Every finding on record at Atrium Health Navicent Baldwin

Based on observation, staff interviews, record review, and review of facility policy titled Pain Management, and Wound Assessment, the facility failed to stop and address verbal and facial expressions during wound care for one of one residents (R) (R14) observed for wound care. On 12/8/2025, actual harm occurred when Licensed Practical Nurse (LPN) AA failed to administer pain medication to R14 prior to providing wound care treatment, resulting in pain during the treatment.Findings Include: Review of the facility policy titled Pain Management, dated 1/9/2024, revealed the Purpose section included, To ensure optimal patient comfort through a proactive pain management plan. (Facility Name) recognizes its responsibility to plan, support, and coordinate activities and resources to assure that the pain of all patients is recognized and addressed appropriately.Review of the facility document titled Wound Assessment, revised 2/24/2025, revealed the Implementation section included Screen for and assess the patient's pain using facility- defined criteria that are consistent with the patient's age, condition, and ability to understand. Treat the patient's pain, as needed and ordered, using nonpharmacologic, pharmacologic, or a combination of approaches. Administer pain medication as needed and prescribed, following safe medication administration practices.Review of the medical record for R14 revealed the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, osteomyelitis on the left heel, pressure ulcers of skin of multiple topographic sites, decubitus ulcer of ankle, peripheral vascular disease, and type 2 diabetes.Review of the Minimum Data Set (MDS) admission assessment for R14, dated 12/4/2025, revealed it was incomplete due to a recent admission and was within the window for data entry before the completion date.Review of the Medication Administration Record (MARS) for R14, dated 11/29/2025 through 12/8/2025, revealed an order dated 12/4/2025 for acetaminophen tablet 325 milligrams (mg) every four hours as needed (PRN) pain level 1-5 or acetaminophen tablet 650 mg every four hours PRN pain level 6-10. Continued review revealed no documentation of the administration of either medication.Observation on 12/8/2025 at 10:10 am, of wound care provided by Licensed Practical Nurse (LPN) AA for R14 revealed that LPN AA began to remove the tape from the wound on the left heel, R14 grimaced and moaned. LPN AA stated, I know this can't be fun for you, but did not ask R14 if he was experiencing any pain. LPN AA proceeded with the dressing change and did not check R14 for signs of pain.In an interview on 12/8/2025 at 10:33 am, LPN AA confirmed that R14 had an order for acetaminophen 325 mg every four hours as needed for pain. LPN AA stated that she did not know that she should have stopped to assess pain when the resident was grimacing and moaning or prior to the wound treatment for pain management.In an interview on 12/8/2025 at 11:30 am, the Director of Nursing (DON) revealed her expectation was for the nurses to ask residents about pain prior to providing wound care and to medicate if needed. She further stated that if the resident showed signs of pain, the nurse should stop the procedure, offer pain medications, and check for effectiveness before continuing wound care.

Based on observations, staff interviews, and record review, the facility failed to implement the baseline care plan for one of one residents (R) (R14) who received wound care. On 12/8/2025, actual harm occurred when Licensed Practical Nurse (LPN) AA failed to administer pain medication to R14 prior to providing wound care treatment, resulting in pain during the treatment.Findings include:Review of the medical record for R14 revealed the resident was admitted with a diagnosis including, but not limited to, osteomyelitis on the left heel, pressure ulcers of skin of multiple topographic sites, decubitus ulcer of ankle, peripheral vascular disease, and type 2 diabetes.Review of the baseline care plan for R14, dated 12/3/2025, revealed a care plan problem/goal for Pain - Adult, Verbalizes/displays adequate comfort level or baseline comfort level. The interventions included assessing pain using an appropriate pain scale and administering analgesics based on the type and severity of pain, and evaluating the response. Review of the baseline care plan for R14, dated 12/4/2025, revealed an area titled Wound Care. The interventions included, . 7. Observe for and document nonverbal signs and symptoms of pain: grimacing, restlessness, inability to sit or lie still, crying, and grinding teeth. 8. Administer pain medication as ordered.Review of the Medication Administration Record (MARS) for R14, dated 11/29/2025 through 12/8/2025, revealed an order dated 12/4/2025 for acetaminophen tablet 325 milligrams (mg) every four hours as needed (PRN) pain level 1-5 or acetaminophen tablet 650 mg every four hours PRN, pain level 6-10. Continued review revealed no documentation of the administration of either medication.Observation on 12/8/2025 at 10:10 am, of wound care provided by Licensed Practical Nurse (LPN) AA for R14 revealed that LPN AA began to remove the tape from the wound on the left heel, R14 grimaced and moaned. LPN AA stated, I know this can't be fun for you, but did not ask R14 if he was experiencing any pain. LPN AA proceeded with the dressing change and did not check R14 for signs of pain.In an interview on 12/8/2025 at 10:33 am, LPN AA stated that she did not know that she should have stopped to assess pain when the resident was grimacing and moaning or prior to the wound treatment for pain management.In an interview on 12/8/25 at 11:30 am, the Director of Nursing (DON) confirmed the baseline care plan for R14 was not implemented for the evaluation and treatment of pain. A request was made for the facilities' baseline care plan, at which time the Administrator stated, We do not have a policy specific to baseline care policy; we follow Medicare guidelines. Cross-Reference F697

