Every finding on record at NHC Healthcare - Mauldin

Based on review of facility policy, interview, and record review, the facility failed to ensure Resident (R)78 was free of accidents by an improper transfer for 1 of 9 residents reviewed for accidents. This failure resulted in R78 sustaining a closed fracture of the mid left humeral shaft (a broken upper arm bone where the skin remains intact ). Findings include:Review of the facility policy titled, Consequences for failure to adhere to the Plan of Care, effective 06/01/2010, revealed, All nursing partners are required to follow the individual resident fall prevention care plans located in the Vanderbilt/Falls book on each unit. Adhering to the plan of care involves using all equipment correctly. Mechanical lifts require the presence of two partners at all times, NO EXCEPTIONS. If a resident falls because the plan of care was not followed, the following consequences have been established: 1. Written Counseling: If the POC was not followed regardless of resident activity. 2. 1 day suspension: If the POC was not followed and the resident falls. 3. Termination: If the POC was not followed and the resident falls and sustains an injury. PLEASE NOTE: Failure to follow any part of the patient's plan of care can result in loss of certification, legal action including but not limited to abuse charges, monetary fines and even jail time.Review of the facility policy titled, Hoyer Lift with a revision date of 02/2010, revealed, Purpose: To enable staff to lift and move a resident safely with as little effort as possible.Review of R78's admission Record revealed the facility admitted R78 on 01/01/21. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of osteoporosis, left hand contracture, and chronic pain syndrome.Review of R78's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/18/25, revealed R65 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated the resident had severe cognitive impairment. The MDS also indicated the resident was dependent on staff for transfer assistance.Review of R78's Care Plan Report, included a problem area initiated on 01/01/21, that indicated the resident had a risk for falls due to impaired mobility and cognition. Approaches directed staff to use Hoyer lift for Transfer, initiated on 07/01/24.Review of R78's Progress Notes dated 09/30/25 at 3:49 PM, written by the Unit Nurse Licensed Practical Nurse (LPN)1, revealed, Resident had Acute c/o pain in left arm/ Elbow Tylenol given at 240pm with little effect, daughter at facility to visit resident made aware of her c/o pain NP [name] aware of residents pain ordered x ray of left arm then notified that resident daughter would like her sent to St [NAME] Eastside. EMS here to pick resident up for transport.Review of a Five-Day Follow-Up Report dated 10/06/25, revealed Certified Nurse Aide (CNA)2 performed a stand pivot transfer with R78, resident arm/hand caught between her chair armrest and body. The report revealed in summary, after returning back from the beauty shop, the resident was transferred from her chair to the bed using a stand pivot transfer. The resident's arm/hand caught between the chair armrest and her body causing a pull/twisting motion. The resident has a diagnosis of Osteoporosis which helped contribute to the fracture.Review of R78's Emergency Provider Report dated 09/30/25, revealed the resident was seen due to fracture of shaft of left humerus, initial encounter for closed fracture.During an interview on 06/16/26 at 12:46 PM, Licensed Practical Nurse (LPN)1 revealed she became aware of the alleged incident of CNA doing an improper transfer that led to injury of the resident, from a Certified Nurse Aide (CNA), although she does not recall which CNA it was and it was not the CNA involved in the alleged incident. LPN1 was not aware that hoyer lift was not used in the transfer of the resident from her chair to the bed and was done without another staff member, which was not the proper procedure. LPN1 stated she reported the alleged incident to Registered Nurse (RN)1. The facility was going to do an in-house X-Ray of the resident's arm; however, resident's mother preferred it to be done at the hospital. LPN1 stated that staff are fully aware of the proper procedures for transferring residents using the Hoyer lift. She informed the surveyor that staff can verify a resident's specific transfer orders using five different methods. First, staff can check for an identifier magnet placed above the resident's bed or reference a chart located inside the resident's closet. Additionally, this information is available in a designated reference book at the nurse's station and is updated on the facility's electronic health records system, which all staff can access. Finally, transfer orders are detailed in the resident's care plan-with a physical copy kept at the desk-and are routinely reviewed during daily stand-up shift reports.During an interview on 06/16/26 at 11:33 AM, R78's Daughter revealed, she came to see her mother shortly after the alleged incident occurred. She stated her mother was in bed and her mother's left arm was hurting, she could tell her mother was in pain. Her mother told her that her arm was hurting, and she stated, the lady picked me up. The resident's daughter reported this to the Director of Nursing and 2 nurses. She asked them to send her mother to the hospital.Telephone interview attempts were made to CNA2 on 06/16/26 at 11:52 AM,11:53 AM, 11:56 AM, and 1:59 PM, CNA2 did not answer and voicemail had not been set up.During an interview on 06/16/26 at 12:38 PM, CNA1 revealed she worked on the day of the incident but did not witness the incident. She informed the surveyor that facility policy and procedure strictly require two staff members for all Hoyer lift transfers, emphasizing that a single-person transfer is never permitted under any circumstance. When asked how staff identify a resident's transfer requirements, CNA1 explained that transfer needs are discussed during daily stand-up meetings. She also noted that staff utilize visual job aids, including a magnet placed above the resident's bed and a chart located inside the resident's closet, both of which the surveyor and CNA1 verified during an observation. Lastly, CNA1 stated that these transfer orders are accessible at the nurse's desk and within the electronic computer systems.During an interview on 06/16/26 at 1:07 PM, RN1 revealed that LPN1 reported to her that R78 was experiencing significant pain. RN1 stated that CNA2 admitted to lifting R78 into bed manually without using the required mechanical lift, despite knowing there are three separate visual reminders in place to signal the need for a lift transfer. RN1 stated that CNA2 said she bypassed the equipment because she did not have enough time. RN1 then escorted CNA2 to the Director of Nursing's (DON) office, where CNA2 repeated her statement, leading the DON to terminate her employment immediately. Following the incident, the facility ordered an X-ray for R78, but the resident's daughter declined the service. The resident's daughter later called the facility to report that the resident's arm was fractured.During an interview on 06/16/26 at 3:10 PM, the DON stated that the resident's daughter reported her mother's arm was hurt by a staff member. According to the daughter, the resident stated that a CNA picked her mother up manually to transfer her, during which her arm became caught in the wheelchair, though it remains unknown if the arm was stuck or struck against the chair. The daughter requested that the resident be sent to the hospital. When investigating the incident, the DON interviewed the CNA in the presence of another staff member. When confronted with allegations of transferring the resident without a Hoyer lift, the CNA claimed she did not have anyone available to help her. The DON responded that the CNA should have left the resident safely in the chair rather than performing a solo manual transfer. The DON noted that care plans are located in the resident's chart, but the CNA admitted she did not look at them. The proper procedures are also in the resident's room on a magnet above the residents bed and on a chart in the residents closet. Additionally, when the DON went in the resident's room the DON observed that the Hoyer lift pad was still sitting unused in the chair during.

