Every finding on record at Patewood Post Acute

Based on facility policy review, record review, observation, and interview, the facility failed to ensure medications were stored safely and securely for 2 (Resident (R)3 and R119) of 8 residents reviewed during the medication administration task and 1 (R120) of 3 sampled residents who had medications in their room. Findings included: Review of a facility policy titled, Storage of Medications, revised November 2020, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The policy further indicated, 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 1. Review of an admission Record indicated the facility admitted R3 on 04/17/2026. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of spondylosis with myelopathy and polyneuropathy. Review of R3's Order Summary Report, with active orders as of 05/21/2026, included an order, dated 04/17/2026, for acetaminophen (a miscellaneous analgesic) oral tablet 325 milligram (mg), two tablets every six hours for pain. The Order Summary Report included an order, dated 04/27/2026, for gabapentin oral capsule 300 mg, one capsule two times a day for neuropathy. Review of an admission Record indicated the facility admitted R119 on 03/22/2026. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of acquired absence of right leg below the knee and gastro-esophageal reflux disease (GERD) without esophagitis.Review of R119's Order Summary Report, with active orders as of 05/20/2026, included an order, dated 04/23/2026, for gabapentin capsule 100 mg, one capsule by mouth two times a day for neuropathy/right lower extremity phantom limb pain. The Order Summary Report included an order, dated 04/08/2026, for famotidine (a gastrointestinal agent) oral tablet 20 mg, one tablet by mouth every morning and at bedtime for GERD. During an observation of the 200 Hallway on 05/20/2026 at 4:36 AM, two medication cups were observed stacked on a medication cart with medications in them. During an interview at the time of the observation, Licensed Practical Nurse (LPN)2 stated that it was not her medication cart and stated that medications should never be left out and unattended on the cart. LPN2 stated the cart was LPN30's, and she was on break. LPN2 stated that the medication in the first cup contained two tablets and one capsule, and the second medication cup contained one capsule and one tablet. The medication cart was locked, and no residents were observed in the area. During an interview on 05/20/2026 at 4:44 AM, LPN30 stated that she pulled the medications prior to going on break and confirmed the medication in one cup was two acetaminophen and one gabapentin for R3 and one gabapentin and one famotidine in the second cup for R119. LPN30 stated that she should not have pulled the medication prior to going on break but had one hour before and one hour after to administer the medication and wanted to have it ready when she came back from break.2. Review of an admission Record indicated the facility admitted R120 on 04/17/2026. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of unspecified bilateral pre-glaucoma.Review of R120's five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/23/2026, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition.Review of R120's Order Summary Report, with active orders as of 05/21/2026, included an order, dated 04/16/2026, for timolol maleate ophthalmic (an antiglaucoma) solution 0.5 %, instill one drop in both eyes two times a day for glaucoma. During an interview on 05/20/2026 at 1:28 PM, R120 stated that the nurse brought in eye drops and placed them on their bedside table when they (R120) were in the bathroom. The resident stated that they administered the medication that day to themselves, and they were waiting for the nurse to come back and get them. The resident stated that the staff typically administered the medication to them (R120), but they did not that day. The resident stated that they took timolol maleate ophthalmic. During an interview on 05/20/2026 at 2:35 PM, Registered Nurse (RN)24 stated she left the timolol eye drops in R120's room on the bedside table. She stated that she knew she should not have left the medication.During an interview on 05/21/2026 at 11:23 AM, Nurse Practitioner (NP)18 stated her expectation was to give one medication at a time and secure them.During a telephone interview on 05/21/2026 at 11:46 AM, the Consultant Pharmacist (CP) stated that the expectation was for staff to administer medication to one resident at a time and keep medication in a locked cabinet. During an interview on 05/21/2026 at 2:39 PM, Licensed Practical Nurse (LPN)33, who was a unit manager, stated that her expectation was to have the medications secured on a medication cart.During an interview on 05/21/2026 at 3:19 PM, the Administrator stated that the expectation was for medications to be locked in the medication cart.During an interview on 05/21/2026 at 3:32 PM, the Director of Nursing (DON) stated that nurses were expected to not leave medication at a resident's bedside and to secure the medication.

Based on interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors, which affected 1 (Resident (R)72) of 25 sampled residents. Specifically, the facility failed to provide prescription eye drops per the physician orders for R72. Findings included: Review of a facility policy titled, Administering Medications, revised April 2019, indicated, Medications are administered in a safe and timely manner and as prescribed. The policy further indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include, which included a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication of food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan. Review of a facility policy titled, Instillation of Eye Drops, revised January 2014, specified, The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes. The policy revealed, Reporting included 1. Notify the supervisor if the resident refuses the care, and 2. Report other information in accordance with facility policy and professional standards of practice. Review of a facility policy titled, Medication and Treatment Orders, revised July 2016, revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing. The policy specified,11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Review of an admission Record indicated the facility admitted R72 on 02/13/2025. According to the admission Record, the resident had a medical history that included but was not limited to a diagnoses of type 2 diabetes mellitus (a disease where the body cannot use insulin properly resulting in high blood sugar levels that can cause damage to other body systems and organs) with diabetic mononeuropathy (localized nerve damage to one nerve caused by diabetes), noninfective gastroenteritis (inflammation of the stomach and intestines not caused by bacteria) and colitis (chronic inflammation of the bowel), and hypertension (high blood pressure). Review of a five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/02/2025, revealed R72 and a Brief Interview for Mental Status (BIMS) score of 14 out 14, which indicated the resident had intact cognition. The MDS indicated the resident had impaired vision and wore corrective lenses.Review of R72's CAA [Care Area Assessment] Worksheet, with an ARD of 10/02/2025, revealed R72 had glaucoma, diabetic retinopathy, decreased visual acuity, and a visual field deficit. The CAA further indicated that the resident wore glasses to correct their vision.Review of a quarterly MDS, with an ARD of 04/22/2026, revealed R72 had a BIMS score of 14 out 15, which indicated the resident had intact cognition. The MDS indicated that the resident wore corrective lenses for their vision. Review of R72's Care Plan Report included a focus area initiated 02/17/2025, that indicated the resident was at risk for complications of diabetes. Interventions directed staff to administer the resident's medications as ordered (initiated 02/17/2025). Review of R72's March 2026 Medication Administration Record [MAR] revealed a transcription of an order, dated 09/11/2025, for latanoprost (an ophthalmic glaucoma agent) solution 0.005%, instill one drop in both eyes at bedtime (9:00 PM) for glaucoma. The MAR indicated that staff documented a 9, Other/See Nurses Notes, which indicated the medication was not given, on 03/16/2026, 03/18/2026, 03/20/2026, 03/21/2026, 03/22/2026, 03/24/2026. 03/25/2026, and 03/27/2026.Review of R72's Progress Notes revealed staff documented that latanoprost solution 0.005% was ordered, on order, awaiting delivery, awaiting, awaiting supply, or Awaiting pharmacy, on 03/16/2026, 03/20/2026, 03/21/2026, 03/22/2026, 03/25/2026, and 03/27/2026. During an interview on 05/18/2026 at 10:03 AM, R72 stated they had not had eye drops for glaucoma in the last week. During an interview on 05/19/2026 at 10:21 AM, R72 stated they had not received their eye drops. The resident stated they had asked different nurses about their eye drops, and they said the staff stated there was an issue with the pharmacy and had not gotten them yet. R72 stated they would go blind eventually if they did not get the eye drops. Review of R72's Progress Notes included a note, dated 05/06/2026 and electronically signed by Nurse Practitioner (NP)34, that revealed the order dated 09/11/2025 for latanoprost solution 0.005%, one drop in both eyes at bedtime for glaucoma, was an active order.Review of R72's May 2026 Medication Administration Record revealed a transcription of an order, dated 09/11/2025, for latanoprost solution 0.005%, instill one drop in both eyes at bedtime (9:00 PM) for glaucoma. The MAR indicated that staff documented a 9, Other/See Nurses Notes, which indicated the medication was not given, on 05/06/2026, 05/10/2026, 05/11/2026, 05/12/2026, 05/16/2026, 05/17/2026, 05/18/2026, and 05/19/2026. Review of R72's Progress Notes revealed staff documented that latanoprost solution 0.005% was on order, awaiting, or ordered, on 05/07/2026 (1:07 AM), 05/10/2026, 05/11/2026, 05/12/2026, 05/16/2026, 05/17/2026, 05/18/2026 and 05/19/2026. During an interview on 05/20/2026 at 5:03 AM, Licensed Practical Nure (LPN)2, who documented on R72's MAR that the eye drops were not given on 05/06/2026, 05/12/2026, and 05/19/2026, stated she had worked two nights, and that she would not have followed up with the pharmacy or physician because the day shift staff stated that R72's eye drops were on order. During a phone interview on 05/20/2026 at 3:56 PM, Registered Nurse (RN)21, who documented on R72's MAR that the eye drops were not given on 05/10/2026, 05/11/2026, 05/16/2026, 05/17/2026, and 05/18/2026, stated they were waiting for the eye medication for R72, and that she passed the information on to the day shift nurse to get an order. RN21 stated she did not contact the physician, NP, or the pharmacy to let them know the medication was out since day shift staff told her that the drops were on order. During an interview on 05/19/2026 at 2:34 PM, RN22 stated they called the pharmacy if they ran out of medications for a resident. RN22 further stated that they could also scan a sheet and fax it over to the pharmacy. RN22 stated there was no consistent staffing on the medication cart and that he did not inform the LPN33, who was a unit manager, or NP18 of R72's missing eye drops because they were not given during his shift.During an interview on 05/19/2026 at 4:20 PM, LPN33 stated the electronic medical record (EMAR) showed a dropdown box that turned grey if the medication was ordered, and that the nurse should have called the pharmacy for the status of the medication and made her aware of the missing medication. She stated that the nurse had a code 9 that showed up on the EMAR if the medication was not available, and the nurses documented the information on a progress note. LPN33 stated she expected to see notes that the pharmacy and provider were notified, not the progress note that said awaiting or on order. LPN33 stated R72's eye drops were for glaucoma and primarily given at bedtime, and without the medication, the resident could potentially lose vision. During a telephone interview on 05/21/2026 at 11:46 AM, the Consultant Pharmacist (CP) stated her expectation was that staff administer R72's medication as ordered, and if they could not find it, look in the refrigerator first, then call the pharmacy. The CP further stated that vision could decrease without the medication.During an interview on 05/21/2026 at 3:32 PM, the Director of Nursing (DON) stated the nurses should notify the leadership team if they had pharmacy issues and stated the side effects for not receiving glaucoma drops would be a discussion to have with the provider.During an interview on 05/21/2026 at 10:54 AM, NP18 stated they had books for the staff to document concerns, and there was no documentation that R72 was missing eye drops. NP18 stated they were not made aware of missing eye drops until 05/20/2026. NP18 stated that R72 was on latanoprost prior to coming into the facility, and that the medication was continued. NP18 stated the eye medication was used to prevent or slow the worsening of eye disease.During an interview on 05/21/2026 at 3:19 PM, the Administrator (ADM) stated his expectation was for the nurses to document accurately, call the pharmacy to get the medication before they ran out or if they could not find it, and to notify the physician and family of the situation.