Every finding on record at Hillcrest Convalescent Center

Based on observations, staff interviews and record review, the facility failed to ensure the following kitchen equipment was clean; the stove, oven, hot box, steam table, plate warmer, plate/dome rack, 2 refrigerators, ice machine and dry storage containers. Findings included: During the initial kitchen tour was conducted on 3/8/21 at 9:30 AM, the following observations were made: The stove had a large volume of heavy buildup of grease on the stove burners, walls and fronts of the stove. There were large amounts of burnt foods, dried liquid encrusted and splatters throughout the stove area. B. During an observation on 3/8/21 at 9:30 AM, the oven had a large volume greasy buildup, dried food and liquids on the inside and outside. The grease buildup was encrusted on doors/shelves where foods were being cooked. There was a large volume of dried grease buildup observed on the fronts of the ovens and on the walls. C. During an observation on 3/8/21 at 9:30 AM, the hot box where warm food is stored, had large volume of dried brown/yellow liquids matter encrusted on edges inside/outside. D. During an observation on 3/8/21 at 9:30 AM, the 5 compartment steam tables had floating food particles in standing water, the lids of the steam table had large volumes of dried food and greasy build up around edges. E. During an observation on 3/8/21 at 9:30 AM, the two-compartment plate warmer had two rows of clean plates stored in them. The inside and outside had dried food particles and liquids spills, old food crumbs all around. The staff removed the plates wiped down the top and returned the clean plates to the warmer. Other dried food particles and liquids remained inside the plate warmer. F. During an observation on 3/8/21 at 9:30 AM, there were two plate/dome racks with dome lids/plates had large amounts of leftover food, yellow, brown crumbs dried liquids were the clean domes/lids were drying. G. During an observation on 3/8/21 at 9:30 AM, the ice machine had brown matter and a black substance inside the creases of the hood the ice machine. H During an observation on 3/8/21 at 9:30 AM, the floors under and behind the stoves/ovens, steam table, prep tables, under ice machine, had a large thick heavy buildup of grease, brown matter, trash, paper cups, straws, spoons, food, wrappers. I. During an observation on 3/8/21 at 9:40 AM, there were 6 dry food containers in the dry storage room labelled breadcrumbs, seafood, cornmeal and cereal had open dried food/liquids brown matter on inside and outside of containers. The containers located in the kitchen area labelled sugar and thickener containers had dry brown liquids/food inside and outside of the containers. J. During an observation on 3/8/21 at 9:45AM, 5 drying carts used for clean dishes were observed to have dried encrusted food/liquid matter on them with stacks of clean cups/glasses and bowls. K. During an observation on 3/8/21 at 9:50 AM there were two refrigerators that had encrusted brown matter dried foods and liquids and opened left over foods of sandwiches, fruit cups and breakfast foods that were not covered. During an interview on 3/11/21 at 11:10 AM, Dietary Aide #1 and Dietary Aide #2 stated they were informed of the kitchen checklist and the requirements of the cleaning process and when to clean kitchen equipment. The Dietary Aides stated they were cleaning the equipment in accordance to the weekly cleaning schedule. During an interview on 3/11/21 at 11:21 AM, the Dietary Manger (DM) stated the expectation was for the kitchen staff to follow the kitchen cleaning checklist. DM stated the 3 supervisors were responsible for ensuring the kitchen team to maintained sanitation conditions in the kitchen. The supervisors should be doing shift checks before and after to ensure all tasks were completed. During an interview on 3/11/21 at 11:30 AM, the Kitchen Supervisor stated she was responsible for monitoring and checking behind the kitchen staff to ensure they were completing the checklist and ensuring all sanitation procedures were being followed. The Supervisor stated they had been checking behind the staff weekly to ensure the cleaning was done.