Based on observation, interviews, record review, and review of facility policy, the facility failed to provide services or care that are acceptable standards of practice. Specifically, the facility failed to ensure accurate accountability of the inventory of controlled substances for 2 of 2 residents reviewed, R48 and R 78 and failed to ensure medications were not pre-poured prior to administration for 5 of 5 residents reviewed, (R159, R170, R59, R22, and R130). 1.Review of the facility policy, titled IIA7: Controlled Substances with a revision date of 02/25/25, revealed, Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. E. Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse/medication technician administering the [NAME] immediately enters the following information on the accountability record and the medication administration record (MAR): 1. Date and time of administration (MAR, Accountability Record). 2. Amount administered (Accountability Record). 3. Remaining quantity (Accountability Record). 4. Initials of the nurse/medication technician administering the dose, completed after the medication is actually administered (MAR, Accountability Record). During an observation on 06/15/2026 at 09:00 AM Resident (R)48 and (R)78 both were given narcotics. RN3 failed to sign out the narcotics before administering the medication. Review of R48's Face Sheet revealed R48 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, depression, anxiety disorder and hemiplegia and hemiparesis following a cerebral vascular accident. Review of R78's Face Sheet revealed R78 was admitted to the facility on [DATE], with diagnoses including but not limited to: chronic respiratory failure, Pulmonary Fibrosis, Vascular Dementia, anxiety disorder and Major Depressive Disorder. Review of R48's Physician Orders revealed an order for Lorazepam- Schedule IV tablet; 0.5mg three times a day [TID] at 8:00 AM, 2:00 PM, and 8:00 PM. Review of R78's Physician Orders revealed an order for Clonazepam- Schedule IV tablet; 1 mg; amt:1 tablet twice a day 8:00 AM and 8:00 PM. During an interview on 06/15/26 at 9:05 AM RN 3 was asked why he did not sign out his narcotics before giving the narcotic. RN3 revealed that he writes the time that he gave the narcotic on his assignment sheet and later around 12:00 PM when he sits down at the nurse's station, he will sign out the narcotics. RN3 revealed that he does this to save time. During an interview on 06/15/26 at 03:15PM, RN3 revealed, I sign the narcotics out in the book when I sit down behind the desk at 12:00PM. I write the date, medicine and time on my assignment sheet and I sign the narcotic out in the book when I sit down at 12:00 PM. I do this to save time. I will sign out for the narcotics when I pull them to give them from now on. During an interview on 06/15/26 at 03:19 PM DON stated that nurses should sign out narcotics when they pull them from the cart and before they give them. 2. Review of the facility policy, titled IIA2: Medication Administration – General Guidelines with a revision date of 01/01/2019, revealed, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. Administration: 4. When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. During a random observation on 06/16/26 at 11:15 AM, RN2 was observed placing five medication cups filled with medications into the 200 Hall Medication Cart #2B. Two of the medication cups contained crushed medications. Three of the medication cups contained whole tablets and capsules. All five medication cups had the last name of a Resident printed in black ink on the side of the cup. During an interview on 06/16/26 at 11:15 AM with RN2, he verified he had pre-poured the medications. He revealed the medications were pre-poured for his next medication pass at 12:00 PM. He stated the cups were for R159, R170, R59, R22, and R130. He revealed the practice of pre-pouring medications was allowed as long as the nurse did not administer the medications early. He stated that as far as he knew NHC policy allowed the pre-pouring of medications. During an interview on 06/16/26 at 11:25 AM with RN1, she revealed she did not know if there was a policy for pre-pouring medications and stated she would need to ask the Director of Nursing (DON). During an interview on 06/16/26 at 12:35 PM with the DON, she revealed she knew from being a nurse that pre-pouring of medications should not be done. She stated she was not aware that the medication administration policy contained a statement about the pre-pouring of [NAME]

Based on review of facility policy, record review, and interview, the facility failed to complete a significant change Minimum Data Set (MDS) within 14 calendar days of the facility determining that there had been a significant change in condition for Residents (R)16 and (R)148, for 2 of 3 residents reviewed for comprehensive assessment after significant change. Findings include: Review of the facility policy titled CMS's RAI Version 3.0 Manual CH2: Assessments for the RAI dated October 2025, Pages 2-10 documented, Significant Change in Status Assessment-SCSA (Comprehensive) 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 days). Review of R16's Face Sheet revealed, he was admitted to the facility on [DATE]. R16's diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysarthria following cerebral infarction and diastolic (congestive) heart failure, Review of R16's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 06/08/26, revealed R16 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R16 had no cognitive impairment. Review of R16's Care Plan revealed, Admit to [NAME] Hospice Services on 05/20/26. Problem: Hospice care- [NAME] HOSPICE SERVICES [hospice address] with a start date of 05/20/26 and last reviewed/revised date of 06/12/26. The Approach directed staff to Hospice referral: as of (date) Include hospice nurse, social worker and chaplain in care plan meetings with a start date of 05/20/26. Review of R16's Physician Orders revealed, Hospice Services Special Instructions: [NAME] Hospice Services: [hospice address] on 06/01/26. Review of R16's Progress Note dated 05/20/26 at 4:18 PM, revealed Resident and RP met with hospice today and he was admitted to [NAME] Hospice Services. Resident and RP aware and in agreement with POC. Record review on 06/16/26, revealed R16's Significant Change MDS was completed on 06/08/26. R16 went on hospice services on 05/20/26. During an interview on 06/16/26 at 1:24 PM, the MDS Coordinator revealed, the resident's updated MDS for Significant Change was not done when it was supposed to be done. When it was realized that the MDS for Significant Change was not done, the MDS was then corrected. MDS Coordinator acknowledged the resident went on hospice on 05/20/26, MDS Significant Change of Status update was done on 06/08/26. The MDS Coordinator revealed, resident was admitted to the hospital during the assessment period and resident's Hospice benefits were revoked. She did not complete the Significant Change MDS until after resident was readmitted to the facility on [DATE]. During an interview on 06/16/26 at 2:48 PM, the Director of Nursing (DON) revealed the MDS Coordinator is responsible to checking MDS(s). The expectation is for MDS(s) to be done according to the RAI (Resident Assessment Instrument) and regulation. The DON further revealed that the MDS Coordinator meant to put the Significant Change MDS in the computer before she went on vacation but she forgot. Review of R186's Face Sheet revealed he was admitted to the facility on [DATE]. Her diagnoses included, but was not limited to, dementia in other diseases classified elsewhere, severe, with anxiety, Alzheimer's disease, and Parkinson's Disease; neurocognitive disorder with Lewy Bodies. Review of R186's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/29/26, revealed R186 had a Brief Interview for Mental Status (BIMS) score of 99 out of 15, which indicated R186 was unable to complete the interview. Review of R186's Care Plan revealed, Problem: Hospice care-Via Hospice services for diagnoses Alzheimer Dementia on 03/27/2026 with a start date of 03/27/26. Further review revealed, Problem: Code Status- Do Not Resuscitate (DNR) with a start date of 03/09/26. Review of R186's Physician Orders revealed an order for Do Not Resuscitate (DNR) 03/09/2026 Open Ended and Hospice Service Special Instructions: Via Hospice services for diagnoses Alzheimer Dementia 03/27/2026 Open Ended. Review of R186's Progress Note revealed, Note Text: Resident was admitted to VIA hospice services on 3/27/26 for Dx of Alzheimer dementia. RP in agreement with POC. Record review revealed there was not an MDS to include R186's Significant Change in Status Assessment update. R186 went on hospice services on 03/27/26, a quarterly MDS was done on 05/29/26. Further review revealed the Significant Change in Status Assessment updated MDS was not done until 06/08/26. During an interview on 06/16/26 at 1:24 PM, the MDS Coordinator revealed, the resident's updated MDS for Significant Change was not done when it was supposed to be done. When it was realized that the MDS for Significant Change was not done, the MDS was then corrected. The MDS Coordinator acknowledged the resident went on hospice on 03/27/26, the MDS Significant Change of Status update was done on 06/08/26, when it was noticed the update was not completed. During an interview on 06/16/26 at 2:48 PM, the Director of Nursing (DON) revealed the MDS Coordinator is responsible for checking MDS(s). The expectation is for MDS(s) to be done according to the RAI (Resident Assessment Instrument) and regulation.