Based on interview and observations, the facility failed to discard expired items and failed to label and date items in the one of two refrigerators. Findings include: Observation on [DATE] at 11:30 a.m. during a brief kitchen tour with the Dietary Manager (DM) revealed the following: 1. In the pantry was a 14 ounce (oz.) package of seasoning which was opened and unlabeled. 2. In the pantry was a 50 oz. can of cream of potato soup which was dented. 3. In the walk-in Refrigerator #2 there was one case of rotting plums. 4. In the walk-in Refrigerator #2 there was one opened container of pasta salad that expired on [DATE]. 5. In the walk-in Refrigerator #2 there was one opened container of peeled potatoes that expired on [DATE]. 6. In the walk-in Refrigerator #2 there was one opened and unlabeled container of sliced apples. 7. In the walk-in Refrigerator #2, there was one six oz. package of molded raspberries. 8. In the walk-in Refrigerator #2, there was one opened and unlabeled three-pound package of garlic. An interview on [DATE] at 12:07 p.m. with the DM revealed that he does routine audits related to checking the refrigerator for expired items. The DM further reported that the cooks are also responsible for making sure expired items are removed from the refrigerators as well as labeled properly. The DM further revealed that his expectation is items in the refrigerator are checked daily for expiration dates.

Based on record review and staff interview, the facility failed to ensure that a Quarterly Minimum Data Set (MDS) Assessment was completed in a timely manner for one of nine sampled residents (R) (#155). Findings include: Review of the Center for Medicare/Medicaid Services (CMS) RAI Version 3.0 Manual, page 5-4 dated October 2016 revealed: Assessment Schedule: An Omnibus Budget Reconciliation Act (OBRA) assessment (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments. R#155 was admitted on [DATE]. Review of the MDS revealed an entry tracking record dated 8/5/2020. Review of the clinical record revealed an admission assessment was completed on 8/5/2020. However, there is no evidence of Quarterly Assessments after 8/5/2020. Interview on 5/25/2021 at 3:15 p.m. with the MDS Coordinator revealed she has not completed or submitted an MDS Quarterly Assessment on R#155. The MDS Coordinator stated three Quarterly Assessments should have been completed on R#155. She confirmed that 8/5/2020 was the last assessment completed for R#155. Interview on 5/26/2021 at 9:40 a.m. with the Director of Nursing (DON) revealed her expectation is that all MDS Assessments are completed and transmitted on time. The DON also revealed she currently does not have an audit in place to ensure MDS accuracy, completion, and transmission.

Based on observation, staff interviews and policy review titled Medication Storage-nonpharmacy locations, the facility failed to ensure that drugs and biologicals were stored in a locked and secure medication room, accessible only to authorized personnel. The census was 11. Findings include: Review of the policy titled Medication Storage-nonpharmacy locations, revised on 9/18/18, revealed 4.0 Process Flow Diagram, section D. Personnel authorized to dispense or administer medications may have access to medication storage areas. Security will be maintained by limiting access through badge swipe doors or doors with coded locks. Observation on 6/4/19 at 12:59 p.m., with Licensed Practical Nurse (LPN) CC, entering medication storage room which is locked with a punch code to access the room. Medications are stored in Pharmacy computer generated system, which is accessed via fingerprint. There are additional medications for each resident stored in plastic bins sitting on the shelf beside the medication machine. During this observation Certified Nursing Assistant (CNA) AA entered the medication room to retrieve a full Oxygen canister for a resident. LPN CC stated that all staff have access to the medication storage room, including the CNA staff. Interview on 6/4/19 ay 2:29 p.m. with Charge Nurse, stated that all the staff have access to the medication room, including the CNA and respiratory therapy, because the Oxygen tanks are stored in the medication room, and she replaces tanks when they are empty. She further stated that the unlicensed staff go into the medication room unattended. She stated that is the way it has been since she has worked here. Interview on 6/5/19 at 3:30 p.m. with Director of Nursing (DON) stated that she had not put any thought into the medication room being accessed by all employees. She verified that prescription medications are stored in individual bins, accessible to any staff member who enters the medication room. Interview on 6/5/19 at 4:05 p.m. with Administrator, stated that she was not aware that all staff had access to the medication room.

Based on observation, record review, staff interviews and policy review titled Skilled Nursing Unit Pharmacy Dispensing, the facility failed to ensure that the licensed pharmacist performed at least once a month drug regimen reviews, failed to monitor for side effects and effectiveness, or perform Gradual Dose Reductions (GDR) for two of 13 sampled residents (R#1 and R#2). Findings include: Review of the policy titled Skilled Nursing Unit Pharmacy Dispensing, revised 1/18/19, revealed section 4.0 Process Flow Diagram: Medication orders are reviewed at order entry, weekly census review of Skilled Nursing Unit (SNU) patients performed in pharmacy, Recommendations/Review notes sent to SNU for placement on chart and pharmacist reviews medication regimens per guidelines once per month. 1. Review of the clinical record for R #1 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, which indicated no cognitive impairment. Section N revealed that the resident received antidepressants seven of seven days. Review of the Physician order [REDACTED]. A review of the care plan revealed that the resident had [MEDICAL CONDITION] medication use related to taking antidepressant medication. Approaches to care include Monitor for complications related to drug use; gait disturbance, weakness, fatigue. Monitor for therapeutic response to medications. 2. Review of the clinical record for R #2 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated mild cognitive impairment. Section N revealed that the resident received antidepressants seven of seven days. Review of the Physician order [REDACTED]. A review of the care plan revealed that the resident had [MEDICAL CONDITION] medication use related to taking antidepressant medication. Approaches to care include Monitor for complications related to drug use; gait disturbance, weakness, fatigue. Monitor for therapeutic response to medications. Record review revealed there was no evidence that R#1 or R#2 were monitored for drug use such as gait disturbance, weakness or fatigue. There was no evidence that the Pharmacist reviewed for GDR or reviewed the medications monthly. Interview on 6/5/19 at 3:30 p.m. with Director of Nursing verified that there was no evidence of monthly pharmacy review documents located in the R#1 and R#2 medical record or monitoring for side effects or effectiveness of the antidepressant medication. Interview on 6/5/19 at 5:05 p.m. with Pharmacist DD, stated that she was not familiar with the regulations related to pharmacy services in Long Term Care, monitoring of side effects or effectiveness, or monthly medication review and gradual dose reductions (GDR). She stated that the pharmacist does not do any gradual dose reductions for residents receiving [MEDICAL CONDITION] medications.

