Every finding on record at Mary Health of the Sick Convalescent & Nursing Hos

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when one of two trash receptacles had trash, and the lid was not closed.This failure had the potential to attract pests and rodents which could cause food borne illness for 49 medically compromised residents.Findings:During a facility tour and observation of the trash receptacle storage area outside the facility and interview with the Director of Maintenance (DM) on 06/08/2026, at 9:11 AM, one of two trash receptacles was observed to be open, and the trash was overflowing from the trash receptacle. The DM stated garbage was collected daily, except Sundays. The DM stated the staff who disposed of trash were responsible for ensuring the trash receptacle lids remained closed and that trash receptacles do not overflow. The DM further stated that unit supervisors should instruct staff not to overfill the trash receptacles and to ensure that trash was disposed of properly during weekends.During a concurrent interview with the DM on 06/10/2026 at 2:45 PM, the DM stated the trash receptacle lids should remain closed, should not overflow, and the surrounding area should be kept free of trash to prevent attracting flies and rodents. The DM acknowledged a plan should have been implemented to ensure the proper disposal of garbage during weekends.During an interview with the Director of Nursing (DON) on 06/11/2026 at 10:09 AM, the DON stated garbage bins should not be full or overflowing to prevent pest infestation. The DON further stated the Maintenance Director should inspect the garbage bins daily as the garbage collection was scheduled daily. The DON acknowledged garbage bins were not monitored adequately to ensure they were properly sealed and emptied.A review of the facility undated policy and procedure titled, Exterior Waste Storage and Sanitation Policy, indicated, .maintain exterior waste storage areas, dumpsters, garbage containers, and waste enclosures in a manner that promotes sanitation, safety, infection prevention, and regulatory compliance. 2. Garbage containers and dumpsters shall be maintained in a manner that prevents excessive accumulation of waste, litter, odors, and unsanitary conditions.3. Container lids, dumpster covers, and enclosure gates or doors should remain closed when practical and when not actively in use. 5. Any observed accumulation of debris, spills, overflowing waste, pest activity, or other sanitation concerns shall be reported promptly and addressed as appropriate.6. Maintenance staff shall coordinate waste removal services and take reasonable measures to ensure adequate waste disposal capacity is maintained. MONITORING.The facility will maintain oversight of exterior waste storage areas and address identified concerns in a timely manner to ensure a clean and sanitary environment.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. A frozen concentrated orange drink was found opened, spilled in its tray, undated, and expired inside the kitchen's walk-in refrigerator.2. Food crumbs, dirt, and trash were found on the floor beneath the dishwasher, compartment sink, and walk-in refrigerator areas.3. The Cook's mustache was not covered with a beard net. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a vulnerable population of 49 residents who received food from the kitchen.Findings:During an initial observation tour of the kitchen and an interview with the Director of Food and Nutrition Services (DFNS), on 06/08/2026, at 8:02 AM, a frozen concentrated orange drink was found opened, spilled in its tray, undated, and expired inside the walk-in freezer. The DFNS stated he did not see the item when he checked the freezer.During an interview and record review with the DFNS on 06/10/2026, at 8:50 AM, the DFNS stated it is important to date food items upon opening and to routinely check expiration dates to ensure resident food safety. The DFNS reviewed and confirmed the facility's undated P&P, titled, Refrigerator and Freezer, indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. 1. Refrigerator and freezer should be on a weekly cleaning schedule.2. Wipe up spills immediately.3. Check all foods at least weekly, being mindful of expiration and use by dates. The DFNS confirmed the finding and stated the policy should have been followed.During an interview with the Director of Nursing (DON) on 6/11/2026, at 10:09 AM, the DON stated food items stored in the refrigerator should always be checked and dated upon receipt, upon opening and according to the expiration date. The DON further stated that expired food items should be discarded immediately to prevent food contamination.During a phone interview with the Registered Dietitian (RD), on 06/11/2026 at 11:10 AM, the RD stated that opened, undated and expired food packages should be thrown away. The RD also stated the expectation is the dietary staff should follow infection control precautions for food safety.A review of the facility's undated P&P titled, Labeling and Dating of Foods, indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Food delivered to facility needs to be marked with a received date. Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines.A review of the FDA Federal Food Code 2022, 3-101.11 titled Safe, Unadulterated, and Honestly Presented.Labeling-General, indicated, .Sources of packaged food must be labeled in accordance with law. Proper labeling of foods allows consumers to make informed decisions about what they eat. Many consumers, as a result of an existing medical condition, may be sensitive to specific foods or food ingredients . 2. During an initial observation tour of the kitchen and interview with the DFNS, on 06/08/2026, at 8:16 AM, food crumbs, dirt, and trash were found on the floor under the dishwasher, compartment sink and walk-in refrigerator areas. The DFNS stated areas in the kitchen should be kept clean and free of crumbs, trash, and dirt daily. The DFNS further stated, the kitchen floor and underneath areas should be swept up and mopped out after breakfast trays were taken out from the kitchen to maintain cleanliness. During a concurrent interview and record review with the DFNS on 06/10/2026, at 8:48 AM, the DFNS reviewed and confirmed the facility's undated policy and procedure (P&P), titled, General Cleaning of Food & Nutrition Services Department, indicated, Floors, floor mats.must be scheduled for routine cleaning and maintained in good condition.1. Floors must be mopped at least once per day.2. Sweep the floor.use a dustpan to remove and dispose of debris as it accumulates.8. Mop under and around equipment, along the walls and in corners. The DFNS confirmed the finding and stated the policy should have been followed.During a concurrent interview with the DON on 06/11/2026, at 10:09 AM, the DON stated that all areas beneath equipment and all corners of the kitchen should always be kept clean. The DON further stated that it is the responsibility of the Kitchen Director to inspect and monitor the kitchen to ensure cleanliness and food safety.During a concurrent phone interview with the RD, on 06/11/2026, at 11:10 AM, RD stated kitchen floors and areas underneath should always be kept clean. The RD acknowledged that multiple areas underneath kitchen equipment should be swept daily.A review of the Food Code, 2022, the Food Code indicated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and the Equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 3. During an initial observation tour of the kitchen and interview with the DFNS, on 06/08/2026, at 9:20 AM, the [NAME] prepared the puree meal and was not wearing a beard net (also known as a beard cover - a lightweight, protective covering worn over the lower face to safely contain facial hair). The DFNS stated the [NAME] should have covered his mustache to prevent hair from falling into the pureed food. During a concurrent interview and record review with the DFNS on 06/10/2026, at 8:48 AM, the DFNS reviewed and confirmed the facility's undated policy and procedure (P&P), titled, Dress Code, indicated, Personal hygiene and appropriate dress are a very important part of the total appearance of the Food & Nutrition Services Department. 8. If applicable, beards and mustaches (any facial hair) must wear beard restraint. The DFNS confirmed the finding and stated the policy should have been followed.During a concurrent interview with the DON on 06/11/2026, at 10:09 AM, the DON stated that facial hair should be covered with hairnets to ensure food safety for the residents.During a concurrent phone interview with the RD, on 06/11/2026, at 11:10 AM, RD acknowledged that kitchen staff with beards or mustaches should wear beard nets to prevent hair from contaminating resident's food and to reduce the risk of food contamination.A review of the Food Code, 2022, the Food Code indicated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and the Equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.

Based on interview and record review, the facility failed to ensure three of five sampled residents (Residents 4, 8, and 15) were free from unnecessary psychotropic medications (medications affecting brain activities associated with mental processes and behaviors) specifically lorazepam (generic for Ativan, a psychotropic medication to treat anxiety [feeling of fear, dread, or unease when stressed or anticipating a problem]) when:Resident 4 received seventeen doses of as needed lorazepam when Resident 4's assessed condition did not meet the clinical indication (the medical reason for a specific treatment, condition, or procedure) of the medication;Resident 8 received two doses of as needed lorazepam without documented justification for the medication administration; andResident 15 received six doses of as needed lorazepam with no behavior monitoring in place.These failures had the potential for the residents to inappropriately receive as needed psychotropic medications and had a risk of inaccurate clinical assessment of medication efficacy.Findings:1. A review of Resident 4's admission Record, (a document showing a summary of the resident's information) dated 6/10/26, indicated Resident 4 was readmitted to the facility on [DATE].A review of Resident 4's Medication Administration Record, ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/1/2026 - 3/31/2026, indicated Resident 4 had a physician's order dated 12/30/25, for Lorazepam Solution 2 mg/ml [milligrams per milliliter, unit of measurement]. Give 0.25 ml sublingually [under the tongue] every 12 hours as needed for Anxiety (feeling of fear, dread, or unease you get when stressed or anticipating a problem) m/b [manifested by] increase worry and fear about her health. Further review of Resident 4's MAR, dated 3/1/2026 - 3/31/2026, indicated Resident 4 had a physician's order, dated 1/4/26, to Monitor for anxiety m/b increase worry and fear about her health every shift for Lorazepam use.During a concurrent interview and record review on 6/10/26 at 10:08 AM with Registered Nurse (RN) 1, Resident 4's MAR, dated 3/1/2026 - 3/31/2026, was reviewed. Resident 4's MAR, dated 3/1/2026 - 3/31/2026 indicated a licensed nurse administered a dose of as needed lorazepam when Resident 4 had the number 0 documented for behaviors of anxiety on the following dates and times:3/1/26 at 2100 (9:00 PM)3/2/26 at 2115 (9:15 PM)3/3/26 at 2036 (8:36 PM)3/6/26 at 2119 (9:16 PM)3/7/26 at 2105 (9:05 PM)3/8/26 at 2040 (8:40 PM)3/9/26 at 2130 (9:30 PM)3/10/26 at 2109 (9:09 PM)3/11/26 at 2130 (9:30 PM)3/12/26 at 2121 (9:21 PM)3/13/26 at 2050 (8:50 PM)3/16/26 at 2130 (9:30 PM)3/22/26 at 2051 (8:51 PM)3/23/26 at 2058 (8:58 PM)3/24/26 at 2058 (8:58 PM)3/25/26 at 2047 (8:47 PM)3/27/26 at 2118 (9:18 PM)RN 1 stated Resident 4's lorazepam was administered during the evening shift and verified Resident 4 did not exhibit episodes of anxiety behavior and the number 0 was documented on the MAR when lorazepam was administered. RN 1 stated the number 0 for behavior monitoring documented on Resident 4's MAR meant Resident 4 was not anxious during the evening shift. RN 1 verified Resident 4 received lorazepam when Resident 4 did not exhibit or verbalize feelings of anxiety.During an interview on 6/10/26 at 11:22 AM, with Licensed Vocational Nurse (LVN) 1 (LVN 1), LVN 1 stated licensed nurses documented the number of behavior episodes during each shift for all psychotropic medications. LVN 1 stated if the MAR indicated zero episodes during the shift, it meant there was no indication to give as needed lorazepam to a resident.2. A review of Resident 8's admission Record, dated 6/10/26, indicated Resident 8 was admitted to the facility on [DATE].A review of Resident 8's MAR, dated 6/1/2026 - 6/10/2026, indicated Resident 8 had a physician's order, dated 6/9/26, for Lorazepam Solution 2 mg/ml solution. Give 0.5 mg sublingually every 2 hours as needed for Anxiety m/b inability to relax with SOB.A review of Resident 8's MAR dated 6/1/2026 - 6/10/2026, indicated a licensed nurse administered four doses of as needed lorazepam on the following dates and times:6/10/26 at 0000 (12:00 AM)6/10/26 at 0400 (4:00 AM)6/10/26 at 0913 (9:13 AM)6/10/26 at 1149 (11:49 AM)Resident 8's MAR further indicated only two episodes of anxiety documented from 6/9/26 at 11:00 PM to 6/10/26 at 3:00 PM.During a concurrent interview and record review on 6/10/26 at 3:59 PM, with the DON, Resident 8's MAR, dated 6/1/2026-6/10/2026, was reviewed. The DON verified the records above indicated Resident 8 received four doses of lorazepam between 6/9/26 - 6/10/26 but only had two episodes of anxiety documented. The DON stated the lorazepam administrations and anxiety behaviors did not match and they should match. The DON stated monitoring of behaviors for psychotropic medications was supposed to be documented to account for appropriate behavior. The DON further stated behaviors were documented to follow the physician's orders. 3. A review of Resident 15's admission Record, dated 6/10/26, indicated Resident 15 was admitted to the facility on [DATE].A review of Resident 15's MAR, dated 4/1/2026 - 4/30/2026, indicated Resident 15 had a physician's order, with a start date of 4/6/26, for Lorazepam Solution 2 mg/ml. Give 0.25 ml sublingually every 2 hours as needed for Anxiety m/b 1. SOB [shortness of breath] 2. SEIZURE for 14 days. Further review of Resident 15's MAR, dated 4/1/2026 - 4/30/2026 indicated an additional physician's order dated 4/15/26, for Lorazepam Solution 2mg/ml. Give 0.25 ml sublingually every 6 hours as needed for Anxiety m/b excessive worry over health/family for 14 days.A review of Resident 15's MAR, dated 5/1/2026 - 5/31/2026, indicated Resident 15 had a physician's order, dated 4/29/26, for Lorazepam Solution 2 mg/ml. Give 0.25 ml sublingually every 6 hours as needed for anxiety m/b excessive worry over health/family.During a concurrent interview and record review on 6/10/26 at 10:50 AM with RN 1, Resident 15's MAR dated 4/1/2026 - 4/30/2026 was reviewed. Resident 15's MAR, dated 4/1/2026 - 4/30/2026 indicated a licensed nurse administered a dose of as needed lorazepam when Resident 15 had no documented behaviors of anxiety on the following dates and times:4/7/26 at 0705 (7:05 AM), 0949 (9:49 AM), 1227 (12:27 PM) and 1559 (3:59 PM)4/8/26 at 0401 (4:01 AM)4/9/26 at 0701 (7:01 AM)4/10/26 at 0915 (9:15 AM)4/26/26 at 1300 (1:00 PM)RN 1 verified Resident 15 received lorazepam on the dates and times mentioned above and stated Resident 15 was not monitored for behaviors of anxiety. RN 1 stated there was no documentation for behavior monitoring found in Resident 15's MAR dated 4/1/2026 - 4/30/2026.During a continued concurrent interview and record review on 6/10/26 at 10:50 AM with RN 1, Resident 15's MAR, dated 5/1/2026 - 5/31/2026 was reviewed. Resident 15's MAR indicated a licensed nurse administered Resident 15 one dose of as needed lorazepam on 5/3/26 at 0819 (8:19 AM) when Resident 15 had no documented behaviors of anxiety. RN 1 verified Resident 15 received lorazepam on 5/3/26 and stated Resident 15 was not monitored for behaviors of anxiety from 4/7/26 - 5/3/26. RN 1 stated nurses were supposed to monitor and document the number of anxiety behaviors on the MAR for residents receiving lorazepam on each shift.A review of the facility's policy and procedure (P&P) titled, Psychotropic Medications, dated November 2020, indicated, It is the policy of this facility not to administer psychoactive [psychotropic] medications in the absence of medical or clinical necessity. and, .check the physician orders for the medication includes the name of the medication.and behavior(s) for which the medication is being administered. The order shall also include monitoring requirements for the behavior(s).A review of the facility's P&P titled, Psychotropic Medication Monthly Review, dated November 2020, indicated, POLICY To ensure that Psychotherapeutic medications used in the skilled nursing facility are being monitored for proper use. and, The IDT [interdisciplinary team, a group of professionals who work together to share expertise, knowledge, and skills to address medical problems and create goals to improve care] and.clinician will meet.to review and discuss each resident that has a Psychotherapeutic medication order. During the meeting we will discuss the following:.Are we monitoring the right behavioral issues are they being documented correctly [sic].Any behavioral issues and number of incidents the [sic] within the past 90 days for each medication that is ordered.

Based on interview and record review, the facility failed to implement interventions according to the care plans for two of five sampled residents (Residents 1 and 16) when:1. Resident 1's oxygen saturation ([O2 sat] - a measurement of how much oxygen the blood is carrying as a percentage) was not checked every shift (the period of a scheduled time of the day a nurse/nurses work), as indicated in the care plan. This failure had the potential for Resident 1's oxygen saturation to go unnoticed even when not within normal limits.2. Resident 16 had edema (swelling from a buildup of extra fluid) on both lower legs and they were not elevated with pillows as indicated in the care plan. This failure had the potential to prevent improved blood flow in the legs that could reduce swelling from fluid buildup.Findings:1. During a review of Resident 1's admission Record, (a document showing a summary of the resident's information) dated 6/11/26, the admission Record indicated Resident 1 was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease ([COPD] - a progressive lung disease which blocks air flow making breathing difficult).During a review of Resident 1's Care Plan Report, dated 10/7/19, the Care Plan Report indicated a care plan problem for, .Focus.at risk for alteration in respiratory status/difficulty of breathing related to (r/t) COPD/Asthma. Interventions included licensed nurse will .LN (licensed nurse) check oxygen saturation every shift.During a review of the facility's Monthly Schedule 2025 (sic), revised 6/5/2020, the schedule indicated there were three shifts per day. The shifts are as follows:7-3 shift (7 AM to 3 PM [Day shift])3-11 shift (3 PM to 11 PM [Evening shift])11-7 shift (11 PM to 7 AM of the succeeding day [Night shift])During an interview on 6/10/26 at 12:39 PM with Resident 1, Resident 1 stated the nurses checked his oxygen saturation twice a day.During a review of Resident 16's Weights and Vitals Summary for June 2026, the summary indicated that O2 sats were taken twice a day from 6/1/2026 to 6/9/2026.During a concurrent interview and record review on 6/10/26 at 3:00 PM with the DON, Resident 1's medical record was reviewed. The DON verified the oxygen saturation was not checked every shift as indicated in the plan of care.During a review of the facility's policy and procedure (P&P) titled, Care Plan Implementation, revised 2024, the P&P indicated, .Policy: [NAME] Health of the Sick shall ensure that each resident's individualized care plan is implemented by nursing staff and other appropriate personnel to meet the resident's identified needs, preferences, goals, and physician orders. Care provided shall be consistent with the resident's current plan of care and updated as needed.2. Nursing staff shall implement care plan interventions as written and provide care consistent with the resident's assessed needs, physician orders, and established goals.2. During an observation on 6/9/26 at 8:19 AM in Resident 16's room, Resident 16 was observed lying on her back in bed. Resident 16 was noted with edema on both lower legs, with both legs at the same level of Resident 16's waist.During a review of Residents 16's admission Record, dated 6/10/26, the admission Record indicated Resident 16 was admitted on [DATE].During a review of Resident 16's Telephone Physician's Order, dated 5/29/26, Resident 16 had an order for Bumetanide (a medication to treat fluid retention and swelling) Tablet 1 milligram (a unit of measurement) by mouth one time a day for BLE (bilateral lower extremity) edema.During a review of Resident 16's Care Plan Report, revised 5/19/26, the Care Plan Report indicated a care plan problem for, Chronic pitting edema (a type of swelling where pressing on a swollen body part leaves behind a dent or pit that takes time to refill) on RLE (right lower extremity) extended to foot. Interventions included to .elevate the extremities involved with pillow as needed. Further review of Resident 16's Care Plan Report indicated the same intervention for the chronic pitting edema on LLE (left lower extremity).During a concurrent observation, interview, and record review on 6/9/26 at 4:18 PM with Licensed Vocational Nurse 2 (LVN 2) inside Resident 16's room, Resident 16 was seen lying on her back in bed, with both legs not elevated with pillows. LVN 2 reviewed the active care plan for Resident 16, and then stated Resident 16's legs should be elevated with pillows to reduce the swelling from edema.During a review of the facility's policy and procedure (P&P) titled, Care Plan Implementation, revised 2024, the P&P indicated, .Policy: [NAME] Health of the Sick shall ensure that each resident's individualized care plan is implemented by nursing staff and other appropriate personnel to meet the resident's identified needs, preferences, goals, and physician orders. Care provided shall be consistent with the resident's current plan of care and updated as needed.2. Nursing staff shall implement care plan interventions as written and provide care consistent with the resident's assessed needs, physician orders, and established goals.

Based on interview and record review, the facility failed to ensure an accurate assessment for one of four sampled residents (Resident 16) was completed when the Minimum Data Set ([MDS] - a federally mandated standardized assessment tool) assessment did not reflect the same hearing assessment conducted by the physician.This had the potential for unmet hearing services and appropriate interventions that may be necessary for Resident 16's care.Findings:During a concurrent observation and interview on 6/8/26 at 12:24 AM with Resident 16 at the facility dining area, Resident 16 was having difficulty hearing questions for an interview. Some questions had to be repeated several times before Resident 16 responded with an answer.During a review of Residents 16's admission Record, (a document showing a summary of the resident's information) dated 6/10/26, the admission Record indicated Resident 16 was admitted on [DATE].During a concurrent interview and record review on 6/9/26 at 4:40 PM with the MDS Coordinator (MDSC), Resident 16's History and Physical, ([H&P] - a formal medical document and evaluation process containing the physician's clinical assessment and plan for a patient), dated 5/8/25 was reviewed. The H&P indicated, .Physical Examination.8b. Ears: Hearing mildly impaired. The MDSC stated the H&P is one of the clinical documents reviewed when assessing residents.During the same concurrent interview and record review on 6/9/26 at 4:40 PM with the MDSC, the MDSC stated one of the periodic assessments of residents were done quarterly (every 3 months). A review Resident 16's MDS, 'Section B - Hearing, Speech, and Vision,' dated 6/10/25, indicated Resident 16 was assessed as .highly impaired- absence of useful hearing. Resident 16's MDS 'Section B - Hearing, Speech, and Vision,' dated 9/9/25, 12/9/25, and 3/10/26 also indicated Resident 16 was assessed as .highly impaired- absence of useful hearing. The MDSC stated there was inconsistency between the H&P and the MDS assessment, further stating that assessments should accurately reflect Resident 16's status.During a review of the facility's policy and procedure (P&P) titled, Resident Assessment, revised November 2024, the P&P indicated, .Purpose: To ensure resident assessments are completed accurately, timely, and consistently to identify resident needs and support appropriate care planning and interventions.3. Assessment findings shall be based on direct observation, resident interview when possible, medical record review, family input, consultant reports, and other relevant clinical information.

Based on observation, interview, and facility document and policy review, the facility failed to ensure foods were stored in accordance with professional standards for food safety. Specifically, the facility failed to ensure warm milk placed into the refrigerator to cool was loosely covered to facilitate heat transfer; failed to ensure food items, including frozen carrots and frozen fish, were stored in closed containers and protected from exposure to the air; and failed to ensure a utensil storage rack was free of an accumulation of dust and debris. These failures had the potential to affect all residents receiving meals from the dietary department. Findings included: 1. A facility policy titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, indicated, Cooked Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) food shall be cooled and reheated in a method to ensure food safety. The policy specified, When PHF or TCS food will not be served right away, it must be cooled as quickly as possible and Food should be loosely covered, or uncovered if protected from overhead contamination, during the cooling period to facilitate heat transfer from the surface of the food. An observation of the walk-in cooler on 02/24/2025 at 9:37 AM revealed a pan of warm milk stored with plastic wrap that tightly covered the pan. During an interview on 02/24/2025 at 9:37 AM, [NAME] #1 stated that she placed the pan of warm milk in the walk-in refrigerator to cool on the morning of 02/24/2025. [NAME] #1 stated that she knew to leave the plastic open a little bit so that the milk could cool, but she forgot and covered the milk so that the milk would not spill. During an interview on 02/24/2025 at 9:39 AM, the Director of Food and Nutrition Services (DFNS) stated that dietary staff were trained to store warm foods so that they were vented; otherwise, the food item may not cool to appropriate temperatures quickly enough. During an interview on 02/26/2025 at 10:57 AM, the Director of Nursing (DON) stated she expected dietary staff to follow the policy on cooling foods to prevent the potential for resident illness. 2. A facility policy titled, Procedure for Freezer Storage, dated 2023, indicated, 5. Store foods in an air-tight, moisture resistant wrapper such as a plastic bag or freezer wrapper to prevent freezer burn. A concurrent interview and observation of the walk-in freezer on 02/24/2025 at 9:49 AM revealed one 20-pound box of crinkle cut carrot coins and one 10-pound box of pressed Alaskan [NAME] fish fillets were stored in open boxes with the contents exposed to air. The Director of Food and Nutrition Services (DFNS) stated that he expected dietary staff to store frozen foods in tightly sealed containers. During an interview on 02/26/2025 at 10:57 AM, the Director of Nursing (DON) stated that foods stored in the walk-in freezer should be stored per the facility policy in a closed container. 3. A facility policy titled, Shelves, Counters, and other Surfaces Including Sinks (handwashing, food preparation, etc. [et cetera, other similar things]), dated 2023, specified, 1. Remove any large debris with warm detergent solution following manufacturer's instructions and 2. Rinse with clear water using a clean sponge or cloth. Wipe dry with a clean cloth. A facility document titled, Daily/Weekly Cleaning Schedule, for the week of 02/24/2025 through 03/02/2025, revealed a list of cleaning tasks for staff to initial as the tasks were completed; however, the log did not include a cleaning task that specified to clean utensil storage racks. An observation on 02/25/2025 at 12:10 PM of the lunch meal tray line in progress revealed a utensil storage rack, which was adjacent to the tray line, stored multiple serving utensils. The storage rack was observed with an accumulation of dust and debris. During an interview on 02/25/2025 at 1:14 PM, the Director of Food and Nutrition Services (DFNS) stated that dietary staff followed the cleaning schedule that included daily and weekly tasks. After reviewing the cleaning schedule, the DFNS stated, We don't [do not] have the utensil racks on the schedule; I will have to add that. The DFNS then observed the utensil storage racks and stated he saw streaks and specks of debris and dust. The DFNS stated the utensil storage rack should have been cleaned better.

Based on interview and record review, the facility failed to have measures in place to prevent the growth of Legionella (a bacteria that can be found in water systems such as air conditioners, showers, sinks, and water fountains) and other opportunistic waterborne (a disease or infection that people can catch from infected water) pathogens in building water systems. This failure resulted in the facility not having a water management program which potentially exposed the residents of the facility to Legionella and other harmful waterborne pathogens. Findings: During an interview and concurrent record review with the Administrator on February 7, 2023, at 3:08 p.m., the Facility Assessment did not address a water management program. The Administrator stated they did not conduct water testing to ensure Legionella and other harmful waterborne pathogens were not present in the facility's water system. The Administrator further stated the facility did not have a water management program in place to prevent the development and transmission of Legionnaires' disease (a severe, often lethal, form of pneumonia [lung inflammation caused by bacterial, in which the lung air sacs fill with pus], caused by the bacterium Legionella pneumophila found in both potable and non-potable water systems [showers, sinks and water fountains]) and other opportunistic waterborne pathogens. The Centers for Disease Control and Prevention (CDC) guideline, titled, Legionella - Water Management in Healthcare Facilities, last reviewed on March 25, 2021, indicated, CDC encourages healthcare facilities included in the scope of ASHRAE [American Society of Heating and Air-Conditioning Engineers] Standard 188 (Section 5.2) to develop and implement comprehensive water management programs. Water management programs can help reduce the risk for Legionella growth and transmission. A comprehensive water management program can have additional benefits in the control of other water-related healthcare-associated infections. Water management programs should therefore be monitored for their efficacy in reducing risk for a variety of pathogens.

Based on interview and record review, the facility failed to create a facility assessment specific to the needs of the facility's population and location as part of the required facility assessment, when the facility assessment did not include the required water management program. This deficient practice failed to establish an individualized facility assessment to meet the requirement for a water management program which had the potential to place the residents at risk for outbreak of an opportunistic waterborne (a disease or infection that people can catch from infected water) pathogen causing disease. Findings: During an interview and concurrent record review of the Facility Assessment with the Administrator on February 7, 2023, at 3:08 PM, the Facility Assessment did address a water management program. The Administrator stated the facility did not have a water management program in place to prevent the development and transmission of Legionnaires' disease (a severe, often lethal, form of pneumonia [lung inflammation caused by bacterial, in which the lung air sacs fill with pus], caused by the bacterium Legionella pneumophila (a bacteria that can be found in water systems such as air conditioners, showers, sinks, and water fountains) found in both potable and non-potable water systems [showers, sinks and water fountains]) and other opportunistic waterborne pathogens. The Administrator verified the facility's assessment failed to show a water management program and assessment was conducted for the facility. The Centers for Disease Control and Prevention (CDC) guideline, titled, Legionella - Water Management in Healthcare Facilities, last reviewed on March 25, 2021, indicated, CDC encourages healthcare facilities included in the scope of ASHRAE [American Society of Heating and Air-Conditioning Engineers] Standard 188 (Section 5.2) to develop and implement comprehensive water management programs. Water management programs can help reduce the risk for Legionella growth and transmission. A comprehensive water management program can have additional benefits in the control of other water-related healthcare-associated infections. Water management programs should therefore be monitored for their efficacy in reducing risk for a variety of pathogens.

Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen and store food in accordance with professional standards for food service safety when: 1. There were several black residue build-up on the floor in the dishwashing area. 2. Food items in the dry storage room had no received date labels and were beyond the best if used by date. 3. Food items in the dry storage room had no received date labels. These failures had the potential to contaminate residents' food and cause foodborne (illness caused by food contaminated with bacteria and viruses) illnesses to a population of 45 medically compromised residents who received food from the kitchen. Findings: 1. During an initial kitchen tour observation on February 6, 2023, at 8:51 AM, in the dish washing area, there were several black residue build-up on the floor under the dishwashing machine. During an observation of the dishwashing area and concurrent interview on February 6, 2023, at 10:03 AM, with the Director of Food and Nutrition Services (DFNS), the DFNS acknowledged the finding and stated the dishwashing area floor should be clean. The DFNS stated the specific area noted with the black residue build-up should be cleaned daily by the evening staff. The DFNS further stated the black residues should not be present. During an interview with the Registered Dietitian (RD) on February 9, 2023, at 10:23 AM, the RD stated the expectations on kitchen cleanliness and sanitation was high. The RD further stated it was expected from the staff to clean their respective areas and mop the floor daily. The facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2018, indicated, Subject: Sanitation and Infection Control. Policy: Sanitation and infection control measures will be followed to ensure resident/patients and staff receives safe food and water. Standards will meet requirements of federal, state and local regulations. Employees must follow specific procedures in all areas listed below to ensure the department operates under sanitary conditions on a daily basis. Areas: .12. Cleaning schedules .14. Dishwashing Procedures (Dish machine) . The facility's P&P titled, Sanitation and Infection Control, dated 2018, indicated, Subject: Pest Control. Policy: .Pest control is designed to maintain a sanitary environment, which prevents contamination, transmission or spread of disease, by insects or rodents. Procedures: 1. The kitchen will be kept clean . During a review of the Food and Drug Administration (FDA) Federal Food Code, dated 2022, indicated ,d+[DATE].13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . The FDA Federal Food Code further indicated, ,d+[DATE].16 Nonfood-Contact Surfaces. Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. The FDA Federal Food Code, dated 2022, further indicated, ,d+[DATE].12 Cleaning, Frequency and Restrictions. (A) Physical Facilities shall be cleaned as often as necessary to keep them clean. 2. During an initial kitchen tour observation and concurrent interview on February 6, 2023, at 9:31 AM, in the dry storage room, with the DFNS, the DFNS confirmed the findings below. The DFNS stated food items had to be labeled with received date and removed from the dry storage room after the best if used by date. One open box of rice hot cereal with no received date label and an open date labeled [DATE] with a best if used by date of [DATE]. (10 months past the best if used by date). Two boxes of unopened rice hot cereal with no received date label and a best if used by date of [DATE] (10 months past the best if used by date). A bottle of unopened Italian Dressing with no received date label and a best if used by date of [DATE] (8 days past the best if used by date). During a subsequent interview on February 6, 2023, at 9:46 AM, in the dry storage room, with the DFNS, the DFNS stated all kitchen staff were responsible for checking the dates and labels on the food items. The DFNS stated he had oversight and was responsible for this process. DFNS further acknowledged the findings and stated the food items were missed to be removed. During an interview on February 9, 2023, at 10:23 AM, with the RD, the RD stated the best practice was to label food items with received date and to follow the first in first out policy. The RD stated the dry storage room was checked on [DATE], but she missed the opened box of rice hot cereal, the two boxes of unopened rice hot cereal, and the bottle of unopened Italian Dressing. The RD further stated the standard of practice was to throw away food items beyond the best if used by date for food safety. During an interview on February 10, 2023, at 10:20 AM with the Kitchen Cook (KC), the KC stated food items in the dry storage area should be labeled with a received date. The KC also stated food items beyond the best if used by date should be tossed away and never used. During an interview and record review of the Dry Storage Chart on February 10, 2023, at 10:23 AM, in the kitchen, with the RD, the RD stated the rice hot cereals fell under the cooked (before preparation) cereals category with recommended storage time of six months both for opened and unopened product. The facility's P&P titled, Food Purchasing, Receiving, and Production, dated 2018, indicated, Subject: Receiving Food. Policy: Food will be received and inspected to ensure orders are correct and food is safe. Any food items not meeting standards will be rejected and sent back to the supplier. Procedures: .6. Expiration dates will be checked on pre-dated packages to ensure food/beverages are not expired. Items not pre-dated will be labeled with the date received to ensure First In First Out . The FDA Federal Food Code, dated 2022, indicated Annex 3. Public Health Reasons/Administrative Guidelines. Manufacturer's use-by dates .the manufacturer's use-by date is its recommendation for using the product while its quality is at its best. Although it is a guide for quality, it could be based on food safety reasons .If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind. 3. During an initial kitchen tour observation and concurrent interview on February 6, 2023, at 9:43 AM, in the dry storage room, with the DFNS, the DFNS confirmed the findings below and stated these food items should have been labeled with received dates. Five boxes of Instant Mashed Potatoes had no received date label A cannister of Pure white sugar had no received date label During a subsequent interview on February 6, 2023, at 9:45 AM, in the dry storage area, with DFNS, the DFNS stated the invoice indicated the food items were received on [DATE] and should have been labeled upon receipt. During an interview on February 9, 2023, at 10:23 AM, with the RD, the RD stated the best practice was to label food items with received date to follow the first in first out policy. The facility's P&P titled, Food Purchasing, Receiving, and Production, dated 2018, indicated, Subject: Receiving Food. Policy: Food will be received and inspected to ensure orders are correct and food is safe. Any food items not meeting standards will be rejected and sent back to the supplier. PROCEDURES: .6. Expiration dates will be checked on pre-dated packages to ensure food/beverages are not expired. Items not pre-dated will be labeled with the date received to ensure First In First Out .

Based on observation, interview, and record review, the facility failed to ensure care plan was updated and revised for one of 15 residents (Resident 37) reviewed for care plans when Resident 37's care plan for self-care deficit was not revised in a timely manner. This failure did not reflect Resident 37's current care status which had the potential to result in inconsistent care coordination and unmet care needs for Resident 37. Findings: During an observation with Resident 37, on February 6, 2023, at 11:20 AM, inside the room, Resident 37 was lying in bed, with a splint (an appliance used for supporting and protecting tissues) on the right arm and holding a rolled towel on the left hand. Resident 37 was awake, non-verbal, calm, and did not appear to be in any acute distress. A review of Resident 37's clinical record, the Admission Record (contains demographic and medical information) indicated Resident 37 was admitted to the facility on [DATE], with diagnoses that included hemiplegia/hemiparesis (brain injury resulting in varying degree of weakness on one side of the body) following cerebral infarction (damage to the brain from interruption of its blood supply) affecting right dominant side, contracture (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and hardening of joints) of the right elbow and hand, and aphasia (language disorder that affects a person's ability to communicate). During an interview and concurrent record review of Resident 37's clinical record with Registered Nurse 1 (RN 1) on February 8, 2023, at 1:38 PM, RN 1 verified that an order dated March 22, 2022 was made for Restorative Nursing Assistant (RNA) to perform bilateral (both) upper extremity (BUE) Passive Range of Motion (PROM) 5 x week and then put on right elbow splint and right resting hand splint for 6-7 hrs. or as tolerated in order to maintain her Range of Motion (ROM) for prevention of worsening contractures. RN 1 also stated the nurse who received this order should have updated the care plan to reflect this intervention when the order was made. RN 1 further stated Minimum Data Set (MDS - resident assessment tool) nurse was expected to review and revise the care plan after every quarterly or annual assessments. During an interview and concurrent record review with the MDS Coordinator on February 8, 2023, at 1:56 PM, the MDS Coordinator stated care plans should reflect resident's problems, goals, and interventions. The MDS Coordinator also stated the care plan must be accurate, complete, updated and revised as needed. The MDS Coordinator reviewed Resident 37's Self-care Deficit (ADL - activities of daily living) care plan and stated the RNA for bilateral upper extremity Passive Range of Motion (PROM) and splinting was missed during the past quarterly reviews, and the care plan should have been revised and updated. The MDS Coordinator further added updating the care plan was important for everyone to be aware of the resident's plan of care. During an interview and concurrent record review with the Director of Nursing (DON) on February 9, 2023, at 2:15 PM, the DON stated care plans should be revised or updated whenever there was a change of condition, services, and new orders or interventions were made. The DON also stated nurses were expected to update the care plan when they get an order and for MDS to oversee, review and revise care plans. DON acknowledged the RNA for bilateral upper extremity PROM and splinting was not reflected in the care plan. The facility's policy and procedure, titled, Comprehensive Care Plan, revised 2013, indicated, Policy: A comprehensive care plan shall be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs. Procedure: 2. The comprehensive care plan has been designated to: a. Incorporate identified problem areas .d. Reflect treatment goals and objectives in measurable outcomes. e. Identified the professional services that are responsible for each element of care. g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program .4. Care plans are revised as changes in the resident's condition dictate. Reviews are made at least quarterly.