Based on review of facility policy, observation, record review, and interview, the facility failed to ensure a medication administration error rate of less than 5 percent. The medication administration error rate was 8%, for 2 errors out of 25 opportunities. Findings include: Review of the facility policy, IIA2: Medication Administration - General Guidelines with a revision date of 01/01/2019, revealed, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. A. Preparation: . 4) Before administering a medication, the nurse should assure he/she is administering to the correct patient, verify the medication, dose, time and route . B. Administration: . 2) Medications are administered in accordance with written orders of the prescriber. Review of the facility policy, IIA7: Controlled Substances with a revision date of 02/25/2025, revealed, Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. E. Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse/medication technician administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1.Date and time of administration (MAR, Accountability Record). 2.Amount administered (Accountability Record). 3.Remaining quantity (Accountability Record). 4.Initials of the nurse/medication technician administering the dose, completed after the medication is actually administered (MAR, Accountability Record). Review of R78's Physician Orders revealed an order with a start date of 11/10/2025 for, Aspirin Childrens (aspirin) [OTC] tablet, chewable; 81 mg; amt: 1 tablet; oral Special Instructions: give daily Once A Day 08:00 AM. Review of R115's Physician Orders revealed an order with a start date of 01/14/2026 for, aspirin [OTC] tablet , chewable; 81 mg; amt: 1 tab; oral Once A Day 08;00 AM. During an observation on 06/15/2026 at 9:00 AM, Resident (R)115 and R78 both were given Aspirin 81 mg (milligram) chewable tablet. Registered Nurse (RN)3 instructed both residents to leave the tablet under their tongues until the tablet dissolved. RN3 further instructed the residents not to chew the aspirin.During an interview on 06/15/2026 at 3:15 PM, RN3 revealed it is just what I learned in school. It is just routine for me. You are right it does not say to give it sublingual (under the tongue) or not crush it. I sign the narcotics out in the book when I sit down behind the desk at 12:00 PM. I write the date, medicine and time on my assignment sheet and I sign the narcotic out in the book when I sit down at 12:00 PM. I do this to save time. I will sign out for the narcotics when I pull them to give them from now on.During an interview on 06/15/26 at 3:19 PM, the Director of Nursing (DON) revealed my expectation is that the nurses follow the policy. They should sign out for narcotics when they pull them from the cart and before they give them. The nurses should follow the physician orders when administering medications.

Based on observation, interview, and review of facility policy, the facility failed to ensure medications were properly labeled in 2 of 6 medication carts.Findings include:Review of the facility policy, Medication Storage in the Facility with a revision date of 02/25/25, stated, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Expiration Dating (Beyond-use dating): . D. Certain medication or package types, such as IV solutions, multiple dose injectable vials, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. For products that required shortened expiration dates upon opening, the nurse will document the date opened on the label.During an observation on 06/16/26 at 10:49 AM, of the 200 Hall Medication Cart 2A with Licensed Practical Nurse (LPN)2, revealed the following: Latanoprost 0.005% Eye Drops for Resident (R)11 with no label indicating the open date. Lubricant Eye Drops 0.5% for R95 with no label indicating the open date. Ayr Saline Nasal Gel for R75 with no label indicating the Resident's name, prescription information, or open date. Lubricant Eye Drops 0.5% for R75 with no label indicating the open date. Optase Hylo Night Eye Ointment with no label indicating the Resident's name, prescription information, or open date. Trelegy Ellipta 100-62.5-25 mcg Inhaler for R101 with no label indicating the open date. Cromolyn sodium Nasal Spray for R101 with no label indicating the open date. Refresh Lacri-Lube Ointment for R70 with no label indicating the open date. Elder Tonic for R78 with no label indicating the open date. Cystex for R78 with no label indicating the Resident's name, prescription information, or open date. During an observation on 06/16/26 at 11:15 AM, of the 200 Hall Medication Cart #2B with Registered Nurse (RN)2, revealed the following: Lumigan 0.01% Eye Drops for R46 with no label indicating the open date. Brimonidine 0.2% Eye Drops for R46 with no label indicating the open date. Spiriva Respimat Inhaler for R153 was found in a different drawer than the bag containing the prescription label. The inhaler was found in the first drawer. The bag with the prescription information was found in the fourth drawer. Debrox Earwax Removal for R22 with no label indicating the open date. During an interview on 06/16/26 at 10:49 AM, LPN2 verified the findings in the 200 Hall Medication Cart 2A. She stated open dates should be put on the multi-dose containers of medications when they are opened. She stated the Ayr Saline Nasal Gel, Optase Hylo Night Eye Ointment, and Cystex were provided by the families of the Residents they were prescribed for. She revealed the medications provided by the families should each have the Resident's name and open date on the medication.During an interview on 06/16/26 at 11:15 AM, RN2 verified the findings in the 200 Hall Medication Cart 2B. He revealed he did not know why the empty bag for the Spiriva Respimat Inhaler was found in a different drawer than the inhaler itself. ****During an interview on 06/16/26 at 11:35 AM with RN1, she revealed they do not usually allow a Resident's family to supply medications. She stated the medications usually come from their pharmacy; however, once in a while, a resident will insist on the brand name of a medication instead of the generic version their pharmacy supplies. She stated they will make exceptions in those cases with an order. During an interview on 06/16/26 at 3:40 PM with the Director of Nursing (DON), she revealed her expectation is that eye drops and other multidose medications are labeled with the open date when opened. She stated each Resident has their own section in the medication cart, so the nurse should be able to tell which Resident a medication without a name label belongs to because it will be in the Resident's section of the medication cart and other Residents would not be prescribed that medication.

Based on review of facility policy, observation and interview, the facility failed to store, prepare and distribute food under professional standards of food safety. This had the potential to affect 167 of 167 residents who resided at the facility and increased the risk of food-borne illnesses. Findings include: Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, under the subtitle Sanitation, Manual Warewashing, dated 11/2017 revealed, on item b A chemical sanitizing solution at the proper concentration and at the correct temperature for the sanitizer used. The policy goes onto to state (see chemical sanitizing on page C28-C29). These policy/pages were not available to the surveyor during the survey. Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, dated 11/2017, revealed no process for loading and unloading the dishwasher and only referenced to the state food code for further instruction. Observations on 03/06/25 at 8:30 AM with Food Service Director (FSD)1 revealed [NAME] 2 washing dishes in the three-compartment sink in the main kitchen. The wash reservoir was to her far right, the rinse was in the center, and the slightly red solution/water or sanitizing solution was to the far left. A 2000 ML pitcher (half gallon) pitcher was standing in the sanitizing solution, with its top third above the waterline. The pitcher had been used to mix puree foods that were served at breakfast earlier. FSD1 confirmed the pitcher lacked proper sanitization. FSD1 immediately submerged the pitcher and left it there after questioning. Further Observations on 03/06/25 at 9:10 AM,revealed Cook2 in the same location, washing, rinsing, and sanitizing dishes. A one-gallon pitcher was observed in the sanitizing solution, with one-third of the pitcher above the sanitizing solution water line and not properly sanitized. Cook2 confirmed that neither pitcher had been submerged in the sanitizing solution. Cook2 stated that the items should remain in the sanitizing solution for three to five minutes. FSD1 submerged the pitcher in the sanitizing solution. He then explained to the surveyor that Cook2 was new. He later told Cook2 that sanitizing requires complete submersion of all items for proper sanitization. Observation on 03/06/25 at 11:10 AM through 11:30 AM revealed Cook1 washing dishes at the dish machine in the main kitchen with a scrubbing device by hand and wearing gloves, putting the rack of scrubbed dishes into the dishwasher, running the dishwasher and removing the dishes from the washer by placing her dirty gloved hands onto the clean dishes. Cook1 was noted to do this four times during this period, with four racks of dishes. The racks of dishes contained two cookie sheets in separate racks, an assortment of utensils and lid, and the plastic container and blades of the Robot Coupe used to process pureed and chopped foods. Each time, Cook1 placed dirty gloved hands on the clean objects as she moved them from the dishwasher to the clean side of the dishwasher. During an interview on 03/06/25 at 11:45 AM, FSD1 stated she knows better and was not sure what happened. Cook1 confirmed she had touched clean dishes with soiled gloves and stated she had a lot of different jobs to do in the kitchen and she was in a hurry to clean the items.

