**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 (CR #1) of 5 residents reviewed for accidents and supervision. The facility failed to ensure CNA A and CNA B did not improperly transfer CR #1. CNA A and CNA B transferred CR #1 without a gait belt from the bed to the shower chair on 04/01/25. This failure could place residents at risk for harm, pain, and injury. The findings included: Record review of CR #1's admission Record, dated 04/11/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), type 2 diabetes mellitus (high blood sugar) without complications, obstructive sleep apnea (sleep disorder that causes breathing pauses at night due to blocked upper airway), and functional quadriplegia (complete inability to move). Record review of CR #1's MDS Assessment, dated 03/31/25, revealed a BIMS score of 13, indicating cognition was intact. Further review revealed resident was dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers was required for the resident to complete the activity with toileting hygiene, shower/bathe, and sit to stand. Record review of CR #1's Care Plan, undated, revealed resident was at risk for falls. Record review of CR #1's progress notes, entered by Nurse A and dated 04/01/25 at 19:30 [7:30 p.m.], revealed CNA came and reported to the nurse that patient was lowered on the floor while transferring her from bed to chair. Patient was being transferred x2 persons to shower chair when her legs gave in. Assessment done; no new skin alteration noted . During a telephone interview on 04/11/25 at 10:17 a.m., CNA A said CNA B got her and told her he needed her to assist him with a shower. She said she went to CR #1's room and the resident was in a sitting position on the bed. She said the resident's family member was in the room. She said they tried to transfer the resident to the shower chair, but the resident was so weak that they had to sit her down in front of the bed on the floor. She said she was holding up the resident by her arm under her armpit. She said they called the nurse on duty (did not know their name) and called another CNA (did not know their name) and resident was transferred from the floor to the shower chair. During an interview on 04/11/25 at 2:02 p.m., Nurse A said CNA A came to her and told her that CR #1 was being transferred to the shower chair and got lowered to floor because the resident was weak. She said she checked for bruises when resident was on the floor, she checked her head, body, and ran her hands through her head. She said she took her vital signs when she was still on the floor. She said she completed change in condition, incident report, and doctor was notified. She said she did not ask them what technique they used to transfer the resident. She said a gait belt should be put on the resident with one person on the right and the other on the left side. She said she did not see a gait belt. She said she did not ask if a gait belt was used. During a follow-up interview on 04/11/25 at 2:26 p.m., CNA A said they were not using a gait belt. She said she had one she used but that day she did not bring it. During an interview on 04/11/25 at 2:45 p.m., CNA B said he went and got CNA A to assist him and in the middle of transferring CR #1 to the shower chair, her legs got weak, and they lowered her to the floor. He said he stood behind the resident until CNA A went and got the nurse and another CNA. He said they should have had a gait belt, but they did not have one. He said he did not really think they needed one. He said she did not have any injuries. He said CR #1 did not express any pain and there was no bruising. During an interview on 04/15/25 at 10:30 a.m., the Director of Rehabilitation said a gait belt should be used for every situation whether it's a 2-person or 1-person transfer. She said it was not a proper technique to lift from under the shoulders because one could pull arm out of socket or hurt themselves. Record review of the facility's Safe Lifting and Movement of Residents policy, revised October 2009, read in part .2. Manual lifting of residents shall be eliminated when feasible .4. Staff responsible for direct care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices .5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment, for 3 of 6 residents (Resident #19, Resident #47, and Resident #13) reviewed for residents' rights. The facility failed to keep Resident #19's and Resident #47's room free of trash. The facility failed to keep Resident #13's wall clean. These failures could place residents at risk of an unsanitary environment. Findings included: Record review of Resident #47's face sheet dated 6/6/24 revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included type 2 diabetes, major depressive disorder, and adjustment disorder with mixed disturbance of emotions and conduct. Record review of Resident #47's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #47's care plan updated 6/4/24 revealed the resident had a behavior problem related to keeping his room unclean due to leaving trash from snacks around room. Interventions were to anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. In an observation on 6/4/24 at 10:29 a.m. of Resident #47's room revealed there were crumbs