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure safe insulin administration for 1 (Resident (R)88) of 2 residents reviewed for insulin administration. Specifically, Licensed Practical Nurse (LPN)30 failed to verify R88's insulin order prior to preparing insulin for administration and failed to immediately document the insulin administration. The facility also failed to follow a procedure to ensure staff accurately acquired, received, and administered medicated eye drops for 1 (R72) of 25 sampled residents.Findings included: 1. Review of a facility policy titled, Administering Medications, revised April 2019, indicated, Policy Statement - Medications are administered in a safe and timely manner and as prescribed. The policy also specified, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. The policy also specified, 22. The individual administering the medication initials the resident's MAR [Medication Administration Record] on the appropriate line after giving each medication and before administering the next ones. The policy also revealed, 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable): and g. The signature and title of the person administering the drug. Review of an admission Record indicated the facility admitted R88 on 05/06/2026. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of Type 2 diabetes mellitus without complications.Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/13/2026, revealed R88 had a Brief Interview for Mental Status (BIMS) score of 14 out 15, which indicated the resident was cognitively intact. The MDS revealed R88 received insulin seven days of the 7-day look-back period.Review of R88's Care Plan Report included a focus area, initiated 05/06/2026, that indicated the resident had diabetes mellitus. Interventions directed staff to administer diabetes medication as ordered by the doctor and to monitor and document for side effects and effectiveness.Review of R88's Order Summary Report, with active orders as of 05/20/2026, revealed an order, dated 05/09/2026, for Humalog (insulin lispro) Solution 100 units per milliliter (units/ml), to inject Humalog per the sliding scale, and if blood glucose was 251 - 300 to administer six units of insulin.During a medication administration task observation and concurrent interview on 05/20/2026 at 5:16 AM, Licensed Practical Nurse (LPN)30 stated R88's blood glucose was 253. LPN30 opened the medication cart that was not equipped with a computer, stated R88 took insulin lispro (a fast-acting insulin), and removed an insulin lispro bottle, dated 05/10/2026, from the medication cart. LPN30 stated R88 received six units of insulin. LPN30 stated they knew the residents, and they did not look at the computer when giving medications, as they had the residents' physicians' orders in their (LPN30's) head. The observation revealed LPN30 did not look at R88's medication orders to verify the medication sliding scale. LPN30 stated she did not use the computer to verify the insulin as she knew her residents and knew that R88 should get about six units based on a blood glucose of 253. LPN30 stated that she was not concerned about medication changes as she would have been notified. The observation revealed LPN30 removed the insulin lispro and drew up six units of insulin lispro and then started to walk toward R88. The observation revealed LPN30 was stopped and asked to verify the insulin orders, and she stated she would verify them if she needed to. The observation revealed LPN30 disposed of the insulin, went to a computer in the dining area and verified the needed insulin was six units, returned to the medication cart, drew up the insulin, and administered the insulin to R88. After administering the insulin to R88, LPN30 did not check off in the records that she gave the insulin; instead, she walked to the nurse's station and printed the census report. LPN30 stated that she recorded all residents' medication as given once she completed the medication administration.During an interview on 05/21/2026 at 11:23 AM, Nurse Practitioner (NP)18 stated that insulin dosage should be verified at the time of drawing up insulin, and it was poor practice on the nurse's part to draw up insulin without verifying the order on the computer.During an interview on 05/21/2026 at 11:46 AM, the Consultant Pharmacist (CP) stated her expectation was that the medication order be reviewed prior to giving medication and that blood glucose and the units of insulin administered were documented in the computer at the time they were given. During an interview on 05/21/2026 at 2:39 PM, LPN33, who was a unit manager, stated her expectation was that the physician's order should be checked and to never go by memory when a resident's blood glucose was checked. LPN33 stated the nurse needed to double-check the orders to see if the order had changed. During an interview on 05/21/2026 at 3:19 PM, the Administrator (ADM) stated the nurse should have looked on the computer to verify the order before giving the insulin.During an interview on 05/21/2026 at 3:32 PM, the Director of Nursing (DON) stated her expectation was that the nurse should verify the insulin order, document the blood glucose, and document the administration of insulin afterwards. The DON stated the nurse should keep the computer with them to verify the orders and should never give insulin without looking at the order. 2. Review of a facility policy titled, Medication and Treatment Orders, revised July 2016, revealed, Orders for medications and treatments will be consistent with principles of safe and effective order writing. The policy specified, 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available.Review of an undated facility policy titled, Pharmacy Services revealed, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. The policy revealed, 4. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. The policy revealed, 5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. The policy revealed, 7. Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice. Review of a facility policy titled, Instillation of Eye Drops, revised January 2014, specified, The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes. The policy revealed, Reporting included 1. Notify the supervisor if the resident refuses the care, and 2. Report other information in accordance with facility policy and professional standards of practice. Review of a five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/02/2025, revealed R72 and a Brief Interview for Mental Status (BIMS) score of 14 out 15, which indicated the resident had intact cognition. The MDS indicated the resident had impaired vision and wore corrective lenses.Review of R72's CAA [Care Area Assessment] Worksheet, with an ARD of 10/02/2025, revealed R72 had glaucoma, diabetic retinopathy, decreased visual acuity, and a visual field deficit. The CAA further indicated that the resident wore glasses to correct their vision.Review of a quarterly MDS, with an ARD of 04/22/2026, revealed R72 had a BIMS score of 14 of 15, which indicated the resident had intact cognition. The MDS indicated that the resident wore corrective lenses for their vision.Review of R72's Care Plan Report included a focus area initiated 02/17/2025, that indicated the resident was at risk for complications of diabetes. Interventions directed staff to administer the resident's medications as ordered (initiated 02/17/2025). During an interview on 05/18/2026 at 10:03 AM, R72 stated they had not had eye drops for glaucoma in the last week.During an interview on 05/19/2026 at 10:21 AM, R72 stated they had not received their eye drops. The resident stated they had asked different nurses about their eye drops, and they said the staff stated there was an issue with the pharmacy and had not gotten them yet. R72 stated they would go blind eventually if they did not get the eye drops. Review of R72's Progress Notes included a note, dated 05/06/2026 and electronically signed by Nurse Practitioner (NP)34, that revealed the order dated 09/11/2025 for latanoprost solution 0.005%, one drop in both eyes at bedtime for glaucoma, was an active order.Review of R72's May 2026 Medication Administration Record revealed a transcription of an order, dated 09/11/2025, for latanoprost solution 0.005%, instill one drop in both eyes at bedtime (9:00 PM) for glaucoma. The MAR indicated that staff documented a 9, Other/See Nurses Notes, which indicated the medication was not given, on 05/06/2026, 05/10/2026, 05/11/2026, 05/12/2026, 05/16/2026, 05/17/2026, 05/18/2026, and 05/19/2026. Review of R72's Progress Notes revealed staff documented that latanoprost solution 0.005% was on order, awaiting, or ordered, on 05/07/2026 (1:07 AM), 05/10/2026, 05/11/2026, 05/12/2026, 05/16/2026, 05/17/2026, 05/18/2026 and 05/19/2026.During an interview on 05/20/2026 at 5:03 AM, Licensed Practical Nurse (LPN)2, who documented on R72's MAR that the eye drops were not given on 05/06/2026, 05/12/2026, and 05/19/2026, stated she had worked two nights, and that she would not have followed up with the pharmacy or physician because the day shift staff stated that R72's eye drops were on order.During a phone interview on 05/20/2026 at 3:56 PM, Registered Nurse (RN)21, who documented on R72's MAR that the eye drops were not given on 05/10/2026, 05/11/2026, 05/16/2026, 05/17/2026, and 05/18/2026, stated they were waiting for the eye medication for R72, and that she passed the information on to the day shift nurse to get an order. RN21 stated she did not contact the physician, NP, or the pharmacy to let them know the medication was out since day shift staff told her that the drops were on order.During an interview on 05/19/2026 at 2:34 PM, RN22 stated they called the pharmacy if they ran out of medications for a resident. RN22 further stated that they could also scan a sheet and fax it over to the pharmacy. RN22 stated there was no consistent staffing on the medication cart and that he did not inform the LPN33, who was a unit manager, or NP18 of R72's missing eye drops because they were not given during his shift.During an interview on 05/19/2026 at 4:20 PM, LPN33 stated the electronic medical record (EMAR) showed a dropdown box that turned grey if the medication was ordered, and that the nurse should have called the pharmacy for the status of the medication and made her aware of the missing medication. She stated that the nurse had a code 9 that showed up on the EMAR if the medication was not available, and the nurses documented the information on a progress note. LPN33 stated she expected to see notes that the pharmacy and provider were notified, not the progress note that said awaiting or on order.During a telephone interview on 05/21/2026 at 11:46 AM, the Consultant Pharmacist (CP) stated her expectation was that staff administer R72's medication as ordered, and if they could not find it, look in the refrigerator first, then call the pharmacy.During an interview on 05/21/2026 at 3:32 PM, the Director of Nursing (DON) stated the nurses should notify the leadership team if they had pharmacy issues.During an interview on 05/21/2026 at 10:54 AM, NP18 stated they had books for the staff to document concerns, and there was no documentation that R72 was missing eye drops. NP18 stated they were not made aware of missing eye drops until 05/20/2026. NP18 stated that R72 was on latanoprost prior to coming into the facility, and that the medication was continued.During an interview on 05/21/2026 at 3:19 PM, the Administrator (ADM) stated his expectation was for the nurses to document accurately, call the pharmacy to get the medication before they ran out or if they could not find it, and to notify the physician and family of the situation.