Based on observation, interview, and review of facility menus and meal cards, the facility failed to follow menus for seven of 167 residents (Resident (R) 145, R13, R29, R80, R135, R149, and R67) whose meal service was observed. This failure had the potential to cause increased blood sugar levels and/or affect the residents' cardiac status. Findings include: 1. Review of the facility's menu for the noon meal on 03/06/25, provided by the facility, revealed residents with diet orders of a consistent carbohydrate diet were to receive one half-piece of frosted peanut butter sheet cake for dessert. During an observation on 03/06/25 at 11:52 AM, R145's meal card was noted to read the resident was to receive a consistent carbohydrate diet. R145 was observed to receive one whole piece of frosted peanut butter sheet cake. During an observation on 03/06/25 at 12:25 PM, R13's meal card was noted to read the resident was to receive a consistent carbohydrate diet. R13 was observed to receive one whole piece of frosted peanut butter sheet cake. During an observation on 03/06/25 at 12:45 PM, R29's meal card was noted to read the resident was to receive a consistent carbohydrate diet. R29 was observed to receive one whole piece of frosted peanut butter sheet cake. 2. Review of the facility's menu for the noon meal on 03/06/25, provided by the facility, revealed residents with diet orders for a heart-healthy diet were to receive baked okra. During an observation on 03/06/25 at 12:08 PM, R80's diet card read the resident was to receive a heart-healthy diet. It was noted that the resident received fried okra instead of baked okra. During an observation on 03/06/25 at 12:18 PM, R135's diet card read the resident was to receive a heart-healthy diet. It was noted that the resident received fried okra instead of baked okra. During an observation on 03/06/25 at 12:21 PM, R149's diet card read the resident was to receive a heart-healthy diet. It was noted that the resident received fried okra instead of baked okra. During an observation on 03/06/25 at 12:52 PM, R67's diet card read the resident was to receive a heart-healthy diet. It was noted that the resident received fried okra instead of baked okra. During an interview on 03/06/26 at 12:25 PM, Food Service Director (FSD) 1 revealed that staff did not serve or prepare baked okra for the noon meal. FSD1 stated the diet listed on the meal card was what the resident was served. FSD1 confirmed staff did not separate and serve half pieces of frosted peanut butter sheet cake on the tray line. During an Interview on 03/06/25 at 12:30 PM, [NAME] 4 stated she did not prepare or serve the baked okra as indicated on the menu and menu/diet cards. She stated she had forgotten to prepare and serve the item. During an Interview on 03/06/25 at 1:30 PM, [NAME] 1 stated she cut the cake after baking it. She stated that while she cut all the pieces into regular sections, some were smaller than others. She stated she did not separate the smaller servings. [NAME] 1 confirmed staff were randomly selecting the cake and placing it on the tray line without separating pieces for the Consistent Carbohydrate diets. During an interview on 03/07/25 at 8:30 AM, the Registered Dietician (RD) confirmed she approved and was involved with developing the menu. She stated the menu included baked okra, a heart-healthy option that should have been served, along with a half-size portion of frosted peanut butter sheet cake.