Based on facility staff, pharmacist, and physician interviews, and facility and hospital record reviews, the facility failed to accurately transcribe a physician's medication order, resulting in a [MEDICAL TREATMENT] resident (Resident #2) receiving a dose of an injectable anticoagulant medication prescribed for another resident and placing him at an increased risk for bleeding. The findings included: Resident #2 was admitted to the hospital from 6/26/19 to 7/11/19 with a cumulative [DIAGNOSES REDACTED]. A review of the hospital discharge summary included recommendations to continue with the following medications: [REDACTED]. Resident #2 was admitted to the facility on [DATE] from the hospital. His admission medication orders included, in part: 75 mg [MEDICATION NAME] to be given by mouth once daily and 81 mg of EC aspirin to be given once daily. A review of the resident's lab results dated 7/11/19 included: Hemoglobin = 9.3 (normal range = 13.0-18.0); Hematocrit = 30.1 (normal range = 39.0-54.0). A review of the resident ' s Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 had intact cognitive skills for daily decision making. The resident required extensive assistance for all of his Activities of Daily Living (ADLs), with the exception of needing limited assistance from staff for toileting and walking in his room or corridor. He was assessed to be independent with eating. Section O of the MDS assessment indicated the resident received [MEDICAL TREATMENT] while a resident. Review of Resident #2's care plan included a Problem/Need (Onset: 7/11/19) related to the resident ' s risk for bruising or bleeding due to daily use of aspirin and [MEDICATION NAME]. The Goal for this Problem/Need was for the resident to remain free from adverse effects and have no complications from aspirin and [MEDICATION NAME] use through the date of the next review. The planned interventions included, in part, for the staff to administer the medications per order and to monitor for any signs and symptoms of bleeding. Review of Resident #2's medical record included an appointment note which indicated the resident went out to the [MEDICAL TREATMENT] center for his appointment on 7/18/19 at 11:30 AM. A review of Resident #2's electronic physician's orders [REDACTED].= 90 mg) subcutaneous every 24 hours. Discard the remainder. The start date for the medication was 7/18/19; it was scheduled to be given at 8:30 PM. [MEDICATION NAME] is an injectable anticoagulant medication. However, a review of the handwritten paper copy of this physician's order [REDACTED].#9 (not Resident #2). The paper copy indicated the order was received by Nurse #1 on 7/18/19 at 1:24 PM. According to Lexi-Comp, a comprehensive electronic medication database used by medical professionals, [MEDICATION NAME]'s elimination from the body is primarily via the renal route (by the kidneys). The area under the curve (a representation of the drug concentration in the blood plasma versus time) is increased 65% in patients with severe renal impairment. [MEDICATION NAME] is not dialyzable (removed via [MEDICAL TREATMENT]). [MEDICATION NAME] is not approved by the Food and Drug Administration (FDA) for use in [MEDICAL TREATMENT] patients. A review of Resident #2's (MONTH) 2019 Medication Administration Record [REDACTED]. Further review of Resident #2's medical record revealed the order for the [MEDICATION NAME] was discontinued on 7/19/19. Review of the resident's medical record included a Progress Note dated 7/19/19 (not timed) and written by the Medical Doctor (MD). The MD's notation indicated Resident #2 was seen on 7/19/19. His notes read, in part: Pt (patient) inadvertently rec'd (received) one dose of [MEDICATION NAME] ([MEDICATION NAME]). A physician's order [REDACTED].#2 which instructed staff to apply a pressure dressing to the resident's left forearm for 48 hours. A review of the resident's lab results dated 7/24/19 included: Hemoglobin = 9.2; Hematocrit = 29.4. An interview was conducted on 8/14/19 at 2:10 PM with Nurse #1. Nurse #1 was identified as the nurse who had received and input into the computer the medication order for [MEDICATION NAME] given to Resident #2 on 7/18/19. During the interview, the nurse was asked to describe the process used to receive and transcribe a medication order. Nurse #1 stated if a physician called in a new medication order, she would handwrite a telephone order and read it back to verify its accuracy. Then, she would input the order into the computer. Nurse #1 reported all hall nurses were trained to input orders into the computer. Nurse #1 reported 1 of the 5 copies of the handwritten telephone orders would go to the facility's in-house pharmacy. The interview with Nurse #1 conducted on 8/14/19 at 2:10 PM continued as she discussed the events surrounding the