Based on observation, interview, and record review, the facility failed to discard two expired over the counter medications in two out of two sampled medication carts. This deficient practice had the potential for loss of strength of the medication and for the residents to receive ineffective medication. Findings: 1. During an observation and concurrent interview with Licensed Vocational Nurse 1 (LVN 1), on February 8, 2023, at 10:31 AM, in Station 2 Medication Cart A, one bottle of Activated Charcoal (indicated for preliminary elimination of the toxin in moderate to severe cases of poisoning) 780 mg (milligram - unit of measure that equals to one of a thousandth gram) was found for Resident 4 with an expiration date of 01/2023. LVN 1 verified the medication was expired and stated expired medications should be discarded to prevent from giving it to the resident. During an interview with the Director of Nursing (DON), on February 8, 2023, at 11:27 AM, the DON stated that any expired medications should be discarded and not given to residents. During a review of Resident 4's Admission Record (contains demographic and medical information) indicated that Resident 4 was admitted to the facility on [DATE], with diagnoses which included Unspecified Atrial Fibrillation (condition of an irregular and often very rapid heart rate that can lead to blood clots in the heart) and Chronic Combined Congestive Heart Failure [condition when heart ventricles (part of the heart that receives blood and pump it to the rest of the body) cannot produce enough pressure to push blood into circulation and cannot relax, expand, or fill with enough blood]. 2. During an observation and concurrent interview with LVN 2, on February 8, 2023, at 1:31 PM, in Station 1 Medication Cart A, one bottle of Magnesium SRT Supplement (commonly used for low magnesium [a nutrient that the body needs in regulating muscle, nerve function, blood sugar levels, and blood pressure] levels and for a certain type of irregular heartbeat) was found for Resident 26 with an expiration date of 01/2023. LVN 2 verified the medication was expired and stated expired medications should be disposed and not stored in the medication cart. During a telephone interview with the Pharmacy Consultant (Ph-C), on February 9, 2023, at 9:01 AM, the Ph-C stated nurses should check the expiration date of medications and remove expired medications from the medication cart and prevent from giving to residents. During a review of Resident 26's Admission Record, indicated that Resident 26 was admitted to the facility on [DATE], with diagnoses which included Chronic Combined Congestive Heart Failure (a condition in which the heart does not pump blood as it should) and Hypertensive Heart Disease with Heart Failure (a condition when heart is not pumping enough blood due to high blood pressure). The facility policy and procedure titled, Medication Administration, dated November 2020, indicated, Policy. To administer medications in a safe and effective manner. Procedure .5. Check expiration date on package/container .

Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 347) was free from significant medication error when Resident 347's controlled medication (medication used and distributed with control because of the potential for abuse) was not administered according to physician's order. This deficient practice had the potential for Resident 347 not to receive the scheduled medication which could lead to the resident's decline in health, hospitalization , or death. Findings: During medication administration observation with Licensed Vocational Nurse 2 (LVN 2), on February 8, 2023, at 7:56 AM, in Station 1 hallway, LVN 2 was observed preparing medications, and administered all prepared medications to Resident 347. During an interview and concurrent record review with LVN 2, on February 8, 2023, at 8:17 AM, the Electronic Medication Administration Record for Resident 347 indicated an order of Lacosamide (medication used to treat seizures [uncontrolled body movements and changes in behavior that occur because of abnormal activity in the brain]) 100 mg (milligram - a unit of measure that equals to one thousandth of a gram) every 12 hours for Todd's Paralysis (a condition experienced by individuals with seizures in which is followed by a brief period of temporary paralysis [loss of ability to move some or all of your body]). The Lacosamide was omitted and was not observed to be given to Resident 347. LVN 2 stated the Lacosamide medication was given along with other medications to Resident 347. During an observation and concurrent interview with LVN 2, on February 8, 2023, at 8:22 AM, in Station 1 hallway, LVN 2 was observed checking all the medication bubble packs (a type of packet containing sealed compartments for medicines to be taken at particular time of the day) in Medication Cart A for Resident 347. The Lacosamide medication bubble pack was missing. LVN 2 stated she would check the medication room first. LVN 2 came back from the medication room and stated, The medication is in controlled meds [medication] drawer. LVN 2 was observed searching for the Lacosamide medication bubble pack in one of a locked drawer in medication cart. When LVN 2 found the Lacosamide medication bubble pack, LVN 2 stated, Sorry, I forgot to give this medication. It happens when you're gone for a month and just came back. LVN 2 further stated, It's important to check all the orders and give all medications to resident so you don't under drug them. During an interview with the Director of Nursing (DON), on February 8, 2023, at 9:32 AM, the DON stated, All medications should be given as ordered. During a review of Resident 347's Admission Record (contains demographic and medical information), indicated that Resident 347 was admitted to the facility on [DATE], with diagnoses which included Cerebral Infarction (occurs as a result of lack of adequate blood supply to brain cells depriving oxygen and vital nutrient which cause parts of the brain to die off), Hemiplegia and Hemiparesis (paralysis of one side of the body), and Todd's Paralysis. During a review of Resident 347's Order Summary Report (document with list of physician's orders), order date February 3, 2023, indicated, Lacosamide Oral Tablet 100 mg (Lacosamide) Give 1 tablet by mouth two times a day related to Todd's Paralysis . During a review of facility policy and procedure titled, Medication Pass Tips, effective date August 2014, indicated, .32. Remember the Ten (10) Rights of Medication Pass: 1. Right Resident 2. Right Drug 3. Right Dose 4. Right Form 5. Right Route 6. Right Time .

Based on observation, interview, and record review, the facility failed to ensure accurate accounting of two controlled substances (medications which are used and distributed with control because of the potential for abuse) for two residents (Residents 2 and 37) in one of two sampled medication carts (Station 1 Medication Cart A). This deficient practice had the potential for loss of accountability and increased the risk that medications may not be available for Residents 2 and 37, when needed, and increased the facility's risk for potential loss, diversion (transfer of a medication from legal to an illegal use), or accidental exposure to controlled substances. Findings: During an observation of Station 1 Medication Cart A, with Licensed Vocational Nurse 2 (LVN 2), on February 8, 2023, at 1:31 PM, the following discrepancies were found between the Controlled Drug Record (a log signed by the nurse with date, time, and amount of medication each time a controlled substance is given to a resident) and the medication container: 1. Resident 2's Controlled Drug Record for Morphine Sulfate (a drug used to treat moderate to severe pain) 100 mg (milligram - a unit of measurement that equals to a thousandth of a gram) / (per) 5 ml (milliliter - a unit of measurement that equals to a thousandth of a liter) indicated there were 18.75 ml left. However, the medication container measurement indicated it was above the line of 20 ml. 2. Resident 37's Controlled Drug Record for Morphine Sulfate 100mg/5mL indicated there were 4.5 ml left. However, the medication container measurement indicated it was above the line of 8 ml. During an interview with LVN 2, on February 8, 2023, at 1:31 PM, LVN 2 verified there were discrepancies between the Controlled Drug Record and amount of medications left in the container as it appears based on the line measurement. LVN 2 further stated, You can under drug or overdose the resident if not properly documenting the right amount. Probably somebody gave the incorrect dose. LVN 2 added, During narcotic drug reconciliation [the process of counting the physical controlled substances and document what is left], we should accurately document what's the actual amount of medications left in the bottle. I did not notice the discrepancy this morning when we checked. The error happened when you did not come to work for a month. During an observation and concurrent record review with Registered Nurse 1 (RN 1), on February 9, 2023, at 8:19 AM, in Station 1 office room across the nurse station, RN 1 presented the following documents: 1. Resident 2's Controlled Drug Record for Morphine Sulfate 100mg/5ml indicated there were 18.75 ml left. However, the medication container measurement indicated it was above the line of 20 ml. RN 1 verified the discrepancy. 2. Resident 37's Controlled Drug Record for Morphine Sulfate 100mg/5ml indicated there were 2.5 ml left. However, the medication container measurement indicated it was above the line of 4 ml. RN 1 verified the discrepancy. During a telephone interview with the Pharmacy Consultant (Ph-C), on February 9, 2023, at 9:01 AM, the Ph-C stated nurses were counting the narcotics every shift. The Ph-C further stated, I don't think there will be variance of 4 or 5 ml in the bottle once they receive medication from the pharmacy, maybe about 2 ml but not 4 to 5 ml. The Ph-C added, If there's a discrepancy in the amount of medication in the container and amount in the count sheet, I will ask the DON to investigate and find out what happened because it should match. The expectation is in the facility policy. During an observation, interview, and concurrent record review with the DON, RN 2, and LVN 2, on February 9, 2023, at 9:56 AM, in Station 1 Medication Room, LVN 2 measured Resident 37's Morphine Sulfate 100mg/5ml, using a tuberculin syringe (a syringe that can hold up to 1 ml of liquid). Controlled Drug Record indicated there were 1.5 ml left, however, the medication container measurement indicated it was 4 ml. LVN 2 was observed aspirating the medication from the container and then tapping the syringe to remove air bubbles. LVN 2 measured 2.5 ml of medication from the container. RN 2 measured it again by using same tuberculin syringe. RN 2 was observed aspirating medication from the container and then tapped the syringe with spillage to remove air bubbles. RN 2 measured 2.75 ml of medication from the container. The DON and RN 2 verified there was a discrepancy between the actual amount of medication in the container and what was documented in the Controlled Drug record. The DON stated there was a discrepancy. During an interview with the Administrator, on February 9, 2023, at 2:10 PM, the Administrator stated they would talk to their pharmacy and order for an alternative form of Morphine Sulfate to avoid issues with accountability. The Administrator added, That's a good catch, at least now we know there's a problem with the measurement that is not exact. We will call the pharmacy maybe we can request for a pre-filled syringe so it's accurate, and we make sure we're giving the right dose to our residents. During an interview with the DON, on February 10, 2023, at 9:33 AM, the DON stated, It's always not exact when we receive that medication from the pharmacy. The measurement in the bottle is not accurate. The DON further stated, It's always above the line but I never receive any report from the nurses that there was a discrepancy. During an interview with LVN 1, on February 10, 2023, at 9:59 AM, in Station 2 hallway, LVN 1 stated, I never had an experience to see like there was 4 or 5 ml over in the Morphine bottle. LVN 1 further stated, If ever it happens to me that there's a big discrepancy like 2 to 3 ml, I will report it to the DON. During an interview with the Administrator, on February 10, 2023, at 10:12 AM, the Administrator stated, They just go with the flow in signing the sheet. We need to do something that it should match. Our system has to be right. The Administrator added, We need to follow our policy that any discrepancies should be reported and investigated to fix the problem right away. I don't have any reports form the DON that there was an investigation in the past regarding discrepancies. During a review of Resident 2's The Administrator Record (contains demographic and medical information) indicated that Resident 2 was admitted to the facility, on March 4, 2020, with diagnoses which included Chronic Kidney Disease (a condition in which the kidneys are damaged and cannot filter blood as they should), Bilateral Primary Osteoarthritis of Hip (a condition of wear and tear of bone related to aging on both hips), and Other Chronic Pain (pain that carries on for a long time despite medication or treatment). During a review of Resident 2's Order Summary Report (document with list of physician's orders), order date February 10, 2022, indicated, Morphine Sulfate (Concentrate) Solution 20mg/ml Give 0.25 ml sublingually [applied under the tongue] every 2 hours as needed for moderate pain scale 4-6/10 (four to six out of ten) to severe pain scale 7-10/10 (seven to ten out of ten) (0.25ml=5mg) *Hold if respiratory rate is below 8 per minute. During a review of Resident 37's The Administrator Record, indicated that Resident 37 was admitted to the facility, on February 24, 2022, with diagnoses which included Pressure Induced Deep Tissue Damage of Head (a serious form of pressure ulcer [damage to an area of the skin caused by constant pressure on the area for a long time] that causes an inadequate supply of blood) and Encounter for Palliative Care ( specialized medical care for people living with serious illness). During a review of Resident 37's Order Summary Report, order date March 3, 2022, indicated the following: - Morphine Sulfate (Concentrate) Solution 20mg/ml Give 0.25 ml sublingually every 2 hours as needed for End of life care (0.25ml=5mg) for break thru pain hold for sedation. - Morphine Sulfate (Concentrate) Solution 20mg/ml Give 0.5 ml sublingually every 4 hours for End of life 0.5ml=10mg) hold for sedation. - Morphine Sulfate (Concentrate) Solution 20mg/ml Give 1 ml sublingually every day shift for End of life care 1ml=20mg 30 minutes before wound care. The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised 10/21/2022, indicated, F755 .D. Controlled Medications .The general standard of practice for documenting usage of liquid controlled medications is to record the starting volume from the label, record each dose administered, subtract the dose administered from the previously recorded volume, and record the remaining amount. Any observed discrepancy between the recorded amount and what appears to be remaining in the container should be reported according to facility policy. The facility's policy and procedure titled, Medication Storage in the Facility, effective date August 2014, indicated, Policy .E. Any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator.