Based on observation, interview, record, and policy review, it was determined the facility failed to conduct medication self-administration assessments and have physician orders for self-administration of medications for one of one resident (Resident (R) 63) reviewed for self-administration of medications out of a total sample of 33. This had the potential to cause harm to R63 through medication administration errors. Findings include: Review of the facility's policy titled, Self-Administration of Medications, revised 02/25/25, revealed, . If a resident desires to self-administer medications, a physician's order should be obtained then an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive (including orientation to time), physical and visual ability to carry out the responsibility. For those residents who self-administer, a member of the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment on a quarterly basis or if needed when there is a significant change in condition. If the resident demonstrates the ability to self-administer medications, a further assessment of the safety of bedside medication storage is conducted . Review of R63's Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R63 was admitted to the facility on [DATE] with diagnoses including but not limited to: chronic respiratory failure with hypoxia, centrilobular emphysema, dependence on supplemental oxygen, long-term current use of inhaled steroids, hypertensive heart and chronic kidney disease, insomnia, and dry eye syndrome of bilateral lacrimal glands. Review of R63'sSelf-Administration of Medication Assessment, dated 09/29/22 and provided by the facility, revealed the resident was appropriate for self-administration of lubricating eye drops as ordered. Review of the clinical record revealed no further medication self-administration assessments. Review of R63's Orders, located under the Orders tab of the EMR, revealed no physician's order for the self-administration of medications. Review of R63's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/25 and located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed R63 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. During an observation and interview on 03/05/25 at 9:30 AM, R63 was sitting in a recliner by her bed. The bed had several items on it within the resident's reach. A small rectangular open top box was on the resident's bed and contained medications with pharmacy labels/tags affixed to the outside of the containers. The resident's living space in the room was closest to the room's entry door, and the medications were visible upon entering the room. R63 stated she kept the items on the bed so she could easily reach them. During a follow-up observation on 03/05/25 at 1:50 PM, the medications were still in the rectangular open-top box on R63's bed. The medications observed were: Fluticasone propionate (a steroid medication) nasal spray 50 micrograms (mcg), with an expiration date of August 2026. The preparation was labeled with instructions for two sprays at 9:00AM and 9:00 PM; Mometasone, with a pharmacy label and directions to use three drops to the scalp two times daily as needed, with an expiration date of 03/2026; Major Deep-Sea Saline Spray (used to treat a stuffy nose and dryness inside the nose), dated as opened on 07/25/2024, but with an expiration date of 01/2026; Ocusoft hypochlor 0.02% eyelid wash, with an expiration date, 01/2026; and X [NAME] Nasal Spray (used to alleviate nasal congestion), with an expiration date of 05/20/27. The preparation had a pharmacy label with directions to use two sprays in each nostril three times a day. During an interview on 03/05/2025 at 3:12 PM, Registered Nurse (RN)3 stated the resident self-administered the medications when he cued her to do so. During an observation and interview on 0 3/06/25 at 3:15 PM with Unit Manager (UM) 2, the medications were still in the open-top box on R63's bed. UM2 stated her concern would be that the resident might use more of the medications than prescribed, but that the resident was alert, oriented, and able to make her own decisions. UM2 stated she was unsure if R63 had a current Self-Administration of Medications Assessment on file, but she would look for one. UM2 stated R63 had a recent discussion with her about keeping the Ocusoft Hypochlor Solution at her bedside. She stated R63's eye doctor told her if she did not want to use Ocusoft Hypochlor, she could use baby shampoo to cleanse her eyes. UM2 stated that the resident thought if she could keep baby shampoo in her room, then she should be able to keep the Ocusoft Hypochlor Solution in her room at the bedside. UM2 stated she could not recall exactly when she and the resident had that discussion. UM2 observed R63's medications and stated the Deep-Sea saline spray was dated as being opened on 07/25/24 and was way too old, but the expiration date listed was acceptable. She stated she was not familiar with Mometasone. UM2 stated all the medications observed in the box had been issued by the facility's contracted pharmacy service. During an interview on 03/06/25 at 4:30 PM, UM2 stated R63 had not been assessed for keeping the medications at her bedside within the past 90 days, but she was completing an assessment today. She stated the Director of Nursing (DON) found one Self-Administration of Medication Assessment in R63's clinical record, but it was not current. During an interview on 03/07/25 at 9:53 AM, UM2 stated after observing the medications in R63's room, she contacted the medical provider and obtained authorization for R63 to keep the medications in her room. During an interview on 03/07/25 at 11:15 AM, the DON stated she could not find evidence of routine quarterly Self-Administration of Medication Assessments for R63; only the one dated 09/29/22. She stated UM2 had just completed a current Self-Administration of Medication Assessment for R63 which showed the resident was assessed to be able to self-administer nasal spray, eye drops, topical medications, and eye wash spray. The DON stated R63 should have been reassessed quarterly for her appropriateness to self-administer medications if she was keeping medications at the bedside. The DON stated R63 had a lockable box in her room for medication storage, but she had not been using it. She stated the resident had said it was not convenient to get up and go to the other side of the room and get the medications from the lockable box. The DON stated she was going to re-visit the matter with R63 and would assist her with moving the box closer so she could make use of it for storing her bedside medications.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) was coded accurately for three of 33 residents (Residents (R) 95, R74, R42) whose clinical records were reviewed. The facility failed to accurately code a quarterly assessment for hospice services for R95 and for therapy services for R42. In addition, the facility failed to accurately code the use of antipsychotic medication for R74. These failures placed the residents at risk of unmet care needs and a diminished quality of life. Findings included. Review of the October 2024 RAI manual, page 1-5 revealed, . An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations . It is important to note here that information obtained should cover the same observation period as specified by the MDS (minimum data set) items on the assessment, and should be validated for accuracy (what the resident's actual status was during the observation period) by the IDT (interdisciplinary team) completing the assessment . Review of R95's Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R95 was admitted to the facility on [DATE] with diagnoses including but not limited to: dementia and malignant neoplasm of the bladder wall. Review of R95's significant change MDS, located in the RAI tab of the EMR and with an Assessment Reference Date (ARD) of 07/10/24, revealed R95 had a Brief Interview of Mental Status (BIMS) score of seven out of 15, which indicated she was severely impaired in cognition. It was recorded R95was receiving hospice services. Review of R95's quarterly MDS, located in the RAI tab of the EMR and with an ARD of 12/26/24, revealed R95 was coded for dialysis and not for hospice services. During an interview on 03/06/25 at 4:26 PM, the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) were asked if R95 was receiving dialysis now instead of hospice services. The DON stated, [R95] has never been on peritoneal or hemodialysis, but she is on hospice. This was an error in coding as it was coded in the wrong place. Review of R74's Face Sheet, located in the Face Sheet tab of the EMR, revealed R74 was admitted to the facility on [DATE] with diagnoses including but not limited to: stroke and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of R74's Physician Orders, located in the Orders tab of the EMR and dated 01/23/25, revealed R74 was to receive aripiprazole, an antipsychotic medication, 10 milligrams (mg) every day. Review of R74's admission MDS, located in the RAI tab of the EMR and with an ARD of 01/29/25, revealed R95 had a BIMS score of nine out of 15, which indicated R95 was moderately impaired in cognition. It was recorded R74 had received an antipsychotic medication daily during the observation period; however, the MDS further recorded that R74 had not received an antipsychotic during the observation period. During an interview on 03/06/25 at 4:19 PM, the MDSC was asked why R95 was coded to have received an antipsychotic in one area and in another area was coded as not having been administered an antipsychotic. The MDSC stated, That was an error in coding. [R95] is receiving an antipsychotic. 52063 Review of R42's Resident Face Sheet, located in the Face Sheet tab of the EMR, revealed R42 was admitted to the facility on [DATE] with diagnoses including but not limited to: hypertensive chronic kidney disease, type 2 diabetes mellitus, glaucoma, difficulty walking, lack of coordination, history of falling, and presence of left artificial hip joint. Review of R42's quarterly MDS, with an ARD of 12/16/24 and located under the RAI tab of the EMR, revealed R42 had a BIMS score of 12 out of 15, which indicated the resident was moderately cognitively impaired. It was recorded that R42 did not receive any physical or occupational therapies. During an interview on 03/06/25 at 9:29 AM, R42 stated she received therapy about four times per week and sometimes twice a day. She stated she thought she had been in therapy services since June 2024. The resident stated she received therapy on her right shoulder and that she also rode a stationary bicycle while in therapy. During an interview, on 03/07/25 at 8:46 AM, the Director of Therapy Services revealed R42 was currently on Medicare Part B, in a maintenance program and received services from skilled therapists. She stated the resident received Physical Therapy (PT) two times per week and Occupational Therapy (OT) two times per week. She stated the resident was admitted to the OT maintenance program on 08/09/24 and to the PT maintenance program on 08/15/24. During an interview on 03/07/2025 at 9:17AM, the MDSC stated the therapy department staff was responsible for coding minutes of therapy completed for the resident during the seven-day look-back of each assessment period. She stated MDS staff used a scrubber software program to identify anything that seemed inaccurate, incomplete, or anything that triggered as a concern with sections of the assessment. She stated that if an error was identified, they would contact the department responsible for completing the specific MDS Assessment section and ask them to fix the discrepancy. The MDSC stated they would run the scrubber program again to ensure all sections of the MDS were completed before signing off on the assessment. The MDSC stated on our end, everything pulled through successfully, so the scrubber would not have triggered a discrepancy. During an interview on 03/07/25 at 9:42 AM, the Director of Therapy reviewed R42's therapy notes and stated that she had found that the resident had completed minutes of PT and OT during the MDS assessment look-back period of 12/09/24-12/16/24. She stated the therapy department transitioned to a new data collection system around October-November 2024, and it was possible that R42's minutes in therapy did not pull through as they should have.

Based on review of the facility policy, observation and interview, the facility failed to ensure a specialized wheelchair was clean and sanitary for one of one resident (Resident (R) 131) reviewed for specialized wheelchairs in a total sample of 33. This failure placed the resident at risk for a diminished quality of life and dignity. Findings include: Review of an undated facility policy titled, Noncritical Patient Care Equipment-Cleaning Procedure Summary revealed, . Dedicated equipment-when dedicated to a particular patient during their stay . Frequency . Consistent with cleaning frequency for patient area, and as needed . Person Responsible . Cleaning Partners . Clean and disinfect with a rapid multi surface disinfectant and cleaner or disinfecting wipes . Review of R131's Face Sheet, located in the Face Sheet tab of the electronic medical record (EMR), revealed R131 was admitted to the facility on [DATE] with diagnoses including but not limited to: multi-system degeneration of the autonomic nervous system. Review of R131's significant change Minimum Data Set (MDS), located in the RAI (Resident Assessment Instrument) tab of the EMR and with an Assessment Reference Date (ARD) of 02/19/25, revealed R131 had a Brief Interview of Mental Status (BIMS) score of 9 out of 15, which indicated R131 was moderately impaired in cognition. It was recorded R131 used a wheelchair for mobility. Review of R131's ADL [activity of daily living]/Mobility Care Plan, dated 01/06/25 and located in the RAI tab of the EMR, revealed, . Limited function ADLs and mobility due to impaired mobility and debility . Approaches included the use of a specialty chair as needed for comfort and positioning. During a family interview on 03/05/25 at 11:32 AM, Family Member (FM)1 was asked if R131's needs were being accommodated by the facility. FM1 stated, Yes, however, there is food all down in the wheelchair, and there is hair on the wheels. The wheelchair has been like this since she first was provided with the specialized chair, and it's still here today. During an observation on 03/06/25 at 9:27 AM, R131's Broda chair (specialized wheelchair) was observed to have a large amount of dried debris from the front to the back on each side of the seat cushion. In addition, the two small wheels in the back of the chair had blonde hair wrapped around the inner portion of wheels and was heavy enough to be sticking out of the wheel attachments. R131 did not have blonde hair. During an interview on 03/06/25 at 9:28 AM, Unit Manager (UM1) was asked when wheelchairs were cleaned and by whom. UM1 stated, [R131]'s chair is to be cleaned on the night shift, by the CNA [certified nurse aide] every Tuesday. UM1 was shown R131's Broda chair and was asked if the chair was clean and sanitary. UM1 confirmed that it was not clean and sanitary. During an interview on 03/07/25 at 12:22 PM, the Administrator confirmed that resident care equipment should be cleaned.

Based on review of the facility policy, observations and interviews, the facility failed to ensure the removal of expired supplies from 3 of 6 medications carts, 1 of 1 treatment cart and 1 of 2 storage rooms. Findings include: Review of the facility's policy titled, Medication Storage in The Facility revised January 2019, revealed, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock and returned to pharmacy if appropriate or disposed of on the units. During an observation on 01/31/24 at 11:44 AM of the Medication Cart #3 on Unit 3 revealed: 1 expired BinaxNOW COVID test kit with expiration date of 06/07/23. During an observation on 01/31/24 at 11:50 AM of the Treatment Cart on Unit 3 revealed: 2 boxes of Sureprep Rapid Dry No Sting - Barrier wipes with an expiration date of July 2023, 1 package of Calcium Alginate dressing with an expiration date of 06/28/23, 1 Telfa Non-Adherent dressing with an expiration date of October 2023 and 1 opened package of sterile gauze. During an observation on 01/31/24 at 12:05 PM of the Medication Storage Room on Unit 2 revealed: 7 boxes of BinaxNOW COVID test with an expiration date of 06/07/23. During an observation on 01/31/24 at 12:50 PM of Medication Cart #A on Unit 2 revealed: 1 opened and used vial of single use Sterile Water with an open date of 01/30/24. During an interview on 01/31/24 at 12:55 PM, LPN2 stated that she did not know she could not keep it because the bottle was labeled and thought it could be multi-use, LPN2 then properly disposed of vial. During ab observation on 01/31/24 at 1:25 PM of Medications Cart #1 on Unit 1 revealed: 1 package of PDI Lubricating Jelly with an expiration date of 01/01/24. During an interview on 01/31/24 at 12:31 PM, Licensed Practical Nurse (LPN)4 stated that it is the responsibility of the unit manager and central supply to check and discard any expired supplies/medications. During an interview on 01/31/24 at 2:04 PM, the Director of Nursing (DON) stated that it is her expectations that expired medications/supplies be removed and discarded.

Based on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the freezer and 2 of 3 unit refrigerators were labeled, dated with a use by date and/or discarded after the manufacturer's expiration date. Findings include: Review of the facility's policy titled, Safety and Sanitation Best Practices Guidelines-Refrigerator and Freezer storage, dated ,d+[DATE] indicated: 9a. Foods will be stored in their original container, or an NSF approved container or wrapped tightly in moisture-proof film, foil, etc. Clearly labeled with the contents and the use by date. (Food Code ,d+[DATE].17). During an observation and interview on [DATE] at 12:03 PM, of the kitchen freezer revealed: a 32 ounce (oz) bag of [NAME] Shrimp unlabeled without a use by date and a 7 pound (lbs) bag of Cold-Water Shrimp unlabeled without a use by date. The Dietary Manager (DM) acknowledged the shrimp were not in their original package and did not have a use by date. Further observation of the freezer revealed: a bag of whole cranberries dated 2017. The Dietary Manager Assistant (DMA) acknowledged the date on the packaging had expired. Further observation in the freezer revealed: a brown box of Churro Donuts dated with manufacturer's expiration date [DATE], a container of Wisconsin Style Cheese unlabeled without a use by date, a bag of English muffins unlabeled with expiration date or use by date, a roll of pureed Travisco sausage unlabeled without a use by date, three bags of crushed crackers unlabeled without a manufacturer's expiration date. The DM and DMA discarded the items that were unlabeled and without a use by date. During an observation on [DATE] at 10:14 AM, the Unit 100 resident refrigerator revealed: a 14 gram container of cottage cheese unlabeled, an 8 oz container of cream cheese unlabeled, and a 15 oz Lays ranch dip with a use by date of 2023. During an observation on [DATE] at 10:24 AM, the Unit 200 resident refrigerator revealed: two 7.5 oz Cokes unlabeled; three 12 oz diet cokes unlabeled, one pint of Blue Bell Dr. Pepper ice cream and one pint oatmeal creme pie ice cream (both) with an expired manufacturer's date, and a brown liquid spill in the refrigerator. During an interview on [DATE] at 10:21 AM, Registered Nurse (RN)1 (Unit 100) acknowledged the unlabeled items and removed them from the refrigerator. RN1 stated the procedure for items brought in by family is for staff to receive the items and label/date them prior to placing them in refrigerator. During an interview on [DATE] at 10:37 AM, RN2 (Unit 200) acknowledged the expired items and the brown liquid spill in refrigerator. RN2 stated she would clean the spill up and continued that she did not know the refrigerator and freezer storage policy. During an interview on [DATE] at 11:44 AM, the Administrator stated his expectations of staff when it comes to food storage, is to follow policy.

Based on observations, interviews, record reviews, review of facility policy and review of manufacturer's guidelines, the facility failed to clean and disinfect a blood glucose meter per device and manufacturer's instructions before and after use for 1 of 1 resident, Resident (R)146. Additionally, the facility failed to ensure that its staff demonstrated proper hand hygiene while assisting a resident during meal time. Findings include: Review of the facility's policy titled, Blood Glucose Monitoring Technique revised 11/13/18, revealed, 15. Clean glucometer with alcohol wipe and place on barrier to air dry. 18. Place clean meter into storage box and return the storage box to the drawer or closet. Review of the Manufacturer's Guidelines titled, Cleaning and Disinfecting the Assure(R) Prism multi-Blood Glucose Monitoring System (BGMS) revised September 2019, revealed, The meter will be cleaned and disinfected after use on each patient. Review of R146's Medication Administration Record (MAR) dated 01/31/24 revealed orders for Insulin Lispro (a fast-acting blood sugar lowering medication) 100 unit/milliliters; per sliding scale, if blood sugar is 250 to 450 give 2 units. If blood sugar is greater than 450, give 4 units. Subcutaneous. During an observation on 01/31/24 at 8:08 AM revealed Registered Nurse (RN)5 removing the BGMS (which was intended for use only by the resident) from R146's nightstand, RN5 proceeded to insert a test strip into the BGMS, then pricked R146's finger and collected her blood to check her blood sugar. RN5 then removed the used test strip and placed the BGMS back into the nightstand of R146. No cleaning or disinfection of the BGMS was observed. During an interview with the Director of Nursing (DON) on 01/31/24 at 2:04 PM, the DON states that it is her expectations that nursing staff are to follow policies and procedures as written when providing care for residents. 49818 Review of the facility policy titled Handwashing, revised 02/2010, revealed, Purpose: Medical asepsis to control infection, To reduce transmission of organisms from resident to resident. General instructions: [NAME] hand-washing techniques must be followed at all times. During an observation on 01/29/24 at 5:15 PM, Certified Nursing Assistant (CNA)1 was assisting R59 with her meal, in the 200 hall dining room. CNA1 gave R59 a bite of food, then touched her face mask and proceeded to pick up the spoon and continue to feed the resident without sanitizing her hands. CNA1 than covered the resident's plate with the plate warmer lid without sanitizing her hands. CNA1 than transferred the resident's straw from one cup to another and proceeded to give R59 a drink from the straw. During an interview on 01/29/24 at approximately 5:30 PM, CNA1 stated that she should have washed her hands before and after feeding the residents. CNA1 further stated CNAs should wash their hands after touching the face mask and when touching a straw, they should clean their hands before or use a napkin. During an interview on 01/31/24 at 11:06 AM, the Infection Control Nurse (ICN) stated that the protocol is for staff to use hand sanitizer before and after feeding. The ICN explained that they encourage staff to not touch anything while feeding residents, but If staff touches their face mask the expectation is for them the sanitize their hands before they go back to feeding the resident. During an interview on 01/31/24 at 1:25 PM, the Director of Nursing (DON) stated that the protocol and her expectation is for staff to clean their hands with hand sanitizer before passing trays, and feeding residents. The DON stated that staff should sanitize their hands if they get soiled and if staff touch their face masks they should stop feeding and sanitize their hands before continuing. All staff receive training on hand washing during orientation, annually, and as needed.