on the floor under the bed near the wall including a sugar packet, opened straw, and other debris. In an observation on 6/4/24 at 10:54 a.m. of Resident #47's room revealed the crumbs were still on the floor with the addition of an opened snack wrapper. In an observation and interview on 6/4/24 at 1:33 p.m. in Resident #47's room revealed a fly was flying around. The crumbs from previous observations were still on the floor. The resident said housekeepers cleaned his room and the facility always had flies. In an observation on 6/5/24 at 3:16 p.m. in Resident #47's room revealed the crumbs were still on the floor under the bed near the wall. In an observation and interview on 6/6/24 at 10:43 a.m. with the Housekeeping Manager of Resident #47's room revealed trash was underneath his bed. The Housekeeping Manager said she did not like the condition of Resident #47's room and said it did not appear to be swept good. She said the trash on the floor could cause ants, slipping or falling. Record review of Resident #19's face sheet dated 6/6/24 revealed an [AGE] year old male who admitted on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), unspecified psychosis, dementia, and anxiety disorder. Record review of Resident #19's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. He required assistance from staff with ADL care. In an observation on 6/4/24 at 1:30 p.m. of Resident #19's closet revealed there were food crumbs and a cup with tan liquid on the floor. The tan liquid was also on the wall. In an observation on 6/5/24 at 3:15 p.m. of Resident #19's closet revealed the crumbs and liquid were still present. In an observation and interview on 6/6/24 at 10:27 a.m. of Resident #19's closet with LVN A, he said the substance on Resident #19's wall and floor appeared to be formula and crumbs. He said the resident might have finished the formula and threw it in the closet. He said the closet should not look like that because it was supposed to be clean, and it could bring ants. He said the housekeeper was responsible to clean the entire room and may not have opened the closet. In an observation and interview on 6/6/24 at 10:43 a.m. of Resident #19's closet with the Housekeeping Manager revealed a tan liquid substance on the floor and wall, along with food crumbs. The Housekeeping Manager said the area appeared to be a drink that spilled down the wall. She said it was dirty and needed to be cleaned. Record review of Resident #13's face sheet dated 6/6/24 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included dementia, heart failure, bipolar disorder, and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of Resident #13's quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 out of 15 which indicated severe cognitive impairment. She was dependent on staff for ADL care. In an observation on 6/4/24 at 10:48 a.m. in Resident #13's room revealed there was a brown area smeared on the wall above Resident #13's bed. In an observation and interview on 6/6/24 at 10:43 a.m. of Resident #13's wall with the Housekeeping Manager revealed a brown colored smear above the resident's bed. The Housekeeping Manager said the spot appeared to be a bug or blood from a bug that should not be there. She said she started at the facility on Monday (6/3/24) and was identifying areas that they needed to improve on. She said housekeeping staff were expected to sweep and mop the floors, clean the walls, bathroom, furniture, and bedside trays and were responsible for anything that needed to be cleaned. She said she expected the facility to be clean. She said she was responsible for ensuring the facility was clean but was still getting acclimated. In an observation and interview on 6/6/24 at 11:06 a.m. the Administrator and this Surveyor observed the areas of concern in Resident #19, Resident #47, and Resident #13's room. She said the areas needed attention and should be cleaned right away. She said she expected the resident rooms to be maintained and clean due to infection control and quality. She said department heads were expected to conduct room rounds and report any concerns to housekeeping. She said the Housekeeping Manager was brand new and the facility transitioned to a new housekeeping company on Saturday (6/1/24) due to quality concerns with the previous company. She said she and the Housekeeping Manager were responsible for ensuring the rooms were clean. Record review of the facility's Quality of Life - Homelike Environment policy dated August 2009 read in part, .Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible .Characteristics of a personalized, homelike setting 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. cleanliness and order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1 of 6 residents (Residents #37 ) reviewed for significant medication errors; - LVN A failed to administer medications as ordered to Resident #37 by attempting to administer 18 units of HumaLOG Insulin (Insulin Lispro), a fast acting insulin, instead of 18 units of long acting Basaglar Insulin. This failure could place residents at risk of adverse reactions such as hypoglycemia (low blood sugar) and hospitalization. Findings Included: Record review of Resident #37's Face Sheet dated 04/24/23 revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: high blood pressure, acute kidney disease and type 2 diabetes . Record review of Resident #37's Quarterly MDS dated [DATE] revealed, use of corrective lenses, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #37's undated Care Plan revealed, focus- diabetes; intervention- diabetes medication as ordered by doctor, observe/document for side effects and effectiveness. Record review of Resident #37's Physician's Order dated 04/21/23 revealed, Basaglar Insulin 100 unit/mL- Inject 18 units under the skin one time a day. Record review of Resident #37's Physician's Order dated 02/16/23 revealed, HumaLOG insulin- inject as per sliding scale under the skin two times a day. If 70-249 = 0 units, 250-350 = 5 units, call MD/NP if blood sugar is greater than 350. An observation and interview on 04/24/23 at 07:20 AM revealed, LVN A preparing for insulin administration to Resident #37. He took his blood glucose (sugar) testing supplies into Resident #37's room and measured her blood sugar which resulted in 249 mg/dL. LVN A informed Resident #37 of her blood sugar, exited the resident's room, discarded the testing supplies and then cleaned the glucose meter. LVN A said since Resident #37's BG was 249 mg/dL he would not administer the sliding scale HumaLOG but he would administer Resident #37's long acting Basaglar Insulin. LVN A then retrieved an Insulin Lispro (HumaLOG) insulin pen labeled for Resident #37 from his nursing cart, cleaned the rubber septum, attached a pen needle, dialed 18 units on the pen, closed his cart, knocked on Resident #37's door frame and proceeded to enter into Resident #37's room to administer the 18 units of HumaLOG. Right after LVN A knocked on Resident #37's door frame and as he stepped into the resident's room the surveyor stopped LVN A, asked him what medication he was about to administer and LVN A said Basaglar. The surveyor alerted him to the wrong medication he selected, HumaLOG instead of Basaglar. LVN A said prior to medication administration nursing staff are expected to double check the medication being administered against the EMR but he must have read it incorrectly. LVN A said if he had administered fast acting HumaLOG to Resident #37 the medication would have dropped the resident's blood sugar too low. In an interview on 04/24/23 at 11:50 AM, the DON said prior to administering medications nursing staff must verify the patient identifiers and then the MAR against the medication blister pack for the right dose, route and frequency. The DON said HumaLOG was a fast acting insulin meant to control anticipated blood sugar increases as a result of meals, and Basaglar was a long acting insulin meant to control blood sugars over a longer period of time. She said if LVN A administered HumaLOG instead of Basaglar to Resident #37 the resident's blood sugar would have dropped significantly. The DON said failure to administer insulin as ordered could place residents at risk for adverse reactions such as hypoglycemia. Record review of LVN A's competency assessment titled Medication Pass Observation dated 02/10/23 revealed, 8- MAR is read prior to preparing medications; competency-met. Record review of the facility policy titled Administering Medications dated 12/2012 revealed, 3- Medications must be administered in accordance with orders, including any required time. 7- The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 2 of 6 residents (Resident #42 and Resident #159 ) reviewed for pharmacy services. - The facility failed to ensure that the 100 hall nursing cart did not contain expired insulin for Resident #42 - The facility failed to have Hydrocodone- Acetaminophen, a pain medication, available for administration to Resident #159 and failed to administer it according to physician orders. This failure could place residents at risk of not receiving the therapeutic benefit of medications. Findings Included Resident #42 Record review of Resident #42's Face Sheet dated 04/24/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: paraplegia (paralysis of the legs and lower body), difficulty swallowing and type 2 diabetes. Record review of Resident #42's Quarterly MDS dated [DATE] revealed, use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, extensive assistance with most ADLs, use of a wheelchair, and always incontinent of both bladder and bowel. Record review of Resident #42's undated Care Plan revealed, focus- Resident #42 has diabetes and is at risk for complication; interventions- give diabetes medication/insulin as ordered. Record review of Resident #42's Physician's Order dated 10/16/21 revealed, Lantus Insulin 100 units/mL - inject 10 units under the skin in the morning for diabetes. Lantus Insulin 100 units/mL- inject 6 units subcutaneously at bedtime for DM. An observation and interview on 04/24/23 at 07:30 AM, inventory of the 100 Hall Nursing Cart with LVN A revealed: - an open, in use and expired vial of Lantus Insulin for Resident #42 with an open date of 03/20/23 with manufacturer's instructions of use within 28 days (04/17/23) after opening. LVN A said nursing staff are expected to check their carts daily as used for expired medications. He said once insulin expires