Based on observation, interview, and record review, the facility failed to flush the gastrostomy tube (g-tube - a tube inserted through the wall of the abdomen directly into the stomach that can be used to give food and medication to a person) before medication administration for one of one resident (Resident 21) with g-tube during medication administration observation. This deficient practice resulted in a clogged g-tube for Resident 21 during medication administration, and had the potential to delay and compromise Resident 21's nutritional needs. Findings: During an observation and concurrent interview with Licensed Vocation Nurse 1 (LVN 1), on February 8, 2023, at 8:28 AM, in the room, LVN 1 was observed administering medications for Resident 21 through g-tube by gravity. LVN 1 did not flush the g-tube with water before administering the medications. Resident 21's medications were not flowing down, and the g-tube was observed to be clogged while LVN 1 was giving the medications. LVN 1 stated Resident 21 did not have an order to flush the g-tube with water before medication administration. During an interview and concurrent record review with LVN 1, on February 8, 2023, at 8:44 AM, the Electronic Medication Administration Record indicated Resident 21 had an order to flush the g-tube with 15 ml (milliliter - a unit of measure that equals to one thousandth of a liter) of water before medication administration. LVN 1 verified the order, and stated the flushing of the g-tube was missed before medication administration. LVN 1 further stated, It is important to flush the g-tube before giving medications to avoid the clog. During an interview with the Director of Nursing (DON), on February 8, 2023, at 9:32 AM, the DON stated, When giving the medications via g-tube, I will check the order if needs flushing before administration. The DON further stated, It is important to flush the g-tube before giving the meds [medications] to facilitate the flow of medications and to avoid clog. During a review of Resident 21's Admission Record (contains demographic and medical information), indicated that Resident 21 was admitted to the facility on [DATE], with diagnoses which included Unspecified Dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), Chronic Kidney Disease (a condition in which the kidneys are damaged and cannot filter blood as they should), and Encounter for Attention to Gastrostomy (a surgical opening through the skin of the abdomen to the stomach). During a review of Resident 21's Order Summary Report (a document with list of physician's orders), order date November 30, 2022, indicated, Enteral Feed (a way of delivering nutrition directly to the stomach) Order every shift Flush GT (Gastrostomy Tube) with 15 ml of water before and after medication administration. The facility's policy and procedure titled, Specific Medication Administration Procedures, effective date October 2017, indicated, IIB13: Enteral Tube Medication Administration .G. Flush the tube with at least 15 ml of water prior to medication administration.

Based on record review and interview, the facility failed to ensure four of 13 sampled residents (Resident 42, 8, 36, and 151) received non-pharmacological interventions (NPI) as ordered by the physician. This failure has the potential for the residents to receive unnecessary pain medication and mismanaged pain. Findings: Review of Potter and Perry, 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician order [REDACTED]. 1. Review of the clinical record for Resident 42 on 10/9/19, indicated an admission date of [DATE] with the [DIAGNOSES REDACTED]. Resident 42 was on multiple pain medications as ordered by the physician including [MEDICATION NAME] (controlled medication) 7.5/325 mg 0.5 tablet by mouth in the morning related to unspecified [MEDICAL CONDITION], [MEDICATION NAME] 7.5/325 mg 1 tablet by mouth two times a day,[MEDICATION NAME]-[MEDICATION NAME] (controlled medication)7.5/325 mg 1 tablet by mouth every 8 hours for [MEDICAL CONDITION] pain,Tylenol 325 mg 2 tablet PO every 8 hours as needed for mild pain, and [MEDICATION NAME] 100 mg by mouth at bedtime related to [MEDICAL CONDITION]. On 9/7/19 another physician order [REDACTED].=Repositioning, 2= Dim light, 3= Cold Applications, 4=Relaxing techniques, 5=Distraction, 6=Music, 7=Quiet Environment. Review of Resident 42's Medication Administration Record (MAR) dated (MONTH) to (MONTH) 2019 indicated the NPIs done prior to pain medication administered were not consistently marked as implemented. During an interview on 10/09/19 at 11:14 a.m., the director of nursing (DON) confirmed the non-pharmacological intervention order was not followed as indicated in the physician's orders [REDACTED].> 2. Review of the clinical record for Resident 8 indicated [DIAGNOSES REDACTED]. The physician order [REDACTED]. give two tablets by mouth every 4 hours of mild pain ordered on [DATE] ,[MEDICATION NAME] 50 mg. by mouth every 4 hours as needed for moderate to severe pain ordered on [DATE], and NPIsprior to pain medication administration: 1= repositioning, 2= dim light, 3= cold applications, 4= relaxing techniques, 5= distraction, 6= music, 7= quiet environment, every shift ordered on [DATE]. Review of Resident 8's MAR dated 10/1/19 to 10/31/19 indicated positioning was implemented on 10/1/19 and 10/3/19 in the day shift. No other NPIs were implemented. For the afternoon and night shift no NPIs were implemented from 10/19 to 10/9/19. Review of the clinical record for Resident 36 indicated [DIAGNOSES REDACTED]. The physician order [REDACTED]. two tablets by mouth every four hours as needed for generalized pain ordered on [DATE] and NPIs prior to pain medication administration: 1= repositioning, 2= dim light, 3= cold applications, 4= relaxing techniques, 5= distraction, 6= music, 7= quiet environment, every shift ordered on [DATE]. Review of Resident 36 MAR dated 10/1/19 to 10/31/19 indicated no NPI interventions was done from 10/4/19 to 10/9/19 for the day shift, 10/1,10/3,10/6, and 10/8/19 for the afternoon shift, and 10/1- 10/8/19 for the night shift. Review of the clinical record for Resident 151 indicated [DIAGNOSES REDACTED]. The physician order [REDACTED]. one tablet every 4 hours as needed for moderate pain , Tylenol 325 mg two tablets by mouth every four hours as needed for mild pain, and NPI prior to pain medication administration: 1= repositioning, 2= dim light, 3= cold applications, 4= relaxing techniques, 5= distraction, 6= music, 7= quiet environment, every shift. Review of Resident 151's MAR indicated no NPI on 10/5-10/6/19 on the day shift, and 10/7/19 on the afternoon shift . Review of the MAR and concurrent interview with the DON on 10/09/19 at 4:26 p.m., the DON indicated the NPIs were not done per doctor's order.