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff followed physician's orders for the use of supplemental oxygen for 2 (Resident (R)26 and R114) of 2 sampled residents reviewed for oxygen therapy. Findings included: Review of a facility policy titled, Oxygen Administration, revised 10/2019, revealed, Purpose - The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation - 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of a facility policy titled, Administering Medications, revised 04/2019, revealed, Policy Statement - Medications are administered in a safe and timely manner, and as prescribed. The policy also indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 1. Review of an admission Record revealed the facility admitted R26 on 12/09/2021. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of acute respiratory failure with hypoxia, unspecified asthma, and anxiety disorder. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/15/2026, revealed R26 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition.Review of R26's Care Plan Report, included a focus area, initiated 05/18/2026, that indicated the resident required the use of continuous oxygen related to congestive heart failure. Interventions directed staff to: break tasks into sub-tasks and encourage the resident to take frequent rests; change humidification and oxygen tubing as indicated; keep room cool and free of irritants; obtain laboratory testing as ordered and report abnormal findings to the physician; monitor and report signs of hypoxia; and observe oxygen precautions. Review of R26's Order Summary Report, with active orders as of 05/18/2026, included a physician's order for oxygen at 4 liters per minute (L/min) via a nasal cannula (NC, a thin flexible tube to deliver oxygen to the nose) every shift, started 12/13/2024. During a concurrent observation and interview on 05/18/2026 at 10:27 AM, revealed R26 sitting in bed with oxygen in use via a NC. R26 stated the oxygen was supposed to be infused at 4 L/min; however, the observation revealed the oxygen concentrator flow rate was observed at 3 L/min per NC.During an observation on 05/18/2026 at 1:41 PM, revealed R26 sitting in bed with oxygen infusing at 3 L/min via NC. During a concurrent observation and interview on 05/18/2026 at 2:59 PM, Licensed Practical Nurse (LPN)25, who was a unit manager, revealed R26's oxygen flow rate was set at between 3.5 L/min and 4 L/min, and the oxygen flow rate should have been set at 4 L/min. LPN25 stated that the floor nurses were responsible for monitoring the physician-ordered oxygen flow rate. LPN25 stated she had not checked R26's oxygen flow rate prior to the current observation because she had just taken over for a nurse who had to leave early. LPN25 stated that she expected oxygen to be administered per the physician's order. During a concurrent observation and interview on 05/19/2026 at 9:38 AM, R26 was observed sitting in bed on top of a mechanical lift pad, and the resident did not have oxygen on. The observation revealed NC tubing was lying on the bed behind the resident's back under their right arm. The observation revealed that the oxygen concentrator was turned off. R26 stated that a Certified Nursing Assistant (CNA) had removed the oxygen tubing and turned off the oxygen concentrator because they were getting the resident ready to get up for activities. The observation revealed there were no staff in the room with the resident at that time. During a concurrent observation and interview on 05/19/2026 at 9:41 AM, CNA26 and CNA27 entered R26's room with a mechanical lift. CNA26 stated that she had removed the oxygen from R26's nose to get the resident up from the bed, and that was the normal procedure and what they always did when they got R26 up into the wheelchair. CNA26 stated that R26 did not wear oxygen when they were out of bed, and removing the oxygen to get the resident up was the procedure she had been instructed to do by various nurses. CNA26 stated that CNAs were allowed to remove/turn off a resident's oxygen as needed. During an interview on 05/20/2026 at 3:39 PM, CNA26 stated different nurses had instructed her that when R26's oxygen saturation (blood hemoglobin oxygen saturation) was below 90% the CNAs could put the resident's oxygen back on, and, other than that, the resident did not need to wear oxygen. CNA26 stated they were not aware of the physician's order requiring R26 to wear the oxygen continuously. CNA26 stated that since 05/19/2026 they had spoken with nursing management and learned that oxygen was considered a medication and could not be applied or removed by a CNA when giving care. During an interview on 05/21/2026 at 1:28 PM, the Director of Nursing (DON) stated that the assigned nurse was responsible for monitoring the resident's oxygen flow rate per the physician's order. The DON stated she expected nurses to round (systematic, scheduled nursing staff visits to check on residents) every two hours and check oxygen flow rates to ensure they were per the physicians' orders, and she expected staff to follow physicians' orders. The DON verified that R26's ordered oxygen flow rate was for 4 L/min via a NC continuously on 05/18/2026 when the resident's oxygen flow rate was observed below 4 L/min. The DON stated R26 would not have been able to change the oxygen flow rate themself. During an interview on 05/21/2026 at 2:10 PM, the Administrator (ADM) stated he expected physicians' orders to be followed. The ADM stated he expected the assigned nurse to monitor oxygen flow rates on rounds each shift and to keep the oxygen flow rate at the physician-ordered rate. 2. Review of an admission Record revealed the facility admitted R114 on 05/27/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of hypoxemia and adult failure to thrive.Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2026, revealed R114 had a BIMS score of 15 out 15, which indicated the resident had intact cognition. Review of R114's Care Plan Report, included a focus area, revised 06/10/2025, that indicated the resident was dependent on oxygen related to hypoxemia. Interventions directed staff to: administer oxygen at 3 liters per minute (L/min) via a nasal cannula (NC, a thin flexible tube to deliver oxygen to the nose) (06/10/2025); keep the room cool and free of irritants (05/28/2025); and obtain laboratory testing as ordered and report abnormal findings to the physician (05/28/2025).Review of R114's Order Summary Report, with active orders as of 05/18/2026, included an order for oxygen at 3 L/min via a NC every shift, started 05/27/2025.During an observation on 05/18/2026 at 9:53 AM, revealed R114 sitting in bed with oxygen in use via a NC, and the oxygen concentrator flow rate was set at 2.5 L/min. R114 stated that the oxygen flow rate was supposed to be set at 2 L/min. During an observation on 05/18/2026 at 1:38 PM, revealed R114 sitting in bed watching television with an oxygen flow rate of 2.5 L/min via a NC. During an interview on 05/18/2026 at 2:54 PM, Licensed Practical Nurse (LPN)25, who was a unit manager, verified R114 had a physician's order for oxygen at 3 L/min via NC continuously to maintain an oxygen saturation (blood hemoglobin oxygen saturation) above 90%.During a concurrent observation and interview with LPN25 on 05/18/2026 at 3:06 PM, R114 was observed sitting in bed with oxygen via a NC in use. LPN25 verified that the flow rate on R114's oxygen concentrator was set at 2 L/min via a NC and stated it should be set at 3 L/min. LPN25 stated she expected all staff to follow physicians' orders for oxygen administration.During an interview on 05/20/2026 at 3:01 PM, LPN28 stated she had been responsible for R114's care on 05/18/2026. LPN28 stated R114 had a physician's order for continuous oxygen at 3 L/min via a NC, and physician's orders were to be followed.During an interview on 05/21/2026 at 1:28 PM, the Director of Nursing (DON) stated that the assigned nurse was responsible for monitoring the resident's oxygen flow rate per the physician's order. The DON stated she expected nurses to round (systematic, scheduled nursing staff visits to check on residents) every two hours and check oxygen flow rates to ensure they were per the physicians' orders, and she expected staff to follow physicians' orders. The DON verified R114's ordered oxygen flow rate was 3 L/min via a NC continuously to keep the resident's oxygen saturation above 90%.During an interview on 05/21/2026 at 2:10 PM, the Administrator (ADM) stated he expected physicians' orders to be followed. The ADM stated he expected the assigned nurse to monitor oxygen flow rates on rounds each shift and to keep the oxygen flow rate at the physician-ordered rate.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure medications were administered by only licensed staff and with a physician's order for 1 (Resident(R)26) of 3 sampled residents who had medications in their room. Findings included: Review of a facility policy titled, Medication and Treatment Orders, revised in July 2016, revealed, 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medication in this state. Review of a facility policy titled, Administering Medications, revised in April 2019, revealed, 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. Review of an admission Record revealed the facility admitted R26 on 12/09/2021. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of acute respiratory failure with hypoxia, unspecified asthma, and anxiety disorder. Review of a Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/15/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. During a concurrent observation and interview on 05/18/2026 at 10:27 AM, R26 was sitting up in bed with a three-ounce bottle of Remedy clinical fungal powder (miconazole nitrate 2% antifungal) on the nightstand. R26 stated they self-administered the antifungal powder under their breasts. R26 stated they usually applied the antifungal powder one time a day, every couple of days after showers on Tuesdays and Fridays. Review of R26's Care Plan Report, revealed no evidence to indicate the resident received an antifungal powder. Review of R26's Order Summary Report, with active orders as of 05/18/2026, revealed no evidence of an order for miconazole antifungal powder. Review of an undated facility document titled, Physicians Services Group Standing Orders, indicated, These orders are standard PRN [pro re nata, as needed] orders designed to streamline care delivery and eliminate lag times in patient care. All orders should be cross-referenced with patient allergies. The document revealed no evidence of a standing order for miconazole 2% antifungal powder. During an interview on 05/19/2026 at 9:38 AM, Certified Nursing Assistant (CNA)26 stated that R26 applied the miconazole 2% antifungal powder as needed. CNA26 said she assisted the resident in applying the antifungal powder if the resident asked for assistance. CNA26 stated the miconazole 2% antifungal powder was kept in the facility's central supply room, and she could get it for any resident that needed it. Per CNA26, there were multiple residents that used the miconazole 2% antifungal powder.During an interview on 05/20/2026 at 10:09 AM, the Administrator confirmed there were no standing physician orders for antifungals. During an interview on 05/20/2026 at 3:01 PM, Licensed Practical Nurse (LPN)28 stated no one should have access to miconazole 2% antifungal powder but the CSM, nurse manager, or nurses. LPN28 stated R26 did not have a physician order for miconazole 2% antifungal powder. During an interview on 05/21/2026 at 11:21 AM, the Central Supply Manager (CSM) confirmed the miconazole 2% antifungal powders were placed in the clean utility rooms every Monday, Wednesday, and Friday. The CSM stated he did not know who could use the miconazole 2% antifungal powder; he just placed it in the utility closet. The CMS did not think the miconazole 2% antifungal cream or powder required a physician's order and was not aware it was a medication. During an interview on 05/21/2026 at 1:12 PM, LPN29 stated that miconazole 2% antifungal powder required a physician's order and had to be applied by a nurse. During an interview on 05/21/2026 at 1:28 PM, the Director of Nursing (DON) stated miconazole 2% antifungal powder could only be applied by a nurse since it was considered a medication and required a physician order. The DON stated R26 did not have a physician's order for miconazole 2% antifungal powder. During a follow-up interview on 05/21/2026 at 2:10 PM, the Administrator stated that CNAs were not allowed to administer antifungal powder to residents.