it could lose efficacy so it must be taken out of circulation and discarded in the sharps container after reorder. LVN A said use of expired insulin could place residents at risk of uncontrolled blood sugars. Resident #159 Record review of Resident #159's Face Sheet dated 04/24/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: bacterial skin infection, depression, hypertension, generalized muscle weakness and age-related physical debility. Record review of Resident #159's admission MDS dated [DATE] revealed, use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, extensive assistance to total dependence on most ADLs, use of a wheelchair and always incontinent of both bladder and bowel. Record review of Resident #159's undated Care Plan revealed, no related focus areas. Record review of Resident #159's Physician Orders dated 04/20/23 revealed, Hydrocodone-Acetaminophen 5-325 mg, give 1 tablet by mouth four times a day for pain for 10 days). Scheduled for 12:00 AM, 06:00 AM, 12:00 PM and 06:00 PM. Record review of Resident #159's Individual Patient's Antibiotic/Narcotic Record with a received date of 04/08/23 revealed, 54 tablets of Hydrocodone/Acetaminophen 5-325 mg were received and the last tablet was administered at 05:13 PM on 04/23/23. Resident #159 did not have any Hydrocodone/Acetaminophen after 04/23/23 at 05:13 PM. An observation and Interview on 04/24/23 at 08:17 AM revealed, MA A preparing medication for administration for Resident #159. She retrieved 9 oral medications, which did not include Hydrocodone-Acetaminophen 5/325 mg, entered into Resident #159's room and administered the medication to the resident. LVN A said she did not administer Hydrocodone to Resident #159 because it was not available and she would contact her nurse to determine what further action to take. Resident #159 appeared to be in no immediate distress. In an interview on 04/24/23 at 11:39 AM revealed, Resident #159 said she was not in pain. She said she received a lot of pain medications and the nurses did a good job administering her pain medications. In an interview on 04/24/23 at 11:45 AM, MA A said the last time Resident #159 received her Hydrocodone was at 11:58 PM on 04/23/23 . She could not provide the control sheet for the medication. In an interview on 04/24/23 at 11:50 AM, the DON said nursing staff are expected to check their nursing carts for expired medication daily. She said Insulin once expired can become less effective and if used could result in uncontrolled blood sugars. She said all expired insulin must be discarded in the drug disposal bin located in the med room. In an interview on 04/25/23 at 10:31 AM, the DON said the last dose of Hydrocodone/Acetaminophen 5-325 mg for Resident #159 was administered on 04/23/23 per the resident's control log, the resident had no more medication and it was only meant to be administered for 10 days and the resident had no more Hydrocodone/Acetaminophen. Record review of the facility policy titled Administering Medications dated 12/2012 revealed, Medications must be administered in accordance with the orders . Record review of the facility policy titled Storage of Medication dated 10/2014 revealed, 4- the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 15 percent based on 7 errors out of 44 opportunities, which involved 4 of 7 residents (Resident #37, Resident #159, Resident #16 and Resident #6) reviewed for medication errors. - LVN A failed to administer medications as ordered to Resident #37 as ordered by attempting to administer HumaLOG Insulin (Insulin Lispro) outside of parameters instead of Basaglar Insulin as ordered. - MA A failed to administer medication to Resident #159 as ordered by administering Multivitamin instead of Multivitamins with Minerals as ordered, Calcium Carbonate 500 mg instead of Calcium Carbonate 600 mg as ordered and by failing to administer Hydrocodone/Acetaminophen 5-325 mg (medication for pain) as ordered due to the medication being unavailable in the facility. - MA B failed to administer medications to Resident #16 as ordered by administering Multivitamin with minerals instead of plain Multivitamins as ordered. - MA B failed to administer medications to Resident #6 as ordered by administering Multivitamin with minerals instead of plain Multivitamins as ordered. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications, and adverse reactions such as hypoglycemia (low blood sugar) and hospitalization. Findings Included: Resident #37 Record review of Resident #37's Face Sheet dated 04/24/23 revealed. a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: high blood pressure, acute kidney disease and type 2 diabetes. Record review of Resident #37's Quarterly MDS dated [DATE] revealed, use of corrective lenses, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #37's undated Care Plan revealed, focus- diabetes; intervention- diabetes medication as ordered by doctor, observe/document for side effects and effectiveness. Record review of Resident #37's Physician's Order dated 04/21/23 revealed, Basaglar Insulin 100 unit/mL- Inject 18 units under the skin one time a day. Record review of Resident #37's Physician's Order dated 02/16/23 revealed, HumaLOG insulin- inject as per sliding scale