Based on observation, record review, staff interviews and policy review titled P[NAME] Bedside Glucose Using (name) glucometer, the facility failed to ensure that a glucometer (a device used to measure blood sugar levels) was disinfected after each resident use to prevent possible cross-contamination. In addition, facility also failed to maintain aseptic technique by not cleaning Intravenous Port prior to starting intravenous antibiotic therapy. The sample size was 13. Findings include: Review of the facility policy titled P[NAME] Bedside Glucose Using (name glucometer) revised 1/2/19, revealed roman numeral V11M: Clean and disinfect according to facility policy. Reagents and Materials: 1V Cleaning and disinfecting materials-Micro Kill with bleach disinfectant wipes, clean and disinfect meter after EVERY patient test. 1. During observation of glucometer testing on 6/5/19 at 11:25 a.m. with Certified Nursing Assistant (CNA) AA revealed that she gather the needed supplies, then entered R#3's room. She washed her hands and donned gloves and placed the glucometer onto residents bed, without the use of a barrier. She proceeded to clean fingertip with alcohol swab, wiped off sample and obtained fresh blood sample onto test strip. She reported result to resident. The CNA then removed her gloves, balled the trash, including the lancet into the gloves, and discarded into the trash can in resident #3 room. She washed her hands and exited room. She did not clean glucometer prior to or after use on resident. Observation on 6/5/19 at 11:45 a.m. CNA AA performing glucometer testing for R#58 revealed that she did not clean glucometer before or after obtaining finger stick blood glucose (FSBS) on R#58. After obtaining FSBS, she discarded garbage into glove and disposed in trash can in residents room. Review of CNA AA Annual Competency Check for (name) glucose meter system dated 8/17/18, revealed she passed competency by direct observation. An interview on 6/5/19 at 11:50 a.m. with CNA AA stated she received training on glucometer testing on a yearly basis. She stated that she has been doing the testing for many years in the hospital setting and for one year in the Skilled Nursing Unit (SNU). When asked about sanitizing the glucometer, she stated that she should have cleaned it with a germicidal wipe before checking the residents blood glucose. She further stated that she did not have any wipes with the supplies when she took them to the residents room, so she did not clean it and did not realize that she placed the glucometer on the residents bed, prior to checking the FSBS. She further revealed that she knows the lancet should be disposed of into the sharps container in the residents room, but stated that she's just used to taking off the gloves and throwing all the trash in the trash can in residents room. An interview on 6/5/19 at 2:23 p.m. with the Charge Nurse she revealed that staff members should provide care to all residents following proper procedure, including proper disposal of all materials appropriately and sanitizing of all equipment. 2. Observation of medication administration on 6/4/19 at 4:00 p.m., with Registered Nurse (RN) BB revealed that she administered intravenous (IV) antibiotic for Resident (R) # 57, through peripherally inserted central catheter (PICC) in residents right upper arm. RN BB removed Orange disinfectant cap from port of PICC line and flushed the PICC line with normal saline. After the flush, she allowed the port to rest on the residents arm, uncapped, while she untangled the IV tubing from the pole. She then proceeded to connect the IV tubing to the PICC port without cleaning the port. An interview on 6/4/19 at 4:15 p.m. with RN BB revealed that she is not sure of the protocol for sanitizing IV access devices. She did revealed that after resting the IV port on residents arm that she should have cleansed it with an alcohol pad, prior to connecting the tubing. Interview on 6/5/19 at 10:04 a.m. with Manager of Quality Accreditation, revealed there was not a specific policy pertaining to Intravenous Therapy. He further stated that the facility uses the Lippincott Nursing Manual for procedures that do not have policies. He provided copy of IV administration procedure guidelines, which indicate to clean the port/injection site with alcohol swab. Interview on 6/5/19 at 3:30 p.m. with Director of Nursing (DON) stated it is her expectation is for staff to provide care by professional standards and best practices.

Based on record review and interview the facility failed to conduct and document a facility wide assessment to determine patient population and prevalent diagnoses, staffing needs, competencies required, and training provided, and resources necessary to provide care for residents during day to day operations and emergencies. The census was 11. Findings include: An interview on 6/5/19 at 12:05 p.m.with the Administrator revealed that she did not think that there was a facility assessment. A follow up interview on 6/5/19 at 12:12 p.m.with the Administrator revealed the hospital Maintenance Director informed her there was not a facility assessment for the Skilled Nursing Unit (SNU). An interview on 6/5/19 at 2:18 p.m. with the Manager of Quality Accreditation, revealed that the hospital did not have a facility assessment for the Skilled Nursing Unit (SNU). He stated that the closest thing they had was the hospital emergency preparedness plan.