Based on observation, record review, interview, and review of the facility policies and the Humalog KwikPen manufacture recommendations, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 32 opportunities for error, resulting in a medication error rate of 6.25%. The findings included: Error #1 On 10/30/18 at approximately 4:50 PM, during an observation of Resident #98's medication administration on the 100 hall, Registered Nurse (RN) #1 checked Resident #98's Blood Sugar (BS) which was 304. RN #1 reviewed the Medication Administration Record [REDACTED]. RN #1 prepared the Humalog KwikPen for administration by attaching the needle, and without priming the Humalog KwikPen, selected 2 units on the Humalog KwikPen Dose Knob dial and administered the insulin to Resident #98. Following the administration RN #1 verified s/he did not prime the Humalog KwikPen before administration of the insulin into Resident #98. Review of the Humolog KwikPen manufactures recommendations reveals under, Priming your Pen. Prime before each injection. Bullet (1.) states, Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the pen is working correctly. Also, bullet (2.) states, If you do not prime before each injection, you may get too much or too little. Review of the facility policy titled, Insulin PEN Administration, revealed under Prime the pen before each injection. Priming the pen gets rid of air bubbles that may be in the pen. Air bubbles can affect the flow of insulin from a pen and cause you to inject the wrong amount of insulin. Error #2 On 10/30/18 at approximately 5:50 PM, during an observation of Resident #437's medication administration on the 300 hall, Registered Nurse (RN) #2 crushed a [MEDICATION NAME] ER (Extended Release) 600 milligram (mg.) tablet and placed the medication in applesauce and administered the medication to Resident #437. During an interview immediately following the administration observation RN #2 was asked by the surveyor to review Resident #437's MAR indicated [REDACTED]#2 verified s/he crushed the [MEDICATION NAME] ER 600 mg. tablet and indicated s/he should not have. On 10/30/18 at approximately 7:30 PM, a review of Resident #437's Active Orders: 10/01/2018 - 11/01/2018 revealed physicians order stating, [MEDICATION NAME] 600 MG ER Take one by mouth twice daily -DO NOT CRUSH-. Also, under Nursing /Ancillary Orders revealed physicians order stating, (MONTH) crush meds and open capsules unless contraindicated. Review of the facility policy titled, Medications-Administering, revealed under procedure (15.) For Administering Tablets and Capsules, bullet (2.) states, Only Crush medications when necessary. Be sure to check the DO NOT CRUSH List or with the pharmacy before crushing any coated or time re-lease medication.

Based on observations, interview, and review of the facility policies and the Humalog KwikPen manufacture recommendations, the facility failed to administer the correct amount of insulin for 1 of 1 resident reviewed for insulin administration. Staff did not follow an established procedure to deliver the correct amount insulin to Resident #98. The findings included: On 10/30/18 at approximately 4:50 PM, during an observation of Resident #98's medication administration on the 100 hall, Registered Nurse (RN) #1 checked Resident #98's Blood Sugar (BS) which was 304. RN #1 reviewed the Medication Administration Record [REDACTED]. RN #1 prepared the Humalog KwikPen for administration by attaching the needle, and without priming the Humalog KwikPen, selected 2 units on the Humalog KwikPen Dose Knob dial and administered the insulin to Resident #98. Following the administration RN #1 verified s/he did not prime the Humalog KwikPen before administration of the insulin into Resident #98. Review of the Humolog KwikPen manufactures recommendations reveals under, Priming your Pen. Prime before each injection. Bullet (1.) states, Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the pen is working correctly. Also, bullet (2.) states, If you do not prime before each injection, you may get too much or too little. Review of the facility policy titled, Insulin PEN Administration, revealed under Prime the pen before each injection. Priming the pen gets rid of air bubbles that may be in the pen. Air bubbles can affect the flow of insulin from a pen and cause you to inject the wrong amount of insulin.

Based on observations, interview, and review of the Center for Disease Control (CDC) Prevention safety recommendations, the facility failed to follow infection control practices during med pass for 1 of 1 resident reviewed for finger stick blood sugar (FSBS). Infection control precautions were not taken during a FSBS check on the 100 unit. The findings included: On 10/30/18 at approximately 4:45 PM, during an observation of med pass on the 100 unit, Registered Nurse #1 used Resident #436's blood glucose monitor to check Resident #98's blood sugar (BS). Following the BS check RN#1 cleaned the blood glucose monitor with an alcohol prep pad and placed the monitor back into Resident #98's individual case on the medication cart. On 10/30/18 at approximately 4:50 PM, during an interview with RN #1, s/he verified Resident #98's BS was checked with Resident #436's blood glucose monitor and then sanitized the blood glucose monitor with an alcohol prep pad, not a solution of 1:10 concentration of sodium hypochlorite (bleach). RN #1 further indicated that all residents had their own monitor. Review of the facility policy on blood glucose monitoring, the policy did not mention the sanitization of the monitor after use. Review of the CDC prevention safety recommendations revealed under, Blood Glucose Meter, (1) Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. (2) If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.

Based on observations and interviews, the facility failed to ensure that residents seated at the same table were served and fed sequentially while others were served and eating. The facility failed to ensure dignity in dining while leaving residents at a table not served or eating, looking at other residents eat while waiting to be served and fed. Staff was observed engaged in conversation with each other and chewing gum while feeding. Staff was observed pulling a resident in a rocker geri chair from the day area down the hallway to his/her room backwards. (Unit 100 and Special Care Unit dining rooms) 2 of 5 dining areas observed. The findings included: A random lunch observation on 9/25/17 of the Special Care Unit at approximately 12:36 PM revealed staff removing food trays from the food cart. Staff was observed providing meals for residents who were capable of feeding themselves. There were two tables with 4 to 5 residents at each table that reportedly required staff to feed the residents. At the table near the day area side, there were three residents seated at the table not served or eating while two residents had meals and were eating or being fed by staff. Staff were observed feeding residents at a table while residents who required assistance with feeding were seated in the dining room not served and eating or being fed. An interview on 9/25/17 at approximately 12:51 PM with Registered Nurse (RN) #1 confirmed the findings that the residents at a table not served or eating where residents that required assistance of staff during meals. Two of the residents at the table not served or eating were looking around at other residents eating, served and/or being fed by staff. RN #1 further stated that staff will assist the residents at the table closer to Unit 100 window once they have fed the residents at the table near the day area side. Two staff members were heard making comments that I am only one person. At approximately 12:57 PM staff was observed providing food trays for some residents at the table close to the Unit 100 window side of the dining room. A Certified Nursing Aide (CNA) was observed touching a resident with his/her bare hands to re-position the resident in his/her geri chair during the meal. The CNA did not wash his/her hands prior to sitting down to feed the residents. The staff that were feeding residents were engaged in having conversations with each other and not residents during meal observation. Staff was observed chewing gum while feeding residents once residents were served. An observation on 9/25/17 at approximately 3:29 PM revealed CNA #2 pulling a resident in a rocker geri chair backwards from the day area on the Special Care Unit to the hallway to the resident's room. An interview with CNA #2 confirmed the findings. The CNA further stated the resident was seated in a chair that required the resident to be pulled backward. An interview on 9/25/17 at approximately 3:34 PM with CNA #3 who was present when CNA #2 pulled the resident backwards in the rocker geri chair stated the resident should not have been pulled backward in the chair the resident was using. A random breakfast meal observation on 9/26/17 on the Special Care Unit at approximately 9:11 AM revealed three residents at a table with staff feeding two of the residents at the table (near day area side). The third resident was not served or eating while staff fed the two other residents. The long table near the 100 unit window had five resident seated not served or eating while seated in the dining room around other residents who are eating or being fed. Staff was observed taking a meal to a resident seated with a bedside table a meal before serving all the residents seated at the same table. At approximately 9:14 AM a resident at the table not served was observed looking around at residents being feed at a table near him/her. An interview and observation on 9/26/17 at approximately 9:16 AM with RN #1 confirmed the findings. RN #1 stated the residents in the dining room will be fed once staff was available. During meal observation, staff was observed engaged in conversations with each other and not the resident they were feeding. Staff was also observed chewing gum while feeding residents. At approximately 9:20 AM during breakfast, three residents were served at a long table near Unit 100. There were two other residents not served. The one resident that was looking around at other residents eat was still looking around. At 9:25 AM the resident who was looking around had food a tray placed in front of him/her but staff was engaged in conversation with another CNA before feeding the resident. A random lunch meal observation on 9/26/17 at approximately 12:48 PM revealed residents seated at the same table not served or fed sequentially. There were four residents seated at the table that required assistance with feeding with one resident not eating or being fed while others are eating. Staff continued to engage in conversation with each other while feeding the residents. An interview on 9/27/17 at approximately 9:26 AM with the Director of Nursing revealed the facility does not have a policy on etiquette in dining. During observation of lunch on unit 1 on 9/25/2017 at 12:15 PM, lunch trays were not passed to tables sequentially. Three residents were observed seated at a table and 2 of the 3 were served lunch. Staff then served the next table. At 12:18 PM, the 3rd resident at the aforementioned table was served lunch.

Based on observation and interview the facility failed to ensure food was distributed and served with professional standards for safety. A facility employee was observed to enter the kitchen area when food was being plated for distribution not wearing a hair net or washing his/her hands. In addition trays were delivered from the dining room to resident rooms without covering all the food items intended for resident consumption. The findings included: During a second observation of the main kitchen on 9/16/17 at 12:10 PM, an activity assistant entered the kitchen area from the hall . The assistant walked into the kitchen and up to the area behind the serving line where the lunch meal was being plated for the residents. This employee did not wash his/her hands nor put on a hair restraint before entering the serving line area. The Dietary Manager was notified immediately who went to talk to the employee. The employee told the manager he/she knew he/she was not supposed to enter the dietary area but every one was busy and he/she decided to look for silverware on his/her own. At 1:30 PM an interview was held with the Activity Director who showed documents that she had done a Performance Coaching sheet with the employee for failure to follow a better way which resulted in negative customer outcome. Documents were presented showing employee was inserviced on infection control issues during orientation on 2/21/17. There was also a sign posted outside the kitchen door Documenting Only Kitchen Employees Allowed. An interview with the Dietary Manager on 9/26/17 at 11:30 AM confirmed that deserts and salads should be covered on the meal trays if staff carried trays down the hall. No covers were required only if the food cart was parked in front of the resident room to be served. Then the tray could be taken off the cart and taken directly into the resident room. The Dietary Manager further stated that the covers were on the beverage carts on each hall for the staff to use. The manager also stated that nursing did an inservice with the nursing staff on covering food when delivering trays. During a random lunch meal observation on 9/25/17 at approximately 12:36 PM in the Special Care Unit, food trays with uncovered foods such as pudding and/or pies were delivered from the dining room to resident rooms on the hallway. At approximately 12:40 PM a staff member with hair in a pony tail was observed holding a food tray high up close to his/her hair with pie not covered. At approximately 12:43 PM Registered Nurse #3 asked staff if they had enough covers to take desserts down hallway. There were no covers provided with the food cart. During lunch meal observation on 9/26/17 at approximately 12:33 PM in the Special Care Unit, food trays with uncovered foods such as brownies and toss salad were delivered from the dining to resident rooms on the hallway. An interview on 9/26/17 at approximately 12:35 PM with Certified Nursing Aide (CNA) #1 confirmed the findings. Further observation of the food cart revealed there were no food covers available. At approximately 12:45 PM staff located food covers for food to be delivered from the dining room to the hallway.

Based on record review and interview, the facility failed to ensure that physician's orders for labs were followed for 1 of 5 sampled residents reviewed for unnecessary medications. Resident #60 did not get [MEDICATION NAME] level labs done per physician's orders and as found to be an intervention in the resident's care plan. The findings included: The facility admitted Resident #60 with [DIAGNOSES REDACTED]. A review of the medical record on 9/26/17 at approximately 11:26 AM revealed a physician's order dated 8/23/17 requested a Complete Metabolic Panel, Magnesium, Complete Blood Count and [MEDICATION NAME] level laboratory be performed. The record revealed labs were done on 8/24/17 for Complete Metabolic Panel, Magnesium and Complete Blood Count. There was no documentation to indicate Resident #60 had the [MEDICATION NAME] level laboratory as ordered by the physician. There was a list of physician's visits in the medical record which indicated the physician completed an annual physical for Resident #60 on 8/23/17. A copy of the physician's report on 8/23/17 was unavailable during survey. The medical records staff stated the physician needed to make some changes prior to submitting the report. Further record review revealed a care plan updated on 8/07/17 that indicated in the problem area: resident on 9 plus medications and at risk for adverse side effects and drug interactions. The approach on the care plan indicated obtain lab values as ordered and assess for signs of medication interactions: abnormal vitals and abnormal labs. An interview on 9/26/17 at approximately 12:04 PM with Registered Nurse (RN) #2 confirmed the [MEDICATION NAME] level laboratory was not done as ordered. RN #2 further stated that he/she could not find any documentation that the physician canceled or discontinued the [MEDICATION NAME] level labs but he/she will talk with the physician. During an interview on 9/26/17 at approximately 12:20 PM, RN #2 stated he/she spoke with the nurse practitioner and the [MEDICATION NAME] level labs will be done stat (immediately).

Based on review of facility files and interview, the facility failed to periodically review and revise the resident's comprehensive care plan. Resident #3's care plan was not updated to reflect bilateral [MEDICAL CONDITION] and anticoagulant therapy. 1 of 5 residents reviewed for care plans. The findings included: Review of Resident #3's Medication Order revealed an order for [REDACTED].#3's Ultrasound Report dated 3/4/16 revealed Doppler results that indicated Acute Right and Left lower extremity [MEDICAL CONDITIONS]. Review of the physician's orders [REDACTED]. Review of Resident #3's Complete Patient Care Plan dated 2/18/16 revealed there was no documentation related to the resident having bilateral [MEDICAL CONDITION] and receiving anticoagulant therapy. Review of the facility's [MEDICATION NAME] Responsibilities of the Nursing Department policy revealed the MDS Coordinator and Nurse will assure an anticoagulant therapy problem is included in the resident's Patient Care Plan and that it includes monitoring for signs and symptoms of bleeding, [MEDICAL CONDITION] Embolism and [MEDICAL CONDITION]. In an interview with the surveyor on 5/3/16 at approximately 5:40 PM, the Director of Nursing reviewed Resident #3's care plan and confirmed that it was not updated to reflect anticoagulant therapy. In an interview with the surveyor on 5/3/16 at approximately 5:50 PM, the ADON (Assistant Director of Nursing) reviewed Resident #3's care plan and confirmed it was not updated to reflect the resident had [MEDICAL CONDITION] and was receiving anticoagulant therapy.