Based on observation, interview and record review, the facility failed to ensure a resident medication brought to the facility from home and not verified by the facility's servicing pharmacy and pharmacist was not left in the medication storage 1 (MS 1). This failure had the potential for medication diversion. Findings: During an observation inside MS 1 on 10/10/19 at 9:18 a.m and concurrent interview with Registered Nurse Supervisor (RNS1), a wall mounted medicine cabinet was noted to contain a bottle of the medication [MEDICATION NAME] (eye medicine) labeled with Resident 2's name. RNS 1 indicated the medication is from home brought by the family and Resident 2 is currently discharged and the medication should have been destroyed. Review of the closed record for Resident 2 indicated an admission date of [DATE]. Resident 2 was discharged to a hospital on [DATE] , readmitted back to the facility on [DATE], and discharged out to the hospital on [DATE]. No record could be located if the medication was verified by the facility's servicing pharmacy or pharmacist. The facility's policy and procedure titled, Disposal of Medications and Medication-Related Supplies dated (MONTH) 2019 indicated .Medications left in the facility after a resident's discharge are destroyed . The facility was not able to present a policy regarding storage of unverified medications inside the medication storage areas upon request.

Based on record review and interview, the facility failed to ensure the careplan developed for two of 13 sampled residents. (Resident 42 and 36) were comprehensive based on the residents assessment and needs: 1. Resident 42's careplan for pain did not include the non-pharmacological interventions (NPI) in conjunction with pain management. 2. Resident 36's did not have a care plan in place for NPI associated with the administration of pain medications. These failures had the potential for Residents 42 and 36 pain needs to be not assessed appropriately to determine if the need to administer pain medication is warranted right away. Findings: The facility policy titled Comprehensive Care Plan dated 2013, indicated .The comprehensive care plan has been designated to reflect treatment goals and objectives in measurable outcomes . 1. Review of the clinical record for Resident 42 on 10/9/19, indicated an admission date of [DATE] with the [DIAGNOSES REDACTED]. The physician orders [REDACTED]. 10/8/19 -[MEDICATION NAME] (controlled pain medication) 7.5/325 mg 0.5 tablet by mouth in the morning related to unspecified [MEDICAL CONDITION] pain. 10/8/19- [MEDICATION NAME] 7.5/325 mg 1 tablet by mouth two times a day, routine pain medication 1/16/19 -[MEDICATION NAME]-[MEDICATION NAME] 7.5/325 mg 1 tablet PO every 8 hours for [MEDICAL CONDITION] pain. 3/14/19 -Tylenol 325 mg 2 tablet PO every 8 hours as needed for mild pain. 4/15/18 - [MEDICATION NAME] 100 mg by mouth at bedtime related to [MEDICAL CONDITION] ordered. 6/19/15 - Assess pain level every shift. 9/7/19- Non-pharmacological intervention (NPI) done prior to pain medication administration every shift: 1=Repositioning, 2= Dim light, 3= Cold Applications, 4=Relaxing techniques, 5=Distraction, 6=Music, 7=Quiet Environment. During the review of Resident 42's careplans and concurrent interview with the Director of Nursing (DON) on 10/9/19 at 11:14 a.m., no careplan on pain was located reflecting the physician's orders [REDACTED]. The DON confirmed the care plan for the non-pharmacological intervention was not developed timely and should have been initiated on the day it was ordered. 2. Review of the clinical record for Resident 36's on 10/09/19 indicated [DIAGNOSES REDACTED]. every 4 hours as needed (PRN). The physician order [REDACTED].= dim light, 3= cold applications, 4= relaxing techniques, 5= distraction, 6= music, 7= quiet environment every shift. Review of Resident 36 care plan initially initiated on 8/1/17 for pain did not reflect any update or revision to include the NPI as ordered on [DATE]. The facility policy and procedures titled Comprehensive Care Plan indicated care plan shall be developed for each resident that includes measurable objectives and time tables to meet the resident medical, nursing and psychological needs. During an interview on 10/9/19 at 4:26 p.m., the DON indicated the non-pharmacological interventions was not care planned as ordered on [DATE] and the careplan was not updated.

Based on observation, interview and record review,the facility failed to ensure safe food handling and sanitation as evidenced by; 1. Inconsistent hand washing between dirty and clean tasks inside the kitchen, and 2. Lack of sanitizing of one of one ice-machine in accordance with the manufacturer's guidelines. The above failures placed the residents at an increased risk of infection. Findings: On 10/1/18 at 9:15 A.M., an observation of a dietary employee (DE 1) running dirty dishes through the dish machine was conducted. DE 1 wore gloves when removing dirty dishes from a utility cart. DE 1 scraped food off the dishes and then retrieved more dishes from the utility cart. After the dirty meal trays and dishes were removed from the utility cart, DE 1 proceeded to obtain a clean cloth from a bin with the same dirty gloves. DE 1 proceeded to use a detergent dispenser that was located on the wall to put the detergent on the cloth and proceeded to wipe down the utility cart that was just cleared off, with the same dirty gloves. DE 1 then proceeded to push the cart that was wiped down with the detergent from the dish machine area into the clean kitchen area. On 10/01/18 at 09:18 AM, DE 1 then touched the door handle to the kitchen door located near the dish machine area to get another utility cart that came from the nursing floor that contained residents dirty meal trays and dishes. DE 1 continued to wear the same pair of dirty gloves as described above. On 10/1/18 at 9:22 AM, DE 1 washed his hands and put on a clean pair of gloves. DE 1 proceeded to the clean side of the dish machine to remove some clean dishes. DE 1 then proceeded to handle more dirty dishes, use same gloved hands after handling soiled dishes to touch the door knob to the kitchen to obtain another dirty utility cart. On 10/1/18 at 9:45 A.M., the clean dish area was overflowing with clean dishes and there was no longer free counter space. DE 1 then proceeded to the dirty side of the dish machine to push the rack of dirty dishes through the dish machine. DE 1 then removed his dirty gloves and immediately went to the clean side of the dish machine, without washing his hands, to remove some clean dishes in order to make room for the dirty dishes he had just loaded into the dish machine. Concurrently, DE 1 stated that he should have washed his hands after removing his dirty gloves prior to touching clean dishes. On 10/01/18 at 09:55 AM, the above observation was discussed with the dietary manager (DM). The DM stated that he would expect employees to wash their hands after removing dirty gloves prior to handling clean dishes. The facility's undated policy and procedure titled Sanitation and Infection Control Handwashing indicated, Handwashing Frequency: .2. After handling carts, soiled dishes and utensils, 3. Before and after doing cleaning procedures, .10. After handling any waste or waste products, 11. After engaging in any activities that contaminate the hands . 2. On 10/2/18 at 9:14 A.M., an ice-machine was observed located in the kitchen. The dietary manager (DM) stated the facility's maintenance employee was responsible for cleaning the ice-machine. On 10/2/18 at 9:24 A.M., in the presence of the DM, the maintenance employee (ME) responsible for cleaning of the ice-machine was interviewed. ME showed the chemical that he used to clean the internal components of the ice-making apparatus. ME was asked how he sanitized the internal components of the ice-machine after the cleaning step was performed. ME pointed to the cleaning chemical for the ice-machine and stated that was the only product that he used to clean the internal components of the ice-machine which was conducted annually. Concurrently, ME provided the ice-machine's manufacturer's guidelines which were jointly reviewed. The ice machine's manufacturer's guidelines indicated B. Cleaning and Sanitizing Instructions; The icemaker must be cleaned and sanitized at least once a year. More frequent cleaning and sanitizing may be required in some water conditions ., .2. Sanitizing Procedure - Following Cleaning Procedure; 1) Dilute 1.5 fl. (fluid) oz. (ounce) of a 5.25% sodium hypochlorite solution (chlorine bleach) with 3 gal. (gallon) of warm water . Concurrently, ME acknowledged that the sanitizing procedure following the cleaning procedure had not been done in accordance with the manufacturer's guidelines. ME confirmed there was only one ice-machine at the facility.

Based on observation, interview and record review, the facility failed to ensure : 1. Dirty lunch trays and dishes should not be on the same cart with fresh food. 2. Staff does not touch food with bare hands and observe hand hygiene in between assistance of residents with meals. 3. Staff sanitize a blood pressure equipment during medication administration and before storage These facility failure had he potential to cross contaminate food and transmit infectious diseases to residents. Findings: 1. During an observation in a resident hallway and concurrent interview with certified nursing assistant #2 (CNA-2) on 10/01/18, at 2:37 PM, an open cart contained fresh snacks and nourishments alongside dirty lunch trays and dishes. CNA-2 acknowledged the dirty trays should not have been on the same cart as fresh food. CNA-2 stated Yes, that's an infection control issue. The undated facility policy and procedure titled Dietary Department indicated food will be transported to other areas by using closed food carts and covered containers; food is to be kept covered during transport. 2. During an observation in the upper dining room on 10/01/18, at 1:06 PM, a certified nursing assistant (CNA-1) held a sandwich with bare hands while assisting Resident 36 to eat. CNA 1 repeatedly and alternately held utensils for Resident 36 and Resident 18 and then subsequently held the straw for Resident 36 with bare hands. During an interview on 10/04/18, at 12:38 PM, the director of staff development (DSD) indicated a napkin is placed on the tray for use when assisting residents to eat finger foods, such as sandwiches. DSD confirmed CNA-1 should have used the napkin provided to hold the sandwich, should have used a different hand to hold the utensils and should have performed hand hygiene before adjusting the straw for the residents. The facility policy and procedure titled Dietary Services - Meals and Service: Assistance with Meals dated (MONTH) 2009, indicated Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity . 3. During observation of medication administration on 10/02/18, at 9:20 AM, a licensed vocational nurse (LVN-1) used a manual blood pressure cuff on a resident then returned the blood pressure cuff to the med cart drawer without cleaning and/or disinfecting the cuff, gauge, tubing, valve or ball. The facility policy and procedure titled Policy for Cleaning & Disinfecting Blood Pressure Machine and Blood Pressure Cuff dated 11/2017, indicated The blood pressure cuff and gauge will be cleaning after each use with a disinfectant wipe .Clean the inside surface of the blood pressure cuff with the disinfectant wipe as well .Be sure to allow for proper 'contact time' as directed by the product label.