under the skin two times a day. If 70-249 = 0 units, 250-350 = 5 units, call MD/NP if blood sugar is greater than 350. An observation and interview on 04/24/23 at 07:20 AM revealed, LVN A preparing for insulin administration to Resident #37. He took his blood glucose (sugar) testing supplies into Resident #37's room and measured her blood sugar which resulted in 249 mg/dL. LVN A informed Resident #37 of her blood sugar, exited the resident's room, discarded the testing supplies and then cleaned the glucose meter. LVN A said since Resident #37's BG was 249 mg/dL he would not administer the sliding scale HumaLOG but he would administer Resident #37's long acting Basaglar Insulin. LVN A then retrieved an Insulin Lispro (HumaLOG) insulin pen labeled for Resident #37 from his nursing cart, cleaned the rubber septum, attached a pen needle, dialed 18 units on the pen, closed his cart, knocked on Resident #37's door frame and proceeded to enter into Resident #37's room to administer the 18 units of HumaLOG. Right after LVN A knocked on Resident #37's door frame and as he stepped into the resident's room the surveyor stopped LVN A, asked him what medication he was about to administer and LVN A said Basaglar. The surveyor alerted him to the wrong medication he selected HumaLOG instead of Basaglar. LVN A said prior to medication administration nursing staff are expected to double check the medication being administered against the EMR but he must have read it incorrectly. LVN A said if he had administered fast acting HumaLOG to Resident #37 the medication would have dropped the resident's blood sugar too low and failure to administer the long acting Insulin would have resulted in Resident #37's blood sugar being inadequately controlled over the duration of the day. LVN A said Resident #37's Basaglar was not in the cart, so he would have to retrieve it from the med room in order to administer it. Resident #159 Record review of Resident #159's Face Sheet dated 04/24/23 revealed, an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: bacterial skin infection, depression, hypertension, generalized muscle weakness and age-related physical debility. Record review of Resident #159's admission MDS dated [DATE] revealed, use of corrective lenses, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, extensive assistance to total dependence on most ADLs, use of a wheelchair and always incontinent of both bladder and bowel. Record review of Resident #159's undated Care Plan revealed, no related focus areas. Record review of Resident #159's Physician Orders dated 04/05/23 revealed, Calcium Carbonate 600 mg- give 1 tablet by mouth one time a day for calcium supplement; Multivitamin w/ Minerals- give 1 tablet by mouth for vitamin supplement. Record review of Resident #159's Physician Orders dated 04/20/23 revealed, Hydrocodone-Acetaminophen 5-325 mg, give 1 tablet by mouth four times a day for pain for 10 days. Scheduled for 12:00 AM, 06:00 AM, 12:00 PM and 06:00 PM. An observation and Interview on 04/24/23 at 08:17 AM revealed, MA A preparing medication for administration for Resident #159. She retrieved 1 tablet of Multivitamin, 1 tablet of Calcium Carbonate 500 mg and 7 other oral medications, which did not include Hydrocodone-Acetaminophen 5/325 mg, entered into Resident #159's room and administered the medication to the resident. LVN A said she did not administer Hydrocodone scheduled for 06:00 AM to Resident #159 because it was not available and she would contact her nurse to determine what further action to take. In an interview on 04/24/23 at 11:45 AM, MA A said that Multivitamins and Multivitamins w/ minerals are not the same and the products are not interchangeable. She said Resident #159 was supposed to receive 1 tablet of a Multivitamin with Minerals but she grabbed the wrong bottle. She said failure to administer medication as ordered could place residents at risk for adverse reactions or over supplementation. In an interview on 04/24/23 at 01:15 PM, MA A said she administered 500 mg of Calcium Carbonate to Resident #159 instead of 600 mg because there was no 600 mg available in the facility. She said when OTC medications/supplements are not available, MAs are required to notify their nurse who then contacts the physician to receive an order for an alternative of the unavailable medication. MA A said she notified the facility staff responsible for ordering the correct Calcium supplement but could not confirm if she notified her nurse. Resident #16 Record review of Resident #16's Face Sheet dated 04/24/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: lack of coordination, age related cognitive decline and high cholesterol. Record review of Resident #16's Quarterly MDS dated [DATE] revealed, impaired vision, severe cognitive impairment as indicated by a BIMS score of 06 out of 15, extensive assistance for most ADLs, use of a wheelchair, and always incontinent of both bladder and bowel. Record review of Resident #16's undated Care Plan revealed, no focus areas related to failure. Record review of Resident #16's Physician Order dated 12/12/18 revealed, Multivitamin- give 1 tablet by mouth one time a day for vitamin deficiency. An observation and interview on 04/24/23 at 