Based on facility policy review, interview, and record review, the facility failed to ensure residents who self-administered medications were assessed as safe to self-administer medications, which affected 2 (Resident (R)134 and R26) of 3 sampled residents who had medications in their room. Findings included: Review of a facility policy titled, Self-Administration of Medication, revised February 2021, revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy revealed, 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self- administering medications is safe and clinically appropriate for the resident. The policy revealed, 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. Review of a facility policy titled, Administering Medications, revised 04/2019, revealed, 27. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. 1. Review of an admission Record revealed the facility admitted R134 on 05/08/2026. According to the admission Record, the resident had a medical history that included but was not limited to a diagnosis of unspecified displaced fracture of surgical neck of left humerus, subsequent encounter for fracture with routine healing. Review of A five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/14/2026, revealed R134 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident had intact cognition. The MDS indicated the resident wore corrective lenses for their vision. Review of R134's Care Plan Report revealed no evidence to indicate the resident self-administered their medications. Review of R134's Order Summary Report, with active orders as of 05/19/2026, revealed an order, dated 05/11/2026, for dorzolamide hydrochloride (HCl)-timolol maleate ophthalmic solution (an ophthalmic glaucoma agent) 2-0.5%, one drop in both eyes two times a day for glaucoma. The Order Summary Report included an order, dated 05/08/2026, for latanoprost ophthalmic solution (an ophthalmic glaucoma agent) 0.005%, one drop in both eyes one time a day for glaucoma. The Order Summary Report revealed no evidence that the resident was able to self-administer their medications. During an interview on 05/18/2026 at 1:09 PM, R134 stated they gave themself two medicated eye drops to treat glaucoma. R134 stated they were dorzolamide-timolol that went in twice a day and latanoprost that went in at night. R134 stated the nurses said it was all right to self-administer the eye drops but also offered to do it for them. During an interview on 05/19/2026 at 4:30 PM, Registered Nurse (RN)22 stated that he knew R134 gave themself the glaucoma eye drops and had since they arrived. RN22 stated he did not tell anyone. During an interview on 05/19/2026 at 4:23 PM, Licensed Practical Nurse (LPN)33, who was a unit manager, stated that R134 should not have been administering the eye drops to themself; the facility went through a process of the doctor writing an order. She stated that then they did an assessment for self-administration, which she completed. She stated that R134 had not been assessed, so the nurses should have been giving the glaucoma eye drops. During an interview on 05/21/2026 at 10:54 AM, Nurse Practitioner (NP)18 stated that it was up to the facility to decide if R134 was able to administer their glaucoma eye drops. During an interview on 05/21/2026 at 3:32 PM, the Director of Nursing (DON) stated that R134 should have been assessed to self-administer medications, or the glaucoma eye drops should have been locked up in the medication cart. During an interview on 05/21/2026 at 3:19 PM, Administrator (ADM) stated that his expectation for residents to self-administer was to have an order for self-administration. 2. Review of an admission Record revealed the facility admitted R26 on 12/09/2021. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of acute respiratory failure with hypoxia, unspecified asthma, and anxiety disorder. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/15/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Review of R26's Care Plan Report, revealed no evidence the resident self-administered their medications. Review of R26's Order Summary Report, with active orders as of 5/18/2026, revealed no evidence of an order for miconazole antifungal powder. The Order Summary Report further revealed no evidence that the resident was able to self-administer their medications. During a concurrent observation and interview on 05/18/2026 at 10:27 AM, R26 was sitting up in bed with a three-ounce bottle of Remedy clinical fungal powder (miconazole nitrate 2% antifungal) on the nightstand. R26 stated they self-administered the antifungal powder under their breasts. R26 stated they usually applied the antifungal powder one time a day, every couple of days after showers on Tuesdays and Fridays. R26 stated that the facility did not assess them to self-administer medications but said they wanted to administer the miconazole 2% antifungal powder themself. During a concurrent observation and interview on 05/18/2026 at 2:59 PM, with Licensed Practical Nurse (LPN)25, who was a unit manager, R26 was observed lying supine in bed. A three-ounce bottle of Remedy antifungal powder remained on the resident's nightstand at their bedside. LPN25 stated R26 did not have an order to self-administer the antifungal powder, had not been assessed to self-administer their medications, and the miconazole 2% antifungal powder should not have been left in the resident's room. During an interview on 05/19/2026 at 9:38 AM, Certified Nursing Assistant (CNA)26 stated that R26 applied the miconazole 2% antifungal powder as needed. CNA26 stated it was acceptable for residents to self-administer the miconazole 2% antifungal powder. CNA26 stated that the miconazole 2% antifungal powder was kept in the central supply room, and she could get it for any resident that needed it. Per CNA26, there were multiple residents that used the miconazole 2% antifungal powder. During an interview on 05/19/26 at 9:47 AM, CNA27 stated that R26 self-administered the miconazole 2% antifungal powder as needed. During an interview on 05/20/2026 at 3:01 PM, LPN28 stated residents were not allowed to and should not self-administer any medications unless they had an assessment completed and a physician's order for self-administration. LPN28 stated there were no residents in the facility that had physician orders to self-administer medications. LPN28 stated she was unaware that R26 had miconazole 2% antifungal powder at their bedside and was unaware the resident was self-administering the antifungal powder. During an interview on 05/21/2026 at 1:12 PM, LPN29 stated that a resident could not self-administer miconazole 2% antifungal powder unless the resident had been assessed to self-administer. LPN29 stated that the miconazole 2% antifungal powder should be kept in the treatment cart; not at the resident's bedside. During an interview on 05/21/2026 at 1:28 PM, the Director of Nursing (DON) stated R26 did not have an assessment to self-administer the miconazole 2% antifungal powder and should not have been allowed to apply the miconazole 2% antifungal powder. The DON stated residents should only be allowed to self-administer their medications after a self-administration assessment and a physician order was completed. During an interview on 05/21/2026 at 2:10 PM, the Administrator stated residents needed an assessment and a physician order to be able to self-administer medications, including antifungal powder.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure a resident was not served their meals on disposable tableware to protect their dignity, which affected 1 (Resident (R)42) of 2 residents reviewed for dignity concerns. Findings included: Review of an undated facility policy titled, Disposable Dishes and Utensils, indicated, This facility will use single-service items only in extenuating circumstances, such as dish-machine failure, individual resident needs, or other documented reason. Review of an admission Record indicated the facility admitted R42 on 07/21/2024. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of personal history of transient ischemic attack (a brief blockage of blood flow to the brain), cerebral infarction (a stroke) without residual deficits, and dysphagia (difficulty swallowing). Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/2026, indicated R42 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicated the resident had severe cognitive impairment. The MDS revealed the resident required setup or clean-up assistance with eating. Review of R42's Care Plan Report included a focus area initiated on 07/24/2024, that indicated the resident was at risk for malnutrition due to depression, diabetes, and gastroesophageal reflux disease (GERD). Interventions directed staff to allow the resident adequate time for eating their meals (initiated 07/24/2024). Review of a facility document titled, Resident Detail, for R42, revealed, under the heading, Meal Service Details, included, Alerts: Disposables. The document revealed under the heading, Additional Tray Card Notes, revealed, USE DISPOSABLES WHEN POSSIBLE for breakfast, lunch, and dinner. During a concurrent observation and interview on 05/18/2026 at 12:15 PM, R42 was observed in bed with their lunch meal on an overbed table. The resident's tray card, dated May 18/26 Lunch, revealed, Notes: >USE DISPOSABLE WHEN POSSIBLE; and Alerts: >DISPOSABLES. R42 fed themself the lunch meal with a plastic spoon, received on a disposable plate. R42 responded by shaking their head from left to right when asked if receiving food on a disposable plate with disposable utensils was okay. During a concurrent observation and interview on 05/21/2026 at 8:15 AM, R42 was observed in bed with their breakfast meal on the overbed table. Certified Nursing Assistant (CNA)8 set up the breakfast tray for R42. R42 fed themself the breakfast meal with a plastic spoon, received on a disposable plate. CNA8 stated R42 received their meals on disposable plate ware and tableware because the resident took a while to eat. R42 responded by shaking their head from left to right when asked if receiving food on a disposable plate with disposable utensils was okay. During an interview on 05/21/2026 at 11:00 AM, CNA9 revealed R42 received food on disposable tableware and that she was told by staff that it was because of a family request, but she did not know for sure. CNA9 stated that she never questioned the reason R42 received food on disposable tableware, but the resident's food was served that way for a while. During an interview on 05/21/2026 at 11:22 AM, Family Member (FM)14 stated that when they visited for the past few months, they saw R42's meals were served on disposable plates, but they did not know why; they just thought it was a decision from the kitchen staff. FM14 stated that when at home, R42 was accustomed to receiving food on regular plates, and they would like the resident to receive food on regular plates. FM14 denied that they asked staff to provide food for R42 with disposable tableware. During an interview on 05/21/2026 at 9:29 AM, Licensed Practical Nurse (LPN)33, who was a unit manager, stated that she noticed the previous day (05/20/2026) at lunch that R42 received food on disposable tableware, but she had not paid much attention before that day and had not noticed it before. LPN33 stated that she did not follow up on the use of disposable tableware for R42, and she did not know the reason the resident received disposable tableware with meals. LPN33 stated she expected all residents to receive food on the same type of tableware and expected disposable tableware to be used only if the dish machine was not working or if there was an infection control issue in the facility, but not for staff convenience. During an interview on 05/21/2026 at 8:51 AM, the Dietary Manager (DM) stated that approximately four months prior, staff informed her that R42 took a long time to eat their meals. She stated that they asked if the dietary staff could provide the resident with disposable tableware and disposable utensils so that the resident could take their time to eat, and staff could throw the disposable tableware away when the resident completed their meal so that dirty dishes were not left in the room. The DM stated that she added the use of disposables to the resident's tray ticket, and the resident had received disposable tableware with meals ever since. During an interview on 05/21/2026 at 9:30 AM, the Director of Nursing (DON) stated she expected disposable tableware would only be used if the dish machine was not functional or if there was an infection control issue in the facility. The DON further stated that she expected all residents to receive a dignified dining experience, and that staff not provide a resident with disposable dishes for staff convenience. The DON also stated that if the resident/family did not request food served on disposables, doing so would be disrespectful to the resident. During an interview on 05/21/2026 at 9:56 AM, the Administrator (ADM) stated he was not aware that R42 received food served on disposable tableware. The ADM stated that he expected all residents to receive their food on regular tableware unless it was a request from the resident/family, or there was a problem with the dish machine or an issue with an infectious disease; otherwise, he expected that all residents have a dignified dining experience and receive their food on regular tableware.