Based on observation, interview, and record review, the facility failed to accurately assess the need and indication of positioning devices used for one resident (Resident 18). This facility failure had the potential to restrain the resident with no indication. Findings: During an observation on 10/1/18, at 2:55 p.m., Resident 18 was sleeping in bed with both quarter rails up and two roll pillows adjacent to the resident's torso and legs. Both roll pillows were attached to the bed frame with hook and loop fasteners and can not be self removed. During an interview with the director of nurses (DON) on 10/4/18, at 9:04 a.m., the DON indicated the roll pillows and side rails are up when the resident is in bed and had been present since the DON started working at the facility. During an interview with the minimun data set coordinator (MDSC) on 10/04/18, at 09:11a.m., the MDSC stated, They (roll pillows and side rails) are used as an enabler. During a review of the clinical record for Resident 18 on 10/4/18, at 9:12 a.m., the minimum data set (MDS- complete assessment of the resident) dated 11/7/17, 5/4/18, and 7/29/18 had physical restraints defined as Any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot removed easily which restricts freedom of movements or normal access to one's body. The MDS dated [DATE], 5/4/18, and 7/29/18 did not indicate the use of roll pillows , side rails, or other devices as enablers and further indicated no limb restraints were being used on Resident 18.

Based on observation, interview, and record review, the facility failed to ensure a resident on insulin (medication for diabetes) received the right amount as ordered by the physician in one of three sampled residents, (Resident 2). The facility's licensed nurse, (LN 1) administered to Resident 2, 100 units of insulin, instead of 2 units as ordered by the physician. The facility failed to inservice, re-assign, counsel, or re-educate its licensed nurses on insulin administration, and effective management of residents receiving insulin to prevent future occurrence. These failures resulted in an avoidable medication error, causing Resident 2 to be hospitalized , and placed the resident at risk for future insulin errors and complications of excessive insulin, including [DIAGNOSES REDACTED] (low blood sugar) and death. Immediate jeopardy (IJ) was called on 12/3/14 at 10:00 a.m., with the facility Administrator, Director of Nursing, facility's Executive Director, Director of Staff Development, and facility's President. On 12/3/14 at 4:20 p.m., the facility provided an acceptable plan of correction, including: 1. Immediate in-service of all Licensed Nurses working on the floor on proper insulin administration. 2. A new form was created for Licensed nurses to complete prior to administering insulin. The form included the following elements: administration date, time of administration, insulin order, blood glucose level, amount of insulin to be administered, signature of administering nurse, and the confirming nurse. 3. Implementation of a two way verification of insulin order, dose, amount withdrawn from the insulin vial prior to administration to the resident by two Licensed Nurses. 4. Revision of the existing policy and procedure in administration of insulin reflecting the two way audit and checking by two Licensed nurses prior to administration. The Department of Public Health Licensing and Certification accepted the plan of correction and abated the IJ on 12/3/14 at 4:20 p.m. with the facility Administrator, Director of Nursing, facility Executive Director/ Director of Staff Development and facility President in attendance. Findings: According to Fundamentals of Nursing, 7th edition, 2009, by Potter and Perry, under Medication Administration-Right Dose, page 707, When preparing a medication from a larger volume or strength than needed, or when the prescriber orders a system of measurement different from what the pharmacy supplies, the chance of error increases .have another qualified nurse check the calculated doses. On 12/2/14, the Department received a complaint from an acute care hospital indicating Resident 2 had been admitted two times within five days, from the facility, (on 11/27/14 and 12/1/14) due to insulin overdose. Review of the clinical records for Resident 2 on 12/3/14, revealed admitting [DIAGNOSES REDACTED]. Resident 2 was transferred to the acute care hospital two times within 5 days, on 11/27/14 due to insulin overdose, and 12/1/14 due to low blood sugar, physician's orders [REDACTED]. * blood sugar level 101-150 give 2 units of [MEDICATION NAME] * blood sugar level 151-200 give 4 units of [MEDICATION NAME] * blood sugar level 201-300 give 6 units of [MEDICATION NAME]. Review of the facility's Medication Error Report indicated on 11/27/14, at 7:30 am, a licensed nurse (LN 1) informed Resident 2 she was going to administer 100 units of fast acting insulin ([MEDICATION NAME]) to the resident. Resident 2 stated I don't think so, but LN 1 administered the medication to Resident 2. LN 1 went back to check the physician's orders [REDACTED]. The facility sent Resident 2 to an acute care hospital via 911 (paramedics). Review of the acute care hospital's notes revealed Resident 2 was admitted twice to the acute care hospital, due to insulin overdose on 11/27/14, and low blood sugar on 12/1/14. The facility was unable to provide documentation to indicate it inserviced, re-assigned, counseled, or re-educated the licensed nurses on insulin administration, and effective management of residents receiving insulin to prevent future occurrence. During an interview on 12/3/14 at 9:20 a.m., the Director of Staff Development (DSD) confirmed she had not provided inservices to all of the facility's licensed nurses after Resident 2 was injected with 100 units of insulin, instead of 2 units by LN 1 on 11/27/14, including LN 1. The facility failed to provide documentation to indicate it had implemented interventions to prevent future insulin errors, including: a) doses of insulin administered cross checked by another qualified nurse prior to administration, and b) re-educate or train all licensed nurses on effective medication administration to prevent future occurrence. During an interview on 12/3/14 at 9:30 a.m., the Director of Nurses (DON) stated I have not put any process in place to address the insulin overdosing incident. The licensed nurses continues to administer insulin to residents without being cross checked by another qualified nurse.

Based on observation, interview, and record review, the facility failed to ensure a resident on insulin (medication for diabetes) received the right amount as ordered by the physician in one of three sampled residents, (Resident 2). The facility's licensed nurse, (LN 1) administered to Resident 2, 100 units of insulin, instead of 2 units as ordered by the physician. The facility failed to inservice, re-assign, counsel, or re-educate its licensed nurses on insulin administration, and effective management of residents receiving insulin to prevent future occurrence. These failures resulted in an avoidable medication error, causing Resident 2 to be hospitalized , and placed the resident at risk for future insulin errors and complications of excessive insulin, including [DIAGNOSES REDACTED] (low blood sugar) and death. Immediate jeopardy (IJ) was called on 12/3/14 at 10:00 a.m., with the facility Administrator, Director of Nursing, facility's Executive Director, Director of Staff Development, and facility's President. On 12/3/14 at 4:20 p.m., the facility provided an acceptable plan of correction, including: 1. Immediate in-service of all Licensed Nurses working on the floor on proper insulin administration. 2. A new form was created for Licensed nurses to complete prior to administering insulin. The form included the following elements: administration date, time of administration, insulin order, blood glucose level, amount of insulin to be administered, signature of administering nurse, and the confirming nurse. 3. Implementation of a two way verification of insulin order, dose, amount withdrawn from the insulin vial prior to administration to the resident by two Licensed Nurses. 4. Revision of the existing policy and procedure in administration of insulin reflecting the two way audit and checking by two Licensed nurses prior to administration. The Department of Public Health Licensing and Certification accepted the plan of correction and abated the IJ on 12/3/14 at 4:20 p.m. with the facility Administrator, Director of Nursing, facility Executive Director/ Director of Staff Development and facility President in attendance. Findings: According to Fundamentals of Nursing, 7th edition, 2009, by Potter and Perry, under Medication Administration-Right Dose, page 707, "When preparing a medication from a larger volume or strength than needed, or when the prescriber orders a system of measurement different from what the pharmacy supplies, the chance of error increases...have another qualified nurse check the calculated doses." On 12/2/14, the Department received a complaint from an acute care hospital indicating Resident 2 had been admitted two times within five days, from the facility, (on 11/27/14 and 12/1/14) due to "insulin overdose." Review of the clinical records for Resident 2 on 12/3/14, revealed admitting [DIAGNOSES REDACTED]. Resident 2 was transferred to the acute care hospital two times within 5 days, on 11/27/14 due to insulin overdose, and 12/1/14 due to low blood sugar, physician's orders [REDACTED]. * blood sugar level 101-150 give 2 units of [MEDICATION NAME] * blood sugar level 151-200 give 4 units of [MEDICATION NAME] * blood sugar level 201-300 give 6 units of [MEDICATION NAME]. Review of the facility's "Medication Error Report" indicated on 11/27/14, at 7:30 am, a licensed nurse (LN 1) informed Resident 2 she was going to administer 100 units of fast acting insulin ([MEDICATION NAME]) to the resident. Resident 2 stated "I don't think so," but LN 1 administered the medication to Resident 2. LN 1 went back to check the physician's orders [REDACTED]. The facility sent Resident 2 to an acute care hospital via 911 (paramedics). Review of the acute care hospital's notes revealed Resident 2 was admitted twice to the acute care hospital, due to insulin overdose on 11/27/14, and low blood sugar on 12/1/14. The facility was unable to provide documentation to indicate it inserviced, re-assigned, counseled, or re-educated the licensed nurses on insulin administration, and effective management of residents receiving insulin to prevent future occurrence. During an interview on 12/3/14 at 9:20 a.m., the Director of Staff Development (DSD) confirmed she had not provided inservices to all of the facility's licensed nurses after Resident 2 was injected with 100 units of insulin, instead of 2 units by LN 1 on 11/27/14, including LN 1. The facility failed to provide documentation to indicate it had implemented interventions to prevent future insulin errors, including: a) doses of insulin administered cross checked by another qualified nurse prior to administration, and b) re-educate or train all licensed nurses on effective medication administration to prevent future occurrence. During an interview on 12/3/14 at 9:30 a.m., the Director of Nurses (DON) stated "I have not put any process in place to address the insulin overdosing incident. The licensed nurses continues to administer insulin to residents without being cross checked by another qualified nurse."