administration of [MEDICATION NAME] to Resident #2 on 7/18/19. The nurse reported when she came in to work the next day (on 7/19/19), a 3rd shift nurse informed her it had been discovered the [MEDICATION NAME] order she had taken on 7/18/19 for Resident #9 had not been put into the computer. However, Nurse #1 stated she recalled putting this order into the computer. After reviewing the medical records, she found the [MEDICATION NAME] order had been input into the computer for the wrong resident (Resident #2, not Resident #9 as intended). Nurse #1 stated, It was clearly an error. The nurse reported she immediately notified the facility's Director of Nursing (DON) and the resident's physician of the error. A telephone interview was conducted on 8/14/19 at 3:18 PM with the pharmacist who dispensed medications from the facility's in-house pharmacy. The pharmacist reported he dispensed [MEDICATION NAME] for Resident #2 on 7/18/19. When he came in to work the following day (7/19/19), he learned an error had been made when the [MEDICATION NAME] order was put into the computer and the [MEDICATION NAME] had actually been ordered for another resident (not Resident #2). When asked about the verification process for dispensing this medication, the pharmacist stated he did not have the paper (handwritten) physician's order [REDACTED].#2. The pharmacist reported he did not normally send a medication to the floor without verifying the order via a handwritten telephone order or a nurse's verbal confirmation of the order. He stated, Because we have an internal pharmacy, I try to recheck it. However, the pharmacist reported he filled and dispensed [MEDICATION NAME] for Resident #2 on 7/18/19 directly from the information put into the computer by the nurse. When asked, the pharmacist stated the paper copies of physician orders [REDACTED]. He thought the order for the [MEDICATION NAME] dispensed for Resident #2 may have been generated after the last paper copies of the orders were picked up for the day. The pharmacist stated that because [MEDICATION NAME] was kept in the facility's backup supply closet, he figured the medication would have been obtained and administered by the nurse even if he had not dispensed it. A telephone interview was conducted on 8/14/19 at 12:54 PM with Nurse #2. Nurse #2 was identified as the nurse who had administered [MEDICATION NAME] to Resident #2 on 7/18/19. The nurse stated she knew an order must have been written for the resident to receive [MEDICATION NAME] because it was included on his electronic MAR. Nurse #2 also reported the [MEDICATION NAME] had been filled by the facility's pharmacy and was labeled with Resident #2's name on it. A telephone interview was conducted on 8/15/19 at 12:54 PM with the MD who was caring for Resident #2. Upon inquiry, the MD stated he remembered seeing the resident on 7/19/19 and recalled he had received [MEDICAL TREATMENT] the preceding day (on 7/18/19). The MD reported he went to check on the resident to be sure the dressing on the resident ' s shunt site (for [MEDICAL TREATMENT]) was appropriate. When asked, the MD indicated he could not say the resident receiving a dose of [MEDICATION NAME] the night before had caused an adverse side effect. An interview was conducted on 8/14/19 at 1:53 PM with the facility's Director of Nursing (DON). During the interview, the administration of [MEDICATION NAME] to Resident #2 on 7/18/19 was discussed. Upon request, the DON checked the resident's electronic medical record and reported from what she could tell, the order for [MEDICATION NAME] was entered by Nurse #1 on 7/18/19 at 1:19 PM. The DON confirmed the paper copy of the physician's order [REDACTED].#9), but Nurse #1 entered the order on the wrong resident (Resident #2) into the computer system. The order entered into the computer then went onto Resident #2's electronic MAR for administration. When the 3rd shift nurse did a chart check on the night of 7/18/19 - 7/19/19, it was noted the order had not been entered into the computer for the correct resident. When Nurse #1 was questioned about it the morning of 7/19/19, she found it had been put in on the wrong resident. The DON confirmed the [MEDICATION NAME] was reported to have been labeled and dispensed for Resident #2 by the pharmacy, but stated she was not sure how that happened. The DON reported she expected the nurses inputting orders into the computer to double check the resident's name an order was written for. During a follow-up interview conducted on 8/14/19 at 4:23 PM with the DON, the DON acknowledged that not all licensed nurses who were responsible to input medication orders into the computer had been in-serviced on the topic of order entry and educated to double check the resident's name before an order was confirmed and sent to the pharmacy.