Based on record review and staff interviews, the facility policy titled POLICY: XVll. Oconee Regional Medical Center Skilled Nursing Unit Assessment/Reassessment. Revision Date: (MONTH) (YEAR). the facility failed to develop baseline care plans for two (2) Resident(R), R#225 and R#256 related to gastrostomy tube ([DEVICE]), [MEDICAL CONDITION] medications, and [MEDICAL CONDITION] (MRSA) infection. Findings include: 1. Review of the medical record for R#255 revealed an admission date of [DATE] which included that the resident was admitted with a gastrostomy tube ([DEVICE]). Review of the Physician order [REDACTED]. Review of the baseline care plan dated 7/11/18 revealed there was not a plan of care, to address the specific interventions to assess/monitor the [DEVICE], feedings, water flushes, for infections of the [DEVICE] and the overall appearance of the [DEVICE] site. In addition, R#255 received the following antipsychotic/[MEDICAL CONDITION] medications: [REDACTED]. [MEDICATION NAME] 50 mg was also given every six (6) hours prn (as needed) for pain. Review of the baseline care plan revealed an omission of a baseline plan of care that included specific interventions to monitor for side effects of antipsychotic/[MEDICAL CONDITION] medications. During an interview on 7/14/18 at 1:50 p.m., with Register Nurse (RN) BB confirmed that a baseline care plan to address the resident's [DEVICE] and to monitor for adverse drug reactions due to use of [MEDICAL CONDITION] medications was not developed by the admitting nurse nor was she aware of the missing care plans. Further interview with RN BB revealed that it is the admitting nurse responsibility to provide baseline care plan for all resident's care areas upon the admission. 2. Review of the medical record for R#256's revealed an admitted [DATE] and that the resident was admitted with a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. An interview with RN BB on 7/14/18 at 2:10 p.m. and record review revealed that a baseline care plan was not developed until today 7/14/18 (after the problem was identified by the surveyor) to monitor the resident care needs and to provide instructions about infection control precaution measures although the resident was on Contract Isolation Precautions. She identified herself as the one who created the care plan and placed the care plan on the resident's record, today. She further stated that the admitting nurse is responsible for developing and placing the baseline care plan on the record at the time of the admission. An interview on 7/15/18 at 9:57 a.m. with the Administrator revealed that her approach as it relates to infection control is for all staff to share the role as a gate keeper. This approach provides communication to Certified Nursing Assistants (CNA) and nurses about infection control. Further interview with the Administrator revealed that the CNA is not given the specifics about the patient's disease, but the CNAs are given instructions about the Personal Protective Equipment (PPE) and infection control protocol. The Director of Nursing (DON) and the Administrator (herself) is responsible for ensuring that an infection control plan of care and that all other care areas are care plan at the time of admission, She stated that her expectations are that the admitting the nurse's is solely responsibility for creating a baseline care plan at the time of an resident admission to the facility. Review of policy titled POLICY: XVll. Oconee Regional Medical Center Skilled Nursing Unit Assessment/Reassessment. Revision Date: (MONTH) (YEAR), the policy stated the physician retains the responsibility for assessment of the resident and for performing a baseline assessment of the resident 's problems/needs within twenty-four (24) hours of the resident's admission. The physician reassesses the resident a minimum of once weekly and prn as the resident 's condition warrants. The licensed nurse, on the Oconee Regional Medical Center Skilled Nursing facility, will be responsible for developing and implementing an interim plan of care. An interdisciplinary for developing and implementing an interim plan of care. An interdisciplinary team approach will be utilizing in assessing, implementing and maintaining an ongoing approach to the assessing of resident's needs and developing a plan of care that meets the individual needs of each resident within the resources available. :

Based on observations and interviews, the facility failed to maintain a clean and sanitary kitchen specifically there was a blackish/grey substance on the freezer wall and the stove had a dried splattered whitish/yellow substance. The facility census was 7 residents. Findings include: During the initial tour on 9/15/17, the walls around the door of the freezer were observed to have a blackish/grey substance, that was darker at the floor that was in a splatter pattern up the wall to approximately head high, that was darker under the electrical wires and around the thermostat. The walls on the outside of the freezer approximately two (2) feet wide on both sides of the freezer door, with the blackish/grey substance covering them on both sides. Addtionally, further observation revealed the stove had splattered dried whitish/yellow substance on the wall behind the stove and on the surface of the stove top. Observation on 9/16/17 at 10:00 a.m., revealed that the walls were cleaned but still had some blackish/grey substance behind the electrical fixture that was approximately face high on the wall and at the bottom of the door around the metal electrical entrance. Further observation revealed the stove top was still splattered and behind the eyes on the wall behind the stove was still splattered with a whitish/yellow substance. In an interview with the food service manager on 9/15/17 at 12:30 p.m. he confirmed the blackish/gray areas on the wall and said that they know that they are supposed to keep this clean. He also confirmed the dried splatters of whitish/yellow substance on and around stove top and wall behind stove and said that he would do an in-service with the staff about cleaning. In an interview with the food service manager on 9/16/17 at 9:30 a.m. he confirmed the blackish/grey substance was still on the wall and the whitish/yellow substance was still on the stove top and behind the stove and said, I'll make sure it's cleaned up, I can't believe they didn't do a better job than this. All of this will be fixed when the new company takes over and replaces this freezer and hires more staff, my staff is tired. My staff knows to clean up between meals, I'm not sure why it's not getting done.

Based on record review and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable, physical, mental and psychosocial wellbeing of the residents. During this revisit survey, Federal Deficiency F371 was re-cited for failure to ensure that the Plan of Correction was fully implemented related to documenting that cleaning was performed to maintain a clean and sanitary kitchen, failed to monitor the cleaning schedule accurately and failed to monitor the kitchen to ensure compliance in the timeframe stated in the Plan of Correction. This failure placed all 7 residents, who consumed food orally, at an increased likelihood of foodborne illnesses. Findings include: Record review and interview revealed that the facility was not in substantial compliance during the Standard survey of 9/15/17 through 9/16/17. Refer to the following deficiencies for specific details of noncompliance during the revisit survey. Cross reference to F 371: The facility failed to support the corrective actions of the Plan of Correction. Specifically, the facility failed to document that cleaning was performed to maintain a clean and sanitary kitchen, failed to monitor the cleaning schedule accurately and failed to monitor the kitchen to ensure compliance in the timeframe stated in the Plan of Correction. Interview via email on 11/2/17 at 9:31 a.m. with the Administrator confirmed that the cleaning was not conducted on these dates because it was an error on her part for not communicating to the Food Service Director (FSD) that the tool used was for Monday through Friday and not a Saturday and Sunday tool. She further stated that the monitoring was not conducted daily because the FDS chose to sign on those dates thinking it was sufficient and that no evidence of weekly monitoring was provided.

Based on record review and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable, physical, mental and psychosocial wellbeing of the residents. During this revisit survey, Federal Deficiency F371 was re-cited for failure to ensure that the Plan of Correction was fully implemented related to documenting that cleaning was performed to maintain a clean and sanitary kitchen, failed to monitor the cleaning schedule accurately and failed to monitor the kitchen to ensure compliance in the timeframe stated in the Plan of Correction. This failure placed all 7 residents, who consumed food orally, at an increased likelihood of foodborne illnesses. Findings include: Record review and interview revealed that the facility was not in substantial compliance during the Standard survey of 9/15/17 through 9/16/17. Refer to the following deficiencies for specific details of noncompliance during the revisit survey. Cross reference to F 371: The facility failed to support the corrective actions of the Plan of Correction. Specifically, the facility failed to document that cleaning was performed to maintain a clean and sanitary kitchen, failed to monitor the cleaning schedule accurately and failed to monitor the kitchen to ensure compliance in the timeframe stated in the Plan of Correction. Interview via email on 11/2/17 at 9:31 a.m. with the Administrator confirmed that the cleaning was not conducted on these dates because it was an error on her part for not communicating to the Food Service Director (FSD) that the tool used was for Monday through Friday and not a Saturday and Sunday tool. She further stated that the monitoring was not conducted daily because the FDS chose to sign on those dates thinking it was sufficient and that no evidence of weekly monitoring was provided.

Based on staff interview, record review and facility policy review, the facility failed to develop an interim plan of care for one resident (#66) from a total sample of fifteen (15) residents. Findings include: The facility had a policy for assessing and reassessing residents. The Assessment/Reassessment of Patients policy documented that the licensed nurse would be responsible for developing and implementing an interim plan of care. The policy also documented an interdisciplinary plan of care will be completed within five (5) days from the date of the resident's admission. Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5 day Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/3/15 documented that the resident received total assistance for all activities of daily living (ADL's). There was no evidence in the resident's clinical record, including in the Medtech electronic system, that licensed nursing staff had developed an interim plan of care. During an interview on 2/9/16 at 1:40 p.m., Licensed Practical Nurse (LPN) AA confirmed there was no interim plan of care.

Based upon record review and staff interviews the facility failed to ensure Registered Nurse (RN) coverage at least eight (8) hours per day for two (2) of fourteen (14) days during the most current two (2) week pay period. Findings include: Review of the two (2) week staffing form for the facility revealed that on 1/26/2015 and 1/28/2015 the facility did not have RN coverage for the minimum eight (8) hours for a twenty four (24) hour time frame as required. An interview with the Administrator on 2/7/15 at 8:00 a.m. revealed that the facility does not always have an R.N. doing supervision or direct nursing care at least eight (8) hours daily. An interview on 2/7/15 at 2:00 p.m. with the Administrator and the Director of Nursing (DON) confirmed the facility does not have a waiver for this requirement.

Based on record review and staff interviews the facility failed to ensure that the Quality Assurance committee included the Medical Director or designee at the Quarterly meetings. Findings include: Record review of the Quality Assurance committee sign in sheets revealed that the Medical Director and the Director of Nursing (DON) attend a monthly hospital meeting but these meetings do not include the Administrator or other facility staff members. An interview with the Administrator and the DON on 2/7/15 at 11:30 a.m. revealed that the Administrator holds a separate meeting which includes the Department Heads but that the Medical Director or designee do not attend these meetings. The DON confirmed that she attends the Full Staff Meeting but that the Administrator does not attend these meetings.

Based upon observation, record review and staff interviews the facility failed to ensure that inhalers were administered correctly for two (2) residents by one (1) of three (3) nurses on one (1) of two (2) medication carts with a Medication Administration error rate of 5.4%. Findings include: 1. Observation on 2/6/15 at 11:00 a.m. of Licensed Practical Nurse (LPN) "AA" during medication administration observation revealed that during administration of a [MEDICATION NAME] inhaler for resident #82 that the inhaler was given to the resident who quickly administered two (2) quick puffs without exhaling first or waiting between puffs. LPN "AA" gave no instructions to the resident. Record review of the Physician order [REDACTED]. 2. During Medication Administration observation on 2/7/15 at 9:05 a.m. with LPN "AA" for resident #83 revealed that during administration of [MEDICATION NAME] Diskus that the inhaler was given to the resident who took one quick inhalation but did not exhale fully before the inhalation or without instructions for LPN "AA". Resident #83 had the following [DIAGNOSES REDACTED]. Record review of Physician order [REDACTED]. An interview with the Director of Nursing (DON) on 2/7/15 at 1:00 p.m. revealed the facility does not have a Policy and Procedure for administration of inhalers. An interview with the Pharmacist on 2/7/15 at 1:30 p.m. revealed she was not aware of a Policy and Procedure for administration of inhalers and that the facility would go by the manufactures recommendations. An interview with the Pharmacist, Administrator, DON and LPN "AA" on 2/7/15 at 2:25 p.m. revealed that review of the manufactures recommendation revealed to exhale completely before inhalation of both the [MEDICATION NAME] and [MEDICATION NAME] Diskus inhaler. The [MEDICATION NAME] inhaler manufactures insert recommends waiting one (1) minute between inhalations. LPN "AA" confirmed that he/she did not follow the manufactures recommendations for administration of either inhaler.

Based on observation, staff interviews, and review of procedures for cleaning and sanitizing equipment, the facility failed to ensure that food and dishes were stored under sanitary conditions and failed to ensure that the ice machine was cleaned accod=rding to facility policy. Census-14. Findings include: Observations on initial tour of kitchen with the Dietary Manager (DM) and Executive Chef (EC) on 3/4/13 between 11:55 a.m. and 1:30 p.m. revealed the following: 1. A cleaning log taped to the side of the ice machine indicated the last time the machine was cleaned was 11/9/12. Procedures for ice machine cleaning and sanitizing taped to the front of the ice machine indicated the ice machine was to be cleaned twice monthly. Review of the log revealed the ice machine was cleaned once in April 2012 and monthly from July through November 2012. Interview with the DM on 3/4/13 at 12:20 p.m. revealed the Executive Chef is responsible for the master cleaning schedule, and the current cleaning log should be in the clear plastic sleeve taped to the side of the ice machine. Review of the current cleaning log, received from the DM on 3/16/13 at 12:15 p.m. revealed no evidence that the machine had been cleaned between 11/9/12 and 1/1/13. 2. Observation with the Executive Chef revealed fifteen (15) wet baking sheets nested horizontally; two (2) wet hotel pans nested horizontally; and four (4) wet shot gun hotel pans nested horizontally. Interview with the Executive Chef revealed the pans should have been stacked vertically until they were dry. 3. Observations in the dry storage area revealed the following containers that were opened but were not dated or the 'use by' date had passed:: * Macaroni in a large clear plastic container, undated * Bowtie pasta in a large clear plastic container dated 6/13/12, use by 8/30/12. * Egg noodles in a large clear plastic container labeled Macaroni, undated. * One (1) 13.25 ounce cardboard box of rotini pasta open to the air, undated. Recommended maximum storage period for Macaroni and other noodles-3 months * One (1) 32 ounce bag of light brown cane sugar wrapped in clear plastic wrap, not dated; there was more than 1/2 of the bag remaining. Recommended maximum storage period -should be refrigerated * One ( 1) 5 pound box of Calumet baking powder with a use by date of 12/30/10-recommended maximum storage period in dry storage-8-12 months . * One (1) 10 pound can of whole potatoes, bent. Recommended maximum storage period in dry storage for canned goods, vegetables-1 year * One (1) box Rainbow sprinkles in a plastic bag in a cardboard box, open to the air; there were loose sprinkles in the bottom of the box. The date on the box was 2010. * One (1) plastic container of caramel chips and chocolate chips, not dated. * One (1) 5 pound bag of Hershey's cocoa in a plastic container, undated. * One (1) plastic bag of peanut butter chips in a box, not dated when opened, best by date 8/2011. Interview with the DM on 3/4/13 at 12:35 p.m. revealed all the above items in the dry storage area should be tagged with an open and use by date. 4. Observations of the bread stored on a baker's rack on Monday, 3/4/13, after the bread delivery revealed the following:: * Block & Barrel thick sliced Wheat Berry bread; three (3) slices left in a thirty-six (36) ounce package with mold on the end piece; use by date 1/24/13; date of initial heating 1/17/13. * Block & Barrel sliced Wheat Berry bread; date of initial heating 1/18/13; use by date 1/22/13; seven (7) slices in bag, covered in green mold. * One (1) package Cobblestone Mill white 6 inch sub rolls - best if used by 2/19/13. * One (1) package Cobblestone Mill wheat 6 inch sub rolls - best if used by 2/27/13. * One (1) loaf Sunbeam white bread - best by 2/9/13 - four (4) slices in bag - gray mold visible. * Five (5) packages of 16 hot dog buns with best by dates of: 2/21/13; 2/24/13; 2/24/13; 3/3/13; and 3/3/13. * One (1) package of eight (8) hamburger buns on the floor. Interview with the Executive Chef on 3/4/13 at 12:50 p.m. revealed the Block & Barrel bread comes frozen, and all opened bread should only be stored in the refrigerator; fresh bread deliveries from Flowers Bakery are on Mondays and Thursdays. He revealed the bakery employee is responsible for rotating the bread stock. 5. Observation of cooler #2 with the Executive Chef revealed the following: * One (1) 5 pound bag of unopened Cole slaw with disintegration of the cabbage and liquid in the bag; it was labeled as ordered on [DATE]. * One (1) 2.5 pound bag of salad mix, opened and wrapped in clear plastic wrap, not dated. * One (1) opened bag of sliced potatoes wrapped in clear plastic wrap, not dated, some liquid in the bag. * Two (2) 2 5 pound bags of diced onions opened, wrapped in clear plastic wrap, not dated. * One (1) 5 pound bag of diced celery, wrapped in clear plastic wrap, not dated. * One (1) 3 pound bag of fresh broccoli, not dated when opened - 1/4 of a bag left. * One (1) 6 x 6 box of tomatoes, ordered 2/27/12, delivered 2/28/13. Twelve (12) tomatoes with rotten areas, ranging from small to half the tomato. * One (1) 25 pound box of green bell peppers, four (4) peppers were rotten. * One (1) 5 pound box of fresh sliced mushrooms with dried (dehydrated) mushrooms covering half the bottom of the box. * One (1) loaf of Block and Barrel Jewish Rye bread with a use by date of 2/28/13. * One (1) 6 pound bag of potatoes opened but not dated; approximately 4 pounds left in the bag. 6. Observation in the big walk-in freezer on 3/4/13 revealed a hand full of frozen french fries scattered on the floor. 7. Observation in the kitchen on 3/6/13 at 12:40 p.m. revealed there were 2 buckets of ice on the floor in front of the ice machine. at 12:42 p.m. a kitchen staff member carried the buckets to the dining room and poured one bucket of ice into the ice machine; the DM stopped the staff and discarded the second bucket of ice. Interview with the DM revealed the ice is typically transported on a cart, as it should be. 8. Observation on 3/04/13 at 1:04 p.m. of cooler #1 with the DM revealed two (2) opened one gallon containers of Seminole Fresh Horseradish with no open date labeled on the containers. One (1) container of the horseradish had more than one-half of the contents remaining in it. The other one (1) gallon container of Horseradish had less than one-half of the contents remaining in it. The "best by" date on one container was 2/20/13. The "best by" date on the second container was 2/28/13. Interview on 3/04/13 at 1:05 p.m. with the DM revealed the containers of horseradish and all food items in the cooler should have been labeled when they were opened. The DM revealed there should not have been two containers of the same product opened at the same time. Continued observations on 3/04/13 at 1:06 p.m. of cooler #1 revealed the following items with no opening date or use by date labeled on the containers: - Two one gallon containers of Red Hot Cayenne Pepper Sauce. One container had one-half of the contents remaining in it. The second container had two-thirds (2/3) of the contents remaining in it. - One container of Cattlemen's Kansas City Classic Barbeque Sauce with one-half of the contents remaining. - One four and one-half (4.5) pound container of Minor's Sweet and Sour- ready to use sauce with two-thirds (2/3) of the sauce remaining in the container. - One one gallon container of Ken's Tarter Sauce with two-thirds (2/3) of the sauce remaining in the container. Interview on 3/04/13 at 1:09 PM with the Dietary Manager revealed all of the above containers should had been labeled with the date they were opened. 9. Observation on 3/07/13 at 1:23 PM of cooler #1 with the Executive Chef revealed the following containers of food products that were open and had no opened or use by date labeling: - Zatirans Creole Mustard - two (2) one gallon containers. One container had one-fourth (1/4) of the contents remaining and had a best by date of 10/2012. The second container had three-fourths (3/4) of the contents remaining. The Executive Chef revealed there should not be two containers opened at the same time. - A one gallon container of Cattlemen's Kansas City Classic Barbeque sauce with one-third of the contents remaining. - Two (2) one gallon containers of Frank's Red Hot original cayenne pepper sauce. One container had one-half (1/2) of the contents remaining. The other container had three-fourths (3/4) of the contents remaining. - Two (2) thirty-two (32) ounce containers of Ken's Blue Cheese Steak House Dressing. One container had two-thirds (2/3) of the contents remaining. The other container had two to three inches of the product used. Interview on 3/07/13 at 1:30 PM with the Executive Chef revealed all items should have an open date and use by date on the containers.

Based on observation and staff interviews, the facility failed to ensure that infection control practices were followed to prevent the possible spread of infection related to hand washing for three (3) residents (#89, #92 and #91) from a sample of fourteen (14) residents Findings: 1. Observation on 3/06/13 at 11:28 a.m. of blood glucose testing for resident #89 performed by Certified Nursing Assistant (CNA) "BB" revealed that the CNA used hand sanitizer before putting on gloves to perform the blood glucose test. After completing the test, CNA "BB" removed and discarded the gloves, and left the resident's room with the blood glucose equipment. Continued observation revealed that the CNA used hand sanitizer and donned a new pair of gloves to clean the glucometer with anti-bacterial cleaner while standing at the counter in the nurses' station. The CNA did not wash her hands before or after resident contact for blood glucose testing or before or after cleaning the glucometer. 2. Observation on 3/06/13 at 11:36 a.m,. of blood glucose testing for resident #92 performed by Certified Nursing Assistant (CNA) "BB" revealed that the CNA used hand sanitizer before putting on gloves to perform the blood glucose test. After completing the test, CNA "BB" removed and discarded the gloves, and left the resident's room with the blood glucose equipment. Continued observation revealed that the CNA used hand sanitizer and donned a new pair of gloves to clean the glucometer with anti-bacterial cleaner while standing at the counter in the nurses' station. The CNA did not wash her hands before or after resident contact for blood glucose testing or before or after cleaning the glucometer. 3. Observation on 3/06/13 at 11:43 a.m of blood glucose testing for resident #91 performed by Certified Nursing Assistant (CNA) "BB" revealed that the CNA used hand sanitizer before putting on gloves to perform the blood glucose test. After completing the test, CNA "BB" removed and discarded the gloves, and left the resident's room with the blood glucose equipment. Continued observation revealed that the CNA used hand sanitizer and donned a new pair of gloves to clean the glucometer with anti-bacterial cleaner while standing at the counter in the nurses' station. The CNA did not wash her hands before or after resident contact for blood glucose testing or before or after cleaning the glucometer. Interview on 3/06/13 at 12:23 p.m. with the Nursing Unit Manager revealed no hand washing was required between patient contact. Using hand sanitizer was acceptable. Interview on 3/06/13 at 12:27 p.m. with the Administrator revealed hand washing was expected after three to five patient contacts unless the hands were visibly soiled. Utilizing hand sanitizer between patient contact was acceptable. Interview on 3/06/13 at 12:41 p.m. with the Infection Control Manager revealed hand hygiene was required before and after patient care. Hand hygiene was required before applying gloves and after removing gloves. The Infection Control Manager revealed utilizing foam antibacterial cleaner was acceptable for hand hygiene for performing blood glucose testing. Review of the facility's Blood Glucose Monitoring Policy with Effective date: February, 2012 revealed the infection control guidelines were to follow universal blood collection precautions when collecting specimens, performing test procedures, and cleaning blood glucose monitoring equipment. Review of the facility's Standard (Universal) Precautions Policy with Review/Revision date: February, 2007 revealed the components of Standard Precautions for hand hygiene include: (1) Hands are to be washed after touching blood, body fluids, secretions, excretions or other contaminated items, whether or not gloves have been worn. (2) Hands must be washed immediately after removal of gloves, between any patient contact and when otherwise indicated.

Based on staff interviews and record review, the facility failed to ensure the physician signed orders timely as required by facility policy and procedure for one (1) resident (#17) from a sample of fourteen (14) residents. Findings include: Review of the clinical record for resident #17 revealed that the resident was admitted to the facility on [DATE] for the intravenous (IV) administration of three (3) antibiotics ([MEDICATION NAME], and [MEDICATION NAME]) secondary to [DIAGNOSES REDACTED]. Review of physician's orders with the administrator revealed the following orders for antibiotics and narcotics were not signed by the physician within 24 hours: 2/3/13 Reorder [MEDICATION NAME]. 2/6/13 Continue [MEDICATION NAME]. 2/8/13 Reorder [MEDICATION NAME]. 2/8/13 Reorder [MEDICATION NAME]. 2/17/13 Continue [MEDICATION NAME]. 2/25/13 Drug re-order - [MEDICATION NAME] and Tylenol #3. 2/27/13 Reorder [MEDICATION NAME] and [MEDICATION NAME]. . Interview with the administrator on 3/6/13 at 3:04 p.m. revealed the expectation is that the physician sign all verbal orders. Review of the facility Policy for Physician Orders:Transcribing, Processing, Reviewing revealed that the verbal/telephone order shall be authenticated (countersigned), dated and timed by the physician or other authorized practitioner giving the order within thirty (30) days except for orders for restraints, narcotics, antibiotics, and [MEDICAL CONDITION] orders which must be signed or countersigned every twenty four (24) hours.

Based on observation and staff interview the facility failed to maintain sufficient sanitizer in the three (3) compartment sink. Findings include: Observation on 10/24/11 at 11:00 a.m. of the three (3) compartment sink revealed that the sanitizer, checked by the Dietary Manager, measured a zero parts per million (ppm) concentration. Continued observation revealed that the container of the sanitizer solution was almost empty. Observation on 10/25/11 at 11:30 a.m. of the three compartment sink revealed that the sanitizer solution, checked by the Dietary Manager, measured between a zero (0) and one hundred (100) ppm concentration. The dietary manager obtained a new test strip package and retested the sanitizer again with the same result. Continued observation revealed that the dietary manager removed the sanitizer solution from the dispensing tubing under the sink and poured four ounces (4 oz) of the sanitizer solution into the sink water. The sanitizing solution was rechecked and measured two hundred (200) ppm as recommended. She then called her dietary porter over to the sink and instructed him to rewash all the dishes that were drying on the rack to the right of the sink. Interview with the Dietary Manager on 10/25/11 at 11:34 a.m. revealed that the Ecolab equipment automatically dispenses the correct amount of the sanitizer solution into the sink and her staff tests the strips daily after breakfast, lunch and dinner. Continued interview revealed that the dietary manager indicated that she would have to retrain her staff on how to read the strips correctly.