Based on observation, interview, and facility policy review, the facility failed to properly label and date food items that had been opened or prepared in the kitchen, and failed to discard expired items. These failures had the potential to affect all 116 residents who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Food Storage: Cold Foods last revised ,d+[DATE] revealed All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code. Procedures .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's policy titled, Food Storage and Retention Guide last revised ,d+[DATE] revealed Ready-to-Eat/Prepared Foods (1)-Food in a form that is edible without additional preparation to achieve food safety. (Examples: leftovers, deli meats and salads, opened canned fruits and puddings) -Up to 7 days. Shelf Stable Foods. Condiments. Mayonnaise After opening 2 months. During an observation on [DATE] at 8:30 AM, of the food storage revealed the following opened food items: beef broth dated [DATE], chicken broth dated [DATE], four opened containers of beef paste dated [DATE], [DATE], [DATE], and [DATE], cut cucumber undated, cut tomato undated, prepared what appeared to be potato salad labeled [DATE], prepared what appeared to be egg salad labeled use by [DATE], mayonnaise labeled ,d+[DATE], barbecue sauce undated, lemon juice labeled ,d+[DATE], chocolate fudge icing labeled ,d+[DATE], and sweet and sour sauce dated [DATE]. None of the dates indicated whether it was an open date or use by date except the egg salad. Also observed was a fast food bag of food and an outside container of Greek yogurt on the bottom refrigerator shelf. At 4:45 PM a box of prepared egg salad sandwiches was observed. During an interview on [DATE] at 8:30 AM, the Dietary Aide (DA) confirmed that the above items were not properly labeled or were expired and should be discarded. The DA stated prepared food should be labeled with the item and have a prepared and use by date. The DA did not know where the outside fast food or yogurt came from and stated that they were not to be stored in the kitchen refrigerator. During an interview on [DATE] at 4:45 PM the Dietary Manager (DM) stated she was unaware of the expired egg salad that was labeled use by [DATE]. The DM confirmed the prepared egg salad sandwiches should be discarded. The DM stated opened or prepared foods should be labeled with the product name, an open date or prepared date, and a use by date and that prepared foods are good for seven days.

Based on record review, interview, document review, and facility policy review, the facility failed to ensure the McGeer criteria was used when an antibiotic was ordered and administered to one resident (Resident (R)45) of five residents reviewed for unnecessary medications out of a total sample of 25 resident. This had the potential for the resident to have unnecessary adverse reactions to a potentially unnecessary antibiotic administered. Findings include: Review of the document titled Suspected Rhinosinusitis dated 12/31/24 revealed a resident had to have at least one major symptom AND two minor symptoms for at least 10 days for antibiotic therapy to be initiated or have severe symptoms for at least 3 days. Otherwise, symptoms should be treated symptomatically. Review of the facility policy titled Antibiotic Stewardship last revised December 2016 revealed Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Review of R45's undated Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R45 was admitted to the facility on [DATE] with the diagnoses of unspecified sequelae of other cerebrovascular disease and a history of asthma. Review of R45's Progress Notes located under the Progress Notes tab in the EMR dated 04/02/25 revealed the first note that indicated upper respiratory symptoms, was a cough. Review of R45's chest x-ray results dated 04/02/25 located under the Results tab in the EMR revealed No acute abnormality identified. Review of R45's complete blood count (CBC) results dated 04/03/25 located under the Results tab in the EMR revealed no white blood cell (WBC) count abnormality. Review of R45's March and April Vitals located in the Weights/Vitals tab of the EMR indicated no change or abnormalities in respiration, temperature, or pulse. Review of an Encounter Progress Note located under the Progress Notes tab in the EMR dated 04/03/25 written by the facility Nurse Practitioner (NP)1 revealed the following: Chief Complaint/Nature of Presenting Problem: This is a NP follow up from most recent hospitalization . On today's visit the patient is sitting up in wheelchair in her room. She is awake, alert, and appears in no acute distress. She does continue to have a congested cough with fatigue and hoarseness, chest x-ray was completed and unremarkable. Will start patient on Z-Pak (azithromycin antibiotic) x 5 days. She did have a CBC and CMP (complete metabolic panel) drawn this morning; results are pending. Patient's vital signs reviewed and stable. Review of R45's Orders located under the Orders tab in the EMR revealed the following orders: Give Azithromycin 500 milligrams (mg) by mouth one time a day for URI (upper respiratory infection) for 1 Day THEN Give 250 mg by mouth one time a day for URI for 4 Days. Review of R45's Medication Administration Record (MAR) located under the Orders tab in the EMR revealed azithromycin 500 mg was started on 04/03/25 and ended on 04/07/24, and was administered as ordered. During an interview on 04/07/25 at 3:50 PM, the Director of Nursing (DON) reviewed R45's CBC and chest x-ray and confirmed they were within normal limits and did not indicate an infection. During an interview on 04/08/25 at 11:30 AM, NP1 confirmed R45's normal chest x-ray and CBC and stated she had started the antibiotic anyway because she took into consideration R45's history of asthma and stroke, with the intent of preventing a hospital admission. NP1 agreed with the DON's assessment that R45 met the McGeer's criteria for the common cold only. NP1 did not know the duration of R45's symptoms but confirmed she had only seen R45 for the upper respiratory symptoms on 04/03/25, when she was first notified of the cough. During an interview on 04/08/25 at 1:10 PM, the DON stated R45 met the McGeer's criteria for the common cold only and stated she felt the antibiotic treatment was appropriate. The DON was unable to explain what criteria was used to determine antibiotic initiation. The DON then referred to the facility antibiotic stewardship binder and identified a decision-making tool for antibiotic initiation. The DON reviewed R45's symptoms using the Suspected Rhinosinusitis algorithm and stated R45 had only one major criteria (nasal congestion) and two minor symptoms (cough and fatigue). The DON was unable to determine the duration of symptoms - The guide went on to ask if duration of symptoms persisted for at least 10 days or 3 days if severe. The DON stated if antibiotic prescribing was inappropriate, she would reeducate providers. The DON was unable to provide further documentation showing when R45's symptoms began or the duration of symptoms.

Based on observation, review of facility policy, and interview, the facility failed to ensure proper hand hygiene was completed, and proper personal protective equipment (PPE) was worn during direct contact/care for two residents (Resident (R)49 and R313) out of two residents observed during direct contact who were on enhanced barrier precautions (EBP) out of a total sample of 25 residents. This failure had the potential to cause cross contamination to the residents. Findings include: Review of policy titled Isolation -Transmission-Based Precautions & Enhanced Barrier Precautions Revised September 2022, revealed, . Enhanced Barrier Precautions, The facility has a framework for reducing MDRO (Multidrug-Resistant Organism) transmission through staff use of gowns and gloves while caring for patients at high risk for MDRO transmission at the point of care during specific activities with greatest risk for MDRO contamination of staff hands, clothes, and the environment. Enhanced Standard Precautions allows high risk residents to participate in activities outside of the room under specified conditions. Enhanced Barrier Precautions are indicated for residents with any of the following: . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO . Review of the facility policy titled Handwashing/ hand hygiene revised October 2023 revealed, .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .1. hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident;. g. immediately after glove removal. 2. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations. 3. Wash hands with soap and water: a. when hands are visibly soiled; . 4. Single-use disposable gloves should be used: a. before aseptic procedures; b. when anticipating contact with blood or body fluids; and . 5. The use of gloves does not replace hand washing/ hand hygiene. 1. During an observation on 04/06/25 at 8:47 AM, Licensed Practical Nurse (LPN)6 was observed in R49's room wearing gloves, however the LPN was not wearing a gown. LPN6 hung a bag of tube feed and water for R49. She removed her gloves, performed no hand hygiene, and stepped out of the room. At 8:53 AM, LPN6 returned to R49's room wearing a mask only and continued with tube feed set up. R49 began to vomit and the LPN ran to the bathroom, grabbed paper towels, and placed them on resident's chest with ungloved hands. R49 vomited on LPN6's bare hand. LPN6 quickly donned gloves after placing paper towels, without performing hand hygiene. During an interview on 04/06/25 at 9:02 AM, LPN6 acknowledged the above observations. LPN6 admitted that she should have been wearing a gown and full PPE per EBP. During an interview with the Director of Nursing (DON) on 04/07/25 at 3:36 PM she stated it was her expectation that staff wear gowns, gloves, mask, and face shield if coming into contact with liquid that might splash and spill. The DON confirmed LPN6 should have been wearing a gown and should have performed hand hygiene immediately before and after glove changes. 2. During an observation of catheter care for R49 on 04/08/25 at 2:01 PM with Certified Nursing Assistant (CNA)1, assisted by CNA3, and with LPN1, present during the observation. CNA1 donned a gown, mask, and gloves without first performing hand hygiene. CNA3 also donned gown, mask, and gloves and was not observed to perform hand hygiene immediately before donning the gloves. LPN1 enquired about emptying R49' catheter bag and CNA1 returned to the room with one glove on and touched R49's catheter bag with a bare hand. CNA1 then donned a second glove without performing hand hygiene, went to the bathroom, returned with a urinal, and emptied R49's catheter bag. During an interview with CNA1 on 04/08/25 at 2:07 PM, CNA1 acknowledged she came out of the bathroom with one glove and touched the catheter bag and then put on another glove. During an interview with the LPN1 on 04/08/25 at 02:08 PM, she stated CNA1 should have changed gloves, performed hand hygiene and re-gloved before touching the catheter bag. 3. During observation on 04/08/25 at 2:20 PM, LPN4 donned a gown and a pair of gloves without performing hand hygiene. CNA1 was assisting and donned a gown and gloves without first performing hand hygiene. CNA1 lifted R313's left leg and removed his sock. LPN4 aborted the wound care when R313 stated he was in pain. LPN4 discarded her gown and gloves in R313's room and returned to the wound care cart without performing hand hygiene. She said the nearest hallway hand sanitizer was flashing red and was not functioning and she was unable to perform hand hygiene before going into R313's room and donning gloves. During an interview with the DON on 04/08/25 at 2:30 PM, the DON stated it was her expectation that staff perform hand hygiene before and after gloving, and that LPN4 should have used soap and water in the resident's room or hand sanitizer provided by the facility before and after wearing gloves. DON stated CNA1 should have performed hand hygiene between glove changes.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure respiratory care equipment was maintained in a clean and sanitary manner for one (Resident (R) 413) of four residents reviewed for respiratory care out of a total sample of 25 residents. This failure had the potential to lead to respiratory infections. Findings include: Review of the facility's policy titled, Departmental (Respiratory), revised 11/22, revealed, . 3. Change the oxygen cannula and tubing every seven (7) days, or as needed. 4. Keep the oxygen cannula and tubing used PRN [as needed] in a plastic bag when not in use. 5. Wash filters from oxygen concentrators with soap and water as needed. Rinse and squeeze dry . Review of R413's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R413 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of R413's admission Minimum Data Set (MDS), located in the EMR under the MDS tab with an assessment reference date (ARD) of 03/24/25, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R413 was cognitively intact. The MDS also indicated R413 received oxygen therapy. Review of R413's Orders located in the Orders tab of the EMR revealed the following: Oxygen at 2 liters / Nasal Cannula, Continuously every shift for Oxygen at 2 liters AND as needed dated 3/18/25. Clean and change tubing every night shift every Sunday dated 3/18/25. Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 3 milliliter inhale orally every 6 hours as needed for COPD SOB (shortness of breath), rinse mouth after each use dated 3/18/25 There was no specific order related to the nebulizer tubing/mask. Review of R413's March and April 2025 Medication Administration Record (MAR) located in the EMR under the Orders tab, revealed R413 had been using oxygen daily and the nebulizer machine was last used on 03/31/25. There was no documentation for the nebulizer tubing, mask, or filter cleaning. During an observation and interview on 04/06/25 at 12:06 PM and 3:42 PM, revealed R413's nebulizer mask was sitting uncovered on the nebulizer machine on his nightstand. The nebulizer tubing was undated. R413's black oxygen concentrator filter was covered in a layer of white dust. R413 stated the nebulizer tubing and mask was from the previous Sunday and there was no storage bag provided. R413 stated the oxygen concentrator was provided on admission in March. R413 confirmed he had been using both the oxygen concentrator and the nebulizer machine during this admission. During an interview on 04/06/25 at 3:20 PM, Licensed Practical Nurse (LPN)3 confirmed that R413's nebulizer tubing was undated and not stored correctly. LPN3 also confirmed that the black oxygen concentrator filter was covered in a layer of white dust. LPN3 stated the nebulizer mask, and tubing should be stored in a plastic bag and the oxygen concentrator filter should be cleaned. During an interview on 04/06/25 at 3:52 PM, LPN2, the facility's Respiratory Nurse confirmed that R413's nebulizer tubing was undated and not stored in a plastic bag. LPN2 stated she did not know where R413's storage bag was. LPN2 also confirmed that R413's oxygen concentrator filter had not been cleaned. LPN2 stated tubing changes and filter cleaning were completed every Sunday. During an interview on 04/07/25 at 1:10 PM, the Director of Nursing (DON) stated the nebulizer tubing should be dated and stored in a plastic bag and oxygen concentrator filters should be cleaned weekly when tubing was changed. During an interview on 04/07/25 at 5:15 PM, the Administrator stated the policy titled Departmental (Respiratory) applied to both oxygen and nebulizer equipment.

Based on review of facility policy, observation, interview, and record review, the facility failed to ensure a palm guard was applied to one (Resident (R) R3) of four residents reviewed for positioning/mobility. A total of 25 residents were reviewed in the sample. This had the potential for the resident to experience a decline in ROM. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion Policy dated 07/2017 read, in pertinent part, Residents will not experience an avoidable reduction in range of motion (ROM);and Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM; and The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Review of R3's Admission Record dated 04/08/25 found in the electronic medical record (EMR) under the Admission tab, indicated R3 was admitted to the facility on [DATE]. The resident's diagnoses included seizure disorder and Alzheimer's Disease. Review of R3's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/25 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident was moderately cognitively impaired. Review of R3's physician's Orders, dated 04/08/25 and found in the EMR under the Orders tab, revealed a current order, with an original order date of 03/18/25, for the resident to wear a Palmar Guard on her left hand daily as tolerated to prevent skin breakdown and further contracture. Review of R3's Treatment Administration Records (TARs) dated 04/01/25 through 04/08/25 and found in the EMR under the Orders tab, revealed entries on each date to indicate the resident's Palm Guard was being applied as ordered. During an observation on 04/06/25 at 3:57 PM, on 04/07/25 at 9:45 AM, 2:49 PM and 5:44 PM, and on 04/08/25 at 8:34 AM and 10:33 AM, R3 was observed to have a contracted right hand. The resident was not observed to be wearing her ordered palm guard during any of the observations. There was nothing in the record to indicate R3 had been refusing to wear her palm guard. During an observation, R3 was observed, along with Certified Nursing Assistant (CNA)2 on 04/08/25 at 11:14 AM, CNA2 confirmed she was familiar with R3 and confirmed the resident was not wearing her ordered palm guard. CNA2 attempted to locate the resident's palm guard in her room and was unable to find it. CNA2 stated the resident had a palm guard and was supposed to wear it during the day, however she had not seen the appliance that morning when the resident was assisted with preparing for the day. CNA2 stated R3 sometimes refused to allow the palm guard to be applied, however she confirmed the refusal should be documented in R3's record if this was the case. During an interview with Licensed Practical Nurse (LPN)5 on 04/08/25 at 11:21 AM, she stated she was familiar with R3 and confirmed the resident was supposed to be wearing her palm guard during the day. LPN5 stated the resident's palm guard was usually placed on her in the morning and then she (LPN5) would remove it later in the day/at bedtime. LPN5 stated she did not know where the resident's palm guard was. During a follow-up interview with CNA2 on 04/08/25 at 11:33 AM, she stated she had not been able to locate R3's palm guard and so the facility's therapy department had provided her with a new one. During an interview with the Director of Nursing (DON) on 04/08/25 at 12:32 PM, she confirmed R3 was expected to be wearing the ordered palm protector or staff was expected to document the resident's refusal to wear the device in the resident record. During an interview with the Therapy Director on 04/08/25 at 1:12 PM, she confirmed R3 was expected to be wearing her ordered palm protector and stated she provided a new one to nursing staff that day when they were not able to locate the resident's original device. She stated sometimes the devices inadvertently ended up in the laundry.

Based on review of review of facility policy, observation, interview, and record review, the facility failed to ensure an ongoing and meaningful program of activities was provided for two (Residents (R) R3 and R67) of four residents reviewed for activities out of a total of 25 residents were reviewed in the sample. This had the potential for the residents to have a decreased quality of life. Findings include: Review of the facility's Activity Evaluation Policy dated 02/2023 read, in pertinent part, In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities; and An activity evaluation is conducted as part of the comprehensive assessment to help develop an activities plan that reflects the choices and interests of the resident; and The activity evaluation is used to develop an individual activities care plan (separate from or as part of the comprehensive care plan) that will allow the resident to participate in activities of his/her choice and interest. 1.Review of R3's Admission Record, dated 04/08/25 found in the electronic medical record (EMR) under the Admission tab, indicated R3 was admitted to the facility on [DATE]. The resident's diagnoses included seizure disorder and Alzheimer's Disease. Review of R3's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/25 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident was moderately cognitively impaired. Review of R3's Activities Care Plan dated 02/06/25 and found in the EMR under the Care Plan tab, revealed, (R3) needs activities for socialization and stimulation. (R3) enjoys remaining in her room listening to music, socializing with staff and peers. Approaches included encourage, inform and invite to activities, help transport to activities, offer religious activities at least once per week, offer sensory stimulation type activities (music, reality orientation, etc.), offer special events, provide with 1:1 activities as needed or requested, provide activity calendar in room, and praise efforts and attendance. Review of R3's Annual Activities assessment dated [DATE] and found in the EMR under the Evaluations tab, revealed the resident enjoyed listening to radio, watching television, having stuffed animals for support, music events, and religious events. The assessment indicated the resident responded well to 1:1 visits from staff and liked to occasionally attend group activities. Review of R3's Activity Participation Records dated 03/09/25 through 04/07/25 and found in the EMR under the Tasks tab, revealed the resident attended one group activity during that time period (Pet Therapy on 03/21/25) and was provided with a total of four 1:1 visits from staff during that period of time (on 03/13/25, 03/17/25, 03/24/25 and 04/07/25). During an observation of R3 on 04/06/25 at 10:00 AM, 3:37 PM, and on 04/07/25 at 9:45 AM, 2:49 PM, and 5:44 PM, R3 was observed to be in her room in bed during all of the observations. R3 was not observed to be engaged in any type of activity during the observations. R3 was observed to remain in her bed all day on 04/06/25 and on 04/07/25. 2.Review of R67's Admission Record, dated 04/08/25 found in the EMR under the Admission tab, indicated R3 was admitted to the facility on [DATE]. The resident's diagnoses included cognitive communication deficit and brain cancer. Review of R67's quarterly MDS with an ARD of 03/10/25 and found in the EMR under the MDS tab, indicated a BIMS score of zero out of 15, which indicated the resident was severely cognitively impaired. Review of R67's Activities Care Plan dated 04/04/24 and found in the EMR under the Care Plan tab, revealed the resident was at risk for social isolation due to generalized weakness. The Care Plan indicated R67 enjoyed watching television, watching shows/movies, pet therapy, listening to all types of music, and socializing with family/friends. The care plan goal was for R67 to have socialization with staff/visitors within her abilities 50% of the time weekly. Approaches included, encourage and assist the resident to engage in activities that do not require great cognitive skill (i.e., watching movies, simple board games, card games, music therapy, gardening, exercise, coloring books, reminiscing, etc.), encourage to attend activities of interest, provide activity calendar in room, provide activity materials like books, magazines, TV, radio, arts and crafts, etc., in accordance with the residents' interests, and room visits 1:1 for socialization if needed. Review of R67's Quarterly Activities assessment dated [DATE] and found in the EMR under the Evaluations tab, revealed the resident enjoyed watching television, pet therapy, all types of music, and socializing with family/friends. The assessment indicated R67 preferred to remain in her room and accepted 1:1 visits from staff and family visits often. Review of R67's Activity Participation Records dated 03/09/25 through 04/07/25 and found in the EMR under the Tasks tab, revealed the resident did not participate in any group activities during that time period of time. The record indicated R67 was provided with a total of eleven 1:1 visits from staff during that period of time (on 03/12/25, 03/13/25, 03/17/25, 03/19/25, 03/24/25, 03/25/25, 03/26/25, 03/31/25, 04/03/25, 04/05/25, and 04/07/25). During an observation of R67 on 04/06/25 at 10:00 AM, 10:30 AM, and 2:20 PM, and on 04/07/25 at 10:30 AM and 2:43 PM, and 4:15 PM., R67 was observed to remain in her bed all day on 04/06/25 and 04/07/25. During an interview with R67 Responsible Party (RP) on 04/07/25 at 2:30 PM, she stated she would like the resident to participate in more activities. She stated R67 rarely came out of her room due to her physical condition, however she would like to see her participate in more 1:1 staff visits, sensory activities, and would like the resident to receive visits from church clergy when they were in the facility each week. She stated she thought R67 would enjoy these activities, but although she was a frequent visitor to the facility, she did not see the resident participating in these things. During an interview with the Activity Director (AD) on 04/07/25 at 4:23 PM, she confirmed group activities were offered daily to residents and pet therapy was available to all residents Monday through Friday. She stated all activity participation was documented in the EMR under the Tasks tab, and the documentation was expected to indicate the date and time of activity participation as well as the type of activity the resident participated in. The AD stated refusals to participate in activities was also to be documented under the Tasks tab. The AD confirmed there was sparse documentation of activity participation indicated in R3 and R67's records and stated her expectation was residents who were not participating regularly in group activities were expected to receive 1:1 visits at least three to four times per week. She confirmed R3 and R67 were not receiving adequate activities programming/visits based on review of their records and confirmed neither resident attended group activities very often and so should be receiving frequent 1:1 visits from activities staff.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an indwelling urinary catheter off the floor for one Resident (R)37 of four residents reviewed for catheter use, in a total sample of 32 residents. This failure resulted in the potential for increased infections to occur. Findings include: Review of the facility's policy titled Catheter Care, Urinary revised August 2022, staff were to, be sure the catheter tubing and drainage bag are kept off the floor. Review of R37's undated Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R37 was admitted to the facility on [DATE] with diagnoses included, but were not limited to neuromuscular dysfunction of the bladder (lack of ability to urinate and empty the bladder). During an observation on 05/31/23 at 4:20 PM, R37 was observed lying in bed on her left side. The dignity bag/urinary catheter bag was lying directly on the floor on the left side of the bed. During an observation on 06/01/23 at 8:45 AM, R37 was observed lying in bed, on her left side and appeared to be sleeping. The urinary catheter bag was observed lying directly on the floor on the left side of the bed. During an observation on 06/01/23 at 3:35 PM, R37 was observed lying in bed and the urinary catheter bag was observed lying directly on the floor. During an observation on 06/02/23 at 8:30 AM, R37 was observed lying in bed, on her left side. The urinary catheter bag was observed attached to the end of the left side of the bed with the bottom edge of the dignity bag/catheter bag resting on the floor. During an observation on 06/02/23 at 1:00 PM, R37 was observed lying in bed. The urinary catheter bag was observed in a dignity bag and was directly resting on the floor. During an interview and observation on 06/02/23 at 1:15 PM with Certified Nursing Assistant (CNA)2, stated the catheter bag should not be placed on the floor, even if it is contained in a dignity bag. During an interview and observation on 06/02/23 at 2:30 PM, CNA3 stated catheter bags should always be up off the floor and contained in a dignity bag. During an interview with the Director of Nursing (DON) on 06/02/23 at 3:30 PM, the DON stated urinary catheter bags should always be covered, placed below the level of the resident's bladder, and never left on the floor.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure that two (Residents (R)44 and R60) from a sampled 39 residents were receiving oxygen therapy according to physicians' orders. The failure has the potential for residents to receive inadequate oxygen therapy. Findings include: Review of the facility's policy, Oxygen Administration, revised 10/2010 stated, Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility's protocol for oxygen administration . 2. Review the resident's care plan to assess for any special needs of the resident . 1. Review of R44's Face Sheet located under the Profile tab of the electronic medical records (EMR) revealed R44 was admitted to the facility on [DATE] with the diagnoses including but not limited to; chronic pulmonary edema, acute pulmonary blastomycosis, acute and chronic resp failure. Review of R44's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 01/31/23, located under the Resident Assessment Instrument (RAI) tab, indicated R44's Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident's cognition was intact. The resident had no functional limitation of his upper and lower extremities and required limited assistance with one-person physical assistance for all activities of daily living (ADLs). The resident was assessed to require oxygen therapy. Review of R44's EMR under the Orders tab indicated the resident was to receive oxygen at three liters per minute via nasal cannula. Change O2[oxygen] filters to the concentrator if applicable. Change the nasal cannula weekly and as needed. Review of the R44's EMR under the Orders Administration Record tab indicated the nurse staff had documented the oxygen tubing was changed on 05/21/23 and 05/28/23. Review of R44's Care Plan, located under the RAI tab and dated 05/17/23, indicated the resident was receiving oxygen therapy, however there was no mention of changing the filter or tubing according to the physicians' orders. During an observation on 05/31/23 at 2:00 PM revealed R44 was returning from dialysis in a wheelchair (w/c) wearing nasal cannula, O2 connected to an oxygen tank on the back of his w/c. There was no visible date on the oxygen tubing. During an observation on 06/01/23 at 9:04 AM revealed R44 was in his room wearing nasal cannula connected to an oxygen tank on the back of his w/c, the oxygen tubing was dated 05/15/23. The resident also had an oxygen concentrator in his room with nasal cannula tubing connected to it. The tubing was undated, and the concentrator had a layer of dust debris. During an observation on 06/02/23 at 10:28 AM revealed R44 with undated nasal cannula tubing connected to the oxygen concentrator which contained a layer of dust debris. The oxygen setting on the concentrator was four liters. The tubing on oxygen tank remains dated 5/15/23. On 06/02/23 at 10:49 AM an interview with Licensed Practice Nurse (LPN)5 revealed the setting should be three liter/min however sometimes the resident will change the setting. LPN5 also stated the tubing should be changed weekly on Sunday by the night shift. The LPN was asked to provide documentation of the resident changing the oxygen setting. The facility was unable to provide documentation. On 06/02/23 at 1:30 PM during an interview with LPN4, she observed the tubing dated 05/15/23 on R44's oxygen tank and the layer of the dust debris on the concentrator. LPN4 stated the tubing should be changed weekly and the concentrator should be cleaned as needed. The LPN reviewed the administration record for documenting the physicians' orders for oxygen therapy and confirmed the night nurses had signed changing the oxygen tubing when it looked as if the tubing had not been changed. On 06/02/23 at 2:10 PM a telephone interview was conducted with LPN6 who signed the administration record on 05/28/23. LPN 6 stated that she only changes the tubing on the oxygen concentrator but did not date the tubing. She had not noticed the layer of dust on the concentrator. 2. Review of R60's Face Sheet located under the Profile tab of the EMR revealed R60 was admitted to the facility on [DATE] with the diagnoses including but not limited to; type II diabetes, heart failure, peripheral vascular disease, and end stage renal disease. Review of R60's MDS with an ARD of 04/19/23, located under the RAI tab, indicated R60 needed extensive assistance of one staff member with bed mobility, dressing and toileting, and extensive assistance of two staff members for transfers. The MDS showed a BIMS score of 15 out of 15 indicating R60 was cognitively intact. Review of R60's EMR under the Orders tab indicated no physician's orders for oxygen. Review of R60's Care Plan, located under the RAI tab and dated 02/03/23, indicated no mention of resident receiving oxygen. Review of two physician orders, provided by the Director of Nursing (DON), indicated one order dated 04/16/22 stated O2 [oxygen] @ 2L[liters] /min via nasal cannula [NC] for shortness of breath and a second order dated 06/02/23 stated O2 at 2L NC prn [as needed] to keep O2 sat [saturation] greater than 90% . During an observation on 05/31/23 at 3:15 PM, R60 was wearing the oxygen nasal cannula attached to the concentrator. The concentrator was observed with two air filters on either side of the machine. The filters had a thick white coating of dust. During an observation on 06/02/23 at 11:30 PM, R60 was wearing the oxygen nasal cannula attached to the concentrator. The concentrator was observed with two air filters on either side of the machine. The filters had a thick white coating of dust. During an interview on 06/02/23 at 12:05 PM, the DON stated the filters should be visualized for cleanliness by a staff member daily. The DON said the Nurse Manager (NM) for the unit should visualize the filters weekly to ensure they are kept clean. Upon showing the DON the filters on R60's concentrator, the DON immediately removed the two filters and made an attempt to clean them but disposed of the filters in the trash. The DON said the filters would be replaced. During an interview on 06/02/23 at 4:50 PM, the DON confirmed she could not locate an order for oxygen for the time periods 05/31/23 or 06/01/23 when R60 was observed wearing oxygen. The DON stated there was an oxygen order, previously, but on 05/30/23 the Medical Director (MD) stated R60's oxygen saturation was at 100% on room air. The DON explained R60's oxygen saturation was found to be at 86%. The DON said due to the drop in R60's oxygen saturation, the staff utilized a standing order for oxygen that says if a resident's oxygen saturation was below 90 %, oxygen should be applied, and the physician contacted. The DON stated the MD was contacted and was in agreement with oxygen being re-started and stated he would address the issue further when he returned to facility on 06/06/23. During an interview on 06/02/23 at 4:58 PM, with Unit Manager (UM)1, she stated R60's oxygen concentrator filters must have been overlooked by staff and herself.

Based on observation, interview, record review, and review of facility policy, the facility failed to properly label enteral feeding bag and properly sanitize the reusable enteral feeding syringes for one Resident (R)63 from a sampled 39 residents. Findings include: Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump with a revision date of November 2018, documents On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Review of the facility's policy titled Sanitation of Reusable Enteral Feeding Syringes dated March 2015 reads in part Rinse 60 milliliter (m)L enteral feeding syringe with running water if the syringe had contact with stomach secretions or enteral feeding. Disassemble the enteral feeding syringe. Place the syringe in bleach solution in the container. Place a lid on the container. Shake well (to sanitize the inside of the lid). Let sit for at least l0 minutes. Remove the lid. Tum wet side up. Place syringe parts on top of the lid and discard the bleach solution. Shake moisture off the container and sanitize items. Place syringe parts inside the container. And place the lid on top. Do not seal completely. During an observation on 05/31/23 at 2:30 PM revealed R63 in bed with head of bed (HOB) elevated 45 degrees. The resident was receiving enteral feeding via continuous pump. The feeding bag did not have a label with the resident's name, date, and time the feeding was hung; rate; or type of feeding. On the nightstand was a reusable irrigation kit unlabeled with the syringe and piston put together inside the container. During an observation on 06/01/23 at 9:37 AM revealed R63 had a tube feeding bag labeled Glucerna 1.5 with approximately 400cc (cubic centimeter) left in bag with the resident's name and date/time. The reusable irrigation kit with the piston and syringe (put together) was at the bedside undated. The feeding pump had a dried beige colored splatter. During an observation on 06/01/23 at 2:33 PM revealed R63 in bed positioned on her back, HOB elevated 45 degrees. Glucerna 1.5 feeding infusing at 100cc/hr. The reusable irrigation container was labeled with a date. However, the syringe and piston were not separated, and the tip of the syringe contained about 2 cc of clear liquid. Water bolus container labeled with date. The feeding pump continues to have a dried beige color splatter. On 06/02/23 at 11:00 AM an interview with the Licensed Practical Nurse (LPN)4 revealed the tube feeding bag should be labeled with resident's name, date/time the feeding started. The reusable irrigation kit should be rinsed after each use and the syringe and piston separated to air dry. And any spillage of feeding formula should be cleaned up. An interview on 06/02/23 at 1:13 PM with the Director of Nursing revealed it was an expectation the staff would label new feeding bag with the resident's name, date and time, and rate. The irrigation kit should be labeled with the date; and rinsed after each use and left to the air dry. The irrigation syringe and piston also should be rinsed after each use and left separated to air dry on a paper towel.

Based on record review, observation, interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two residents (Resident (R)39 and R58) out of 29 sampled residents had an accurate Minimum Data Set (MDS) assessment. Findings include: Review of the RAI Manual, dated 10/01/19 indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. 1. Review of R39's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R39's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/23 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated the resident was moderately cognitively impaired. Further review of the MDS indicated R39 was on a prescribed weight loss program. Review of R39's EMR titled Physician Orders located under the Order tab indicated the resident was not on a prescribed weight loss program. Review of R39's EMR titled Nutrition/Dietary Note dated 03/01/23, in the Progress Notes tab, failed to indicate the resident was on a physician prescribed weight loss program. The progress notes revealed the resident sustained 11.1 percent weight loss in the past 180 days. 2. Review of R58's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R58's significant change MDS with an ARD of 03/28/23 indicated the resident had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. Further review of the MDS indicated R58 was not impaired bi-laterally with her upper extremities which included the shoulder, elbow, wrist, and hands. During an observation and interview on 05/31/23 at 4:11 PM, R80 showed her left arm and explained her arm could not be extended fully since the doctor told her she had arthritis in her elbow. Observed her left arm to be fixed at approximately 80 to 90 degrees from the elbow. During an interview on 06/02/23 at 8:49 AM the MDS Coordinator stated the MDS was to be accurate and would verify the MDS information for both R39 and R58. During an interview on 06/02/23 at 8:49 AM, the MDS Coordinator stated both assessments for R39 and R58 were inaccurate. During an interview on 06/02/23 at 3:41 PM, the Administrator stated the MDS was to be accurate.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure personal privacy by covering an indwelling urinary catheter collection bag for one Resident (R)13 of four residents reviewed for catheter care in a total sample of 32 residents. This failure resulted in the potential for an undignified appearance for the resident. Findings include: Review of the facility's policy titled, Catheter Care, Urinary revised August 2022, indicated staff were to, ensure privacy or dignity with urinary catheter bags. Review of R13's undated Admission Record located in the resident's electronic medical record (EMR) under the Profiles tab, revealed a current admitted to the facility of 02/04/22 and a readmission on 12/02/22 indicated R13 had diagnoses including but not limited to; chronic obstructive pulmonary disease (COPD), congestive heart failure and malignant neoplasm (cancer) to the prostate. According to the unspecified Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/14/23, R13 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. During an observation on 05/31/23 at 3:30 PM, R13 was observed lying in bed, with the urinary catheter bag attached to the end of the bed on the left side not covered in a dignity bag. The urinary catheter bag and contents were visible from the hallway. During an observation on 06/01/23 at 3:15 PM, R13 was observed lying in bed with the urinary catheter bag hanging from the end of the bed frame with the drainage spout/corner sticking out of the dignity bag. During an interview on 06/02/23 at 1:30 PM with certified nursing assistant (CNA)3 stated catheter bags should not be placed on the floor and should always be covered with a dignity bag. During an interview with the Director of Nursing (DON) on 06/02/23 at 3:30 PM, the DON stated urinary catheter bags should always be covered, placed below the level of the resident's bladder, and never left on the floor.

Based on observation, interviews, and policy review, the facility failed to ensure one Resident (R)80 was provided with an adapted call light control (referred to as a soft touch), to be able to request assistance from the staff when he was in need. Findings include: Review of a facility policy titled Accommodation of Needs dated 03/21 indicated .Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being .The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. Review of R80's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of but not limited to; anoxic brain injury and paralysis. Review of R80's EMR titled Care Plan located under the Care Plan tab dated 10/27/22 indicated an activity of daily living self-care performance deficit related to deconditioning and weakness. Review of R80's EMR titled annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/23 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed the resident was cognitively intact. Further review of the MDS indicated R80 was impaired bi-laterally with his upper extremities which included the shoulder, elbow, wrist, and hands. During an observation and interview on 05/31/23 at 2:30 PM, R80 stated he could not use his call light control. R80's call light was observed on his bed next to him. The resident demonstrated that he could not open both of his hands to operate the device. During an interview on 06/01/23 at 3:20 PM, Social Services Assistant (SSA) stated the building recently had an entirely new call light system installed and a soft touch call light was ordered over a month ago. During an interview on 06/01/23 at 3:31 PM, Certified Nurse Aide (CNA)1 stated R80 could not use the current call light control. CNA1 stated he checks on the status of the resident every two hours. During an interview on 06/01/23 at 6:30 PM, the Administrator confirmed the facility ordered a soft touch call light control for R80 since he was aware the resident required an adapter. A request was made for a copy of the purchase receipt. During an interview on 06/02/23 at 10:30 AM, the Administrator stated he had to reach out to the Maintenance Director since he was unavailable during the survey. The Administrator stated the Maintenance Director did not re-order a soft touch control for R80 which would be compatible with the new call light system. The Administrator stated he did not follow up with the Maintenance Director prior to today on the status of the soft touch control.

Based on review of facility's Abuse/Neglect Policy, review of facility investigative file, and interviews, the facility failed to ensure that allegations of Abuse/Neglect were reported timely to the state agency for 1 of 3 Residents (R)1, reviewed for abuse. Findings include: Review of the facility's