Based on staff and family interviews, record review, the facility failed to implement or follow the abuse policy in the area of reporting for 1 of 3 sampled resident who had an allegation of abuse (Resident #1). The findings included: Record review of the policy titled Abuse Reporting not dated, revealed Policy Statement All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of an unknown source and misappropriation of resident property. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was readmitted on ,[DATE]/ 19 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was coded as severely cognitively impaired with no documented behaviors. He had a feeding tube. The resident was coded as having had received antianxiety medications, and antidepressant medication each day of the seven-day assessment period. Review of an unscheduled MDS assessment dated [DATE] revealed Resident #1 had behavior symptoms directed toward others 4-6 days but less than daily and rejection of care 1-3 days of 7. Record review of the Quality Assurance Complaint Review 6/4/19, revealed Concern identified family member of Resident #1 with physically holding his arms and mouth to promote medication administration and hit his face. The employee statements were contained in the Quality Assurance program. During an interview on 6/12/19 at 10:15 AM, Family Member indicated she had been accused of abuse of Resident #1. She indicated that the Nurse Supervisor #1 (NS) tried to give Resident #1 medication orally. He spit his medications out. NS #1 asked her to try and she gave him the pill. She explained that she put the medication into his mouth, covered his mouth and massaged his cheeks to get him to swallow. On Tuesday 6/4/19, Nursing Supervisor #2 asked her to leave the facility because there was a report that she had abused Resident #1, and she didn't know the specifics. The family member stated to Nurse Supervisor #2 that she had not abused Resident #1 and refused to leave. She said Nursing Supervisor #1 was in the room during the alleged abuse and she didn't say anything to her. During an interview on 6/12/19 at 12:36PM NS #1 indicated that Resident #1 had had a great day. Around 4PM he has a scheduled antianxiety medication which he received. Later in the shift he was still agitated. The medication aide was unsuccessful to administer the PRN (as needed) antipsychotic medication. NS #1 stated that she had also attempted to administer the medication by mouth and was unsuccessful. The family member got up from the chair and put her weight on him. She leaned on him trying to keep his a/rms restrained. He resisted the family member. She asked for the medication, and put it into his mouth and pinched his lips to gather with both hands. She used her left hand to scrape the medication back into his mouth. He bit her. She removed her hand paused while she looked at her hand and then took her right hand and slapped him across his left side of his face. When NS was asked if that wasn't considered abuse? She stated that she didn't consider it as abuse because she was a family member. Afterwards the family member joked that they had brawls like this before. It was not big deal. NS #1 stated she had access to the administrative staff, but she didn't report this incident. She told the oncoming night Nurse Supervisor #2, when she came on duty. The information made it to the Director of Nursing by Tuesday. During a telephone interview on 6/12/19 at 1:59 PM Medication Aid (MA) indicated that the nurse supervisor tried to orally administer medication and Resident #1 resisted. The family member volunteered to give the medication. She used a spoon with food, she put it in his mouth and pinched his lips together. He was fighting and shook his head. He had food on his face. He had bit her and she popped him in the face. MA said, It didn't look like abuse to me. She continued If she had witnessed abuse or neglect she would go straight to the supervisor and she was in the room with me. During a telephone interview on 6/12/19 at 3:10 PM Nurse Supervisor #2 indicated during report Nurse Supervisor #1 reported that Resident #1 was agitated when he returned to the bed and she saw a family member slap him because he did something to her. At the time she assumed Nurse Supervisor #1 had reported the abuse. She didn't clarified it with Nurse Supervisor #1 and she didn't think about it at the time. She stated that she didn't think to report the abuse to management. She assumed Nurse Supervisor #1 reported it since she witnessed it. During interview on 6/12/19 at 4:00PM the Director of Nursing (DON) indicated she was notified on Tuesday the 4th by the Staffing Coordinator (SC) that Resident #1 was slapped. She told the SC to interview Nurse Supervisor #1 to determine if it was abuse or not. Resident #1 was severely impaired. Based on the staff statements we asked the family member to leave on Tuesday. She refused to leave and stated that she had nowhere to go. We offered her a room in assisted living. She declined. We initiated 1:1 supervision. The investigation was completed with staff statements. We used the regulatory guidelines for visitor resident abuse the staff should have called me when this situation occurred. The nurse supervisor had struggled with whether it was abuse or not. During an interview on 06/13/19 at 10:59 AM the Administrator indicated that the DON got the information and staff made clear that there was no willful injury. Our decision was that there was no abuse. take all reports seriously and we take we go above and beyond to make sure the residents are safe. We put into place 1:1 observation to confirm that there was no abuse. We never considered abuse had occurred based on the witnesses. We were over protective doing the one on one at our expense.

Based on observations, staff interviews and record review, the facility failed to maintain and clean, steam table, meal carts, silverware container and plate warmer in the kitchen. The findings included: 1 a. During an observation on 12/17/18 at 9:46 AM, the 8-compartment steam table had a large volume of food left from breakfast in standing water and the inside surfaces as well as the steam table lids had large volumes of dried food, liquids and brown matter encrusted with the surfaces. The bottom portion of the steam table had large volumes of old food crumbs, dried liquids, trash and old fruit. During an interview on 12/17/18 at 9:46 AM, the Registered Dietician(RD) and Dietary Manager(DM) stated the expectation was for staff to empty and clean the steamtable inside and out prior to each meal. There should be no food left in the water and the lids should be thoroughly cleaned prior to placement on the stable. 2 a. During an observation on 12/17/18 at 9:46, there were 5 meal carts located in the kitchen that had a large volume of dried foods and liquids encrusted on the surfaces where food and clean trays were stored. The enclosed carts had dried food and liquids on the shelving area base, walls and the floor of the cart and surfaces. b. During a follow-up observation on 12/17/18 at 12:00 PM to 1 :00 PM, 6 meal carts on 1st and 2nd floors continued to have dried foods/liquids encrusted in the shelving area, base and walls of the cart from previous observation from breakfast. The leftover meal particles were hanging over onto the tray of the meal being served. During an interview on 12/19/18 11:05 AM, the Registered Dietician and Dietary Manager stated the expectation was for staff to clean and wipe down all the kitchen appliances after each meal and deep clean weekly. The meal carts should be broken down and wiped out inside/out. 3 a. During an observation on 12/17/18 at 9:46 AM, 4 containers of clean silverware was stored in dirty compartments that had large volumes of dried encrusted food, liquids and dried brown substance in the compartments where clean silverware was stored. During an interview on 12/17/18 9:46 AM, the Registered Dietician and the Dietary Manager indicated all silverware and containers should be cleaned after each meal. 4 a. During an observation on 12/17/18 at 9:46 AM, the 3 plate warmers that had clean plates and dome bases had large volumes of dried food liquids and foods on the inside and outside. There were old food crumbs and encrusted dried brown matter inside where the clean plates were stored. During an interview on 12/17/18 at 9:46 AM, the Registered Dietician and Dietary Manager stated the expectation was for staff to clean and wipe down all the kitchen appliances after each meal and deep clean weekly.

Based on observations and staff interviews the facility failed to label and date previously opened food items, failed to discard left over foods past their use-by date and failed to store previously opened meat products appropriately which were stored in one of two walk-in refrigerators, one of one kitchen walk-in freezer and one of two reach-in refrigerators. The findings included: 1. An Observation of foods stored in the kitchen's walk-in refrigerator on 03/20/2017 at 09:20 AM revealed the following: a. A container of prunes which was labeled and dated 3/12/17 and a container of diced green peppers dated 3/16/17. During an interview with Cook #1 on 03/22/2017 at 11:19 AM, Cook #1 indicated that any food product that was pre-made or canned and transferred to a container, the label on this food would indicate the product name, current/today's date and a use by date of 3- 4 days. Cook #1 stated the product should be discarded after the use by date. Review of the facility's Food Discarding Policy read in part: Refrigerated opened food items will be discarded within seven days of opened date. b. Three transparent opened bags containing lettuce and two opened transparent bags containing broccoli that were not dated when opened. Dietary Manager indicated that the produce should be labeled with date when opened. During an interview with the Dietary Manager on 03/20/2017 at 09:35 AM, Dietary Manager indicated that the produce in the refrigerator when opened was used within 7 days of opening. 2. An Observation of the kitchen's walk-in freezer on 03/20/2017 at 09:25 AM revealed the following: a. A previously opened bag of French fries that was not dated when opened. A plastic bag with a sliced meat patty with no label or date. Interview with the Dietary manager, at the time of the observation revealed the sliced meat was an uncooked veal patty. b. Observations of the kitchen's walk-in freezer revealed a large plastic bin on top of the cart. Observations revealed the large plastic bin contained the following meat products which were not labeled or dated and had been removed from their original containers/boxes. A previously opened bag of raw shrimp, a bag of previously opened meat patties, previously opened bag of raw meat, a bag of pepperoni which was previously opened, and a previously opened bag of breaded meat patties. Interview with the Dietary manager, at the time of the observation, revealed the breaded meat patties were chicken strips. During an interview with the Dietary Manager on 03/20/2017 at 09:35 AM, Dietary Manager indicated that the meat products were used in past meals and the leftover products should have been stored in appropriate boxes in the freezer. 3. An observation of the kitchen's reach-in refrigerator on 03/20/17 at 09:30 AM revealed a container of leftover green beans dated 3/11/17. During an interview with the Dietary Manager on 03/20/2017 at 09:35 AM, the Dietary Manager indicated that the leftovers were usually used within 48 hours and the leftover green beans should have been discarded by staff. During an interview with Cook #1 on 03/22/2017 at 11:19 AM, Cook #1 revealed that leftover foods were labeled with product name, date of preparation and use by date. She indicated that leftover food were stored for 3-4 days and discarded after the use by date. Review of the Storing Leftover food Policy dated 08/03/04 read in part: Leftover food will stored for up to three days with the day of preparation being day one. During an interview with Dietary Manager on 03/22/2017 at 1:58 PM, she indicated that the leftover prepared food was used as alternative and used within 5 to 7 days from the day of preparation. She indicated that leftover foods were discarded after 7 days. She indicated that it was her expectation that staff use proper labels and label foods accurately. She also indicated that it was her expectation that staff check dates on foods on a regular basis and discard food appropriately.

Based on observations, record review, and staff interviews, the facility did not maintain medication refrigerator temperatures per the guidelines by the insulin manufacturers in 2 of 2 medication refrigerators observed, compromising the integrity of the insulins. Findings included: On 04/07/2016 at 2:08 PM, a tour of the medication storage room located on Pinehurst Place was made with Nurse #1. A review of the Refrigerator Temperature Graph for April 2016 which was attached to the medication refrigerator revealed the recorded temperature was 32 degrees F (Fahrenheit.) on 2 consecutive dates, April 1, 2016, and April 2, 2016. An observation of the refrigerator interior revealed there were 4 unopened vials of insulin inside: two vials of Lantus, one vial of Novolog, and one vial of Humulin. In an interview with Nurse #1 on 04/07/2016 at the time of the observation, she stated the temperature in the medication refrigerators was checked once daily to ensure the temperatures were between the range of 32 degrees F and 40 degrees F as shown on the log. Nurse #1 stated she had never seen any frozen insulin in the refrigerator and that if the temperature were to go down to 31 degrees F, she would call maintenance to repair it. Nurse #1 acknowledged she was not aware of the temperature recommendations for insulin storage. During a tour of the medication storage room located on Recovery Road with Nurse #1 on 04/07/2016 at 2:15 PM, a review of the Refrigerator Temperature Graph (log) dated April 2016 revealed the temperature recorded was 32 degrees F on April 1, 2016, April 5, 2016, and April 6, 2016. The same graph revealed the medication refrigerator temperature was 35 degrees F on April 2, 2016, and was 34 degrees F on April 3, 2016, and on April 4, 2016. An observation of the refrigerator interior revealed it contained one unopened vial of Humolog insulin. Nurse #1 stated in an interview during the observation on 04/07/2016 at 2:15 PM that the temperature in the medication refrigerator on Recovery Road was maintained at 32 degrees F to 40 degrees F, just as it was for the refrigerator on Pinehurst Place. Review of the patient package insert for Lantus, revised July 2015, revealed the following: Store unused Lantus vials in the refrigerator between 36 degrees F and 46 degrees F . Do not freeze Lantus. If a vial has been frozen or overheated, throw it away. Review of the patient insert for Novolog insulin revealed the following: Unused Novolog should be stored in a refrigerator between 36 degrees and 46 degrees F. Do not store in the freezer or directly adjacent to the refrigerator cooling element. In bold face type, the patient package insert for storage revealed: Do not freeze Novolog and do not use Novolog if it has been frozen. Review of the patient package insert for Humulin revealed the following: unopened Humulin .vials should be stored in a refrigerator .36 degrees to 46 degrees F, but not in the freezer. In an interview with the Director of Nursing (DON) on 04/07/2016 at 3:00 PM, she stated she would want the nurses to discard any insulin that might have frozen if the manufacturer of the insulin recommended to do so. The DON also stated she did not know why the refrigerator graphs included a range of 32 degrees F to 40 degrees F to be initialed, and that she would check the facility's policy related to medication refrigerator temperatures. The facility's pharmacist stated in an interview on 04/07/2016 at 3:15 PM if the temperature in the medication refrigerator registered 32 degrees F, the nurse should check for signs of freezing and then check the insulin manufacturer's package insert. The pharmacist referred to the insulin manufacturers ' package inserts and stated that if the refrigerator temperature was freezing, it should not be used, and he would expect the nurse to call him to determine if the insulin was not an appropriate temperature. He stated he would want the facility to follow the instructions provided on the package insert. The DON stated in an interview on 04/07/2016 at 3:40 PM, she stated she had not been able to find a facility policy related to medication refrigerator temperature for guidance. The DON stated she did not know why the temperatures on the Refrigerator Temperature Graph were set to have the range of 32 degrees F to 40 degrees F, especially if insulins should not be kept below 36 degrees per the insulin manufacturer. The DON stated she would expect the facility to follow the guidelines provided for insulin use. In an interview with the Administrator on 04/07/2016 at 4:04 PM, he stated that the insulin vials that were stored in the 2 medication storage refrigerators would be discarded per the manufacturer recommendations for use and that the temperatures in the refrigerators would be adjusted.

Based on observations, record review, and staff interviews, the facility failed to provide proper oral (mouth) care for 1 of 1 sampled resident (Resident #19). Findings included: A review of the facility's policy/procedure entitled "Oral hygiene procedure" (undated) read in part, "Oral care is an essential part of morning and evening care. Supplies needed for routine mouth care: toothpaste or powder, towel, emesis basin, glass of water, toothpaste (repeat)." According to the National Nurse Aide Assessment Program candidate handbook dated 2011, page 37 - a guide for minimal competency evaluation for nurse aide certification in North Carolina: mouth (oral) care include toothpaste applied to a toothbrush, and the mouth is cleaned - including the tongue, and surfaces of the teeth. Resident #19 was admitted into the facility on [DATE] and readmitted on [DATE]. Cumulative [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) completed on 2/22/12 indicated Resident #19's short and long term memory was intact. Resident #19 had the ability to recall location of own room, staff names/faces, and that he resided in a nursing home. The MDS indicated Resident #19 had difficulty (modified independence) in new situations only. The MDS revealed extensive assistance of two people was required for bed mobility, transfers, and ambulation did not occur. Extensive assistance of one person was required with personal hygiene. Total assistance of one person assist was required for dressing and bathing. Balance was impaired in that Resident #19 was only able to stabilize with staff assistance during surface to surface transfer. Range of motion was impaired on both sides of the upper/lower extremities (shoulder, elbow, wrist, hand, hip, knee, ankle, and foot). A review of the care plan initiated on 2/23/12 (problem onset date) for communication, indicated Resident #19 communicated with gestures, sometimes with a communication board, and responded better with concrete yes/no questions. Approach/intervention strategies included encouraging Resident #19 to increase voice volume - to assist with effective communication, due to a tendency to whisper. A review of the care plan initiated on 2/23/12 (problem onset date) for hand contracture's stated Resident #19 was dependent on the staff for most of daily care. Stated goal indicated the staff would provide oral hygiene with resident assisting, if able. Approach/intervention strategy included provision of dental care. In a family interview on 5/1/12 at 11:47 am, with Resident #19 present revealed concerns that Resident #19's teeth was not being brushed on a daily basis. Clarification with Resident #19 during the interview, he indicated the staff did not provide oral care which included brushing his teeth on a daily basis, through a head gesture "No". On 5/2/12 at 8:35 am, Resident #19's teeth were observed with whitish-brownish matter between several of the upper/lower teeth, when asked to open mouth. Resident #19 confirmed that his teeth/mouth care had not been provided through a slow head gesture "No". This was confirmed a second time, and Resident #19 was consistent with a gesture "No". Located on the window seal in Resident #19's room were green peppermint mouthwash, toothpaste, emesis basin, and a toothbrush. On 5/2/12 at 9:47 am, Resident #19 was observed in his room eating breakfast. In an interview on 5/2/12 at 9:52 am, Resident #19 indicated through a slow head gesture "No" that he had not received oral care prior to eating breakfast. On 5/2/12 at 12:36 pm, Resident #19 was observed eating lunch. In an interview on 5/2/12 at 2:20 pm, NA (Nurse aide) #1 primary care giver for the day, indicated she noticed around 7:30 am, during morning care that Resident #19 had matter on the inside of his mouth, and dried drool (saliva) on the outside of his mouth from the previous night. NA #1 stated she wiped the inside and outside of Resident #19's mouth with a wash cloth. NA #1 added, she did not brush Resident #19's teeth, tongue, or use the oral rinse (peppermint mouthwash) that was located in his room all day. NA #1 concluded Resident #19 was not capable of providing mouth care independently, nor did he refuse oral care to be completed. In an interview on 5/2/12 at 2:27 pm, with NA #1 present Resident #19 indicated via head gesture "Yes" that he wanted his teeth brushed with toothpaste, and mouth rinsed with the oral peppermint mouthwash daily. In an interview on at 5/2/12 2:30 pm, the Director of Nursing (DON) stated mouth care was individualized per resident/family member. The DON indicated she expected mouth care to be performed during morning care, prior to eating breakfast. In an interview on 5/2/12 at 5:38 pm, the DON indicated she expected during mouth care items that could have been utilized for oral care included: lemon swabs, toothpaste, toothbrush and pink swaps. In an interview on 5/2/12 at 6:20 pm (prior to conclusion of the annual survey departure) the DON explained she had talked with the restorative aide (RA) approximated 5 minutes ago, and the RA informed her she wetted a pink swap with water, and swapped Resident #19's mouth during the morning hours. She added, the RA stated she did not brush Resident #19's teeth/tongue, use toothpaste, or mouthwash.