08:37 AM revealed, MA B preparing for medication administration to Resident #16. She retrieved 1 tablet of Multivitamin w/ Minerals and 5 other oral medications, entered into the resident's room and administered the medications. Resident #6 Record review of Resident #6's Face Sheet dated 04/24/23 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: seizures, joint pain, anxiety disorder, pressure ulcer, dementia and type 2 diabetes. Record review of Resident #6's Quarterly MDS dated [DATE] revealed, use of corrective lenses, severely impaired cognition as indicated by a BIMS score of 06 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #6's Physician Order dated 09/17/20 revealed, Multivitamin- give 1 tablet by mouth one time a day for vitamin deficiency. An observation and interview on 04/24/23 at 08:53 AM revealed, MA B preparing for medication administration to Resident #6. She retrieved 1 tablet of Multivitamin w/ Minerals and 3 other dietary supplements, entered into the resident's room, and administered the medications. In an interview on 04/24/23 at 11:30 AM, MA B said prior to preparing medication for administration, staff must verify the patient identifiers, and the medications against the MAR. She said she administered Multivitamin w/ Minerals to both Resident #16 and Resident #6 and she did not know if there was a difference between Multivitamin w/ Minerals and Multivitamins. MA B said she believed they were interchangeable but she would confirm with her DON. MA B said she failure to administer medications as ordered could place residents at risk for upset stomach or over supplementation. In an interview on 04/24/23 at 11:50 AM, the DON said prior to administering medications nursing staff must verify the patient identifiers and then the MAR against the medication blister pack for the right dose, route and frequency. She said Multivitamins and Multivitamins with Minerals are not the same thing, and not interchangeable. The DON said HumaLOG was a fast acting insulin meant to control anticipated blood sugar increases as a result of meals, and Basaglar was a long acting insulin meant to control blood sugars over a longer period of time. She said if LVN A administered HumaLOG instead of Basaglar to Resident #37 the resident's blood sugar would have dropped significantly and failure to administer Basaglar insulin would leave the resident's blood sugars uncontrolled over the day. The DON said failure to administer supplements and insulin as ordered could place residents at risk for adverse reactions, over or insufficient dietary supplementation and hypoglycemia. Record review of LVN A's competency assessment titled Medication Pass Observation dated 02/10/23 revealed, 8- MAR is read prior to preparing medications; competency-met. Record review of MA B's competency assessment titled Medication Pass Observation dated 02/10/23 revealed, 8- MAR is read prior to preparing medications; competency-met. Record review of MA A's competency assessment titled Medication Pass Observation dated 02/14/23revealed, 8- MAR is read prior to preparing medications; competency-met. Record review of the facility policy titled Administering Medications dated 12/2012 revealed, 3- Medications must be administered in accordance with orders, including any required time. 7- The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (100 Hall Nursing Cart) reviewed for medication storage. - The facility failed to ensure the 100 Hall Nursing Cart did not contain insulin pens with no open dates for Resident #10, Resident #37 and Resident #77. This failure could place residents at risk of adverse medication reactions. Findings Included: Resident #10 Record review of Resident #10's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: hypoglycemia and type 2 diabetes. Record review of Resident #10's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 11 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #10's undated Care Plan revealed, focus- type 2 diabetes; intervention- diabetes medication/insulin as ordered by doctor. Record review of Resident #10's Physician Order dated [DATE] revealed, Admelog Insulin- Inject as per sliding scale under the skin before meals and at bedtime for type 2 diabetes; if 70-200 = 0 units, 201-250= 4 units, if greater than 250, give 4 units and call the NP. Resident #37 Record review of Resident #37's Face Sheet dated [DATE] revealed. a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: high blood pressure, acute kidney disease and type 2 diabetes. Record review of Resident #37's Quarterly MDS dated [DATE] revealed, use of corrective lenses, severely impaired cognition as indicated by a BIMS score of 04 out of 15, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #37's undated Care Plan revealed, focus- diabetes; intervention- diabetes medication as ordered by doctor, observe/document for side effects and effectiveness. Record review of Resident #37's Physician's Order dated [DATE] revealed, HumaLOG insulin- inject as per sliding scale under the skin two times a day. If 70-249 = 0 units, 250-350 = 5 units, call MD/NP if blood sugar is greater than 350. Resident #77 Record review of Resident #77's Face Sheet dated [DATE] revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: dementia and type 2 diabetes. Record review of Resident #77's Quarterly MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, supervision for all ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #77's undated Care Plan revealed, focus- diabetes; intervention- diabetes medication as ordered by doctor. Record review of Resident #77's Physician Order dated [DATE] revealed, Lantus ( Insulin Glargine)- Inject 30 units under the skin in the evening for diabetes. Record review of Resident #77's Physician Order dated [DATE] revealed, NovoLIN N ( Insulin NPH Human)- inject as per sliding scale subcutaneously in the morning. If 70-119 = 0, 120-350 =25 units, BG greater than 350 call MD/NP and hold for BG under 120. An observation and interview on [DATE] at 07:30 AM, inventory of the 100 Hall Nursing Cart with LVN A revealed: - an open and in-use Lantus Insulin pen and NovoLIN N Insulin vial for Resident #77, with no open date. - an open and in-use Admelog Insulin pen for Resident #10, with no open date. - an open and in-use Humulin Insulin for Resident #37, with no open date. LVN A said nursing staff are expected to check their carts daily for expired and inappropriately labeled medications. He said when an insulin pen or vial is opened nursing staff are expected to label the vial with the date in order to track the expiration date. LVN A said when insulin expires it becomes ineffective and since the insulin pens/vial did not have an open date their expiration dates could not be determined so they have to be discarded in the sharps container. He said use of expired insulin could place residents at risk for uncontrolled blood sugars. In an interview on [DATE] at 11:50 AM, the DON said nursing staff must check their medication carts daily as used for expired and inappropriately labeled medications. She said multidose insulin containers should be labeled with the date opened in order to track the expiration date, and any containers with no open dates cannot be used because their expiration date cannot be determined. The DON said she did not know what happened to insulin after it expires but it must be discarded in the drug disposal bin because use of expired insulin could result in residents experiencing adverse effects. Record review of the facility policy titled Administering Medications dated 12/2012 revealed, 9- the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Record review of the facility policy titled Storage of Medication dated 10/2014 revealed, 3- drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4- the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review, the facility failed to prepare puree and regular food by methods that conserve nutritive value, flavor, texture and appearance for 4 of 4 residents (#159, #15, #40, #10) on puree and regular diets. The facility failed to ensure that puree diet was prepared by methods that conserve nutritive value, flavor, and appearance. This failure could place residents on regular and pureed diet at risk of experiencing a decreased quality of life and possible weight loss. Findings included: Interviewed on 4/23/23 at 9:20 am Resident #159 stated the food is not good tasting. Resident #159 said the food was not seasoned enough and the meat is cooked too much. Interviewed on 4/23/23 at 9:21 am Resident #15 stated the food is terrible and has no flavor. Interviewed on 4/23/23 at 9:45 am Resident #40 stated the food is not good and the meat is hard, chewy and not easy to eat. Interviewed on 4/23/23 at 10:20 am Resident #10 stated the food is not great, has no flavor and the meat is hard. Observation of the Surveyors taste tested meal trays on 04/23/23 at 12:08 pm, revealed 1) puree diet and 2) regular diet. The pureed meal revealed the pureed carrots and turkey patty were tasteless. The regular meal revealed the roast beef was difficult to chew. Observed on 04/23/23 at 12:08 pm, The Dietary manager when he tested the puree meal with surveyors, he stated there is no flavor in the carrots and he did not personally like the turkey patty puree. For the regular meal the Dietary manager stated, The meat could have been more tender, resident with bad teeth could have a hard time chewing this. Interviewed on 4/25/23 at 7:40 am the Dietary Manager stated regarding pureed carrots served on 4/23/23, the staff do use chicken broth when pureeing vegetables, but for some reason on 4/23/23 [NAME] J added too much water, and Dietary Manager stated he was embarrassed at the taste of the carrots that day. He stated the cooks are instructed to cook as if they are cooking for their family. Interviewed on 4/25/23 at 10:18 am the Dietary Manager stated the cook was nervous and prepared the chicken broth with too much water on 4/23/23. Record Review: Food Quality and Palatability: Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs. Definitions: Food Palatability refers to the taste and/or flavor of the food. Procedures: 1. the Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 3. Food and liquids/beverages are prepared in a manner, form and texture that meets the resident's needs. 4. The Cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences , as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention.