glucometer and her finger stick supplies on the resident's dressers in their rooms without any barrier. *After she had completed the blood sugar checks she returned to the medication cart and wiped the glucometer with a Cavi-Wipe disinfectant cloth for approximately three to five seconds. *She then set the glucometer on the top of its case on top of the medication cart. Interview on 11/20/19 at 2:30 p.m. with the assistant director of nursing agreed proper hand hygiene and glove use had not been completed. 3. Review of the provider's revised August 2015 Handwashing/Hand Hygiene policy revealed: *All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *Use an alcohol-based hand rub or soap and water: -Before and after direct contact with residents. -Before moving from a contaminated body site to a clean body site during resident care. -After removing gloves. *The procedure for washing hands included: -Vigorously lather hands with soap and rub them together creating friction to all surfaces. -That should have been done for a minimum of twenty seconds. Review of the provider's revised October 2011 Obtaining a Fingerstick Glucose Level policy included to Clean and disinfect resusable equipment between uses according to manufacturer's instructions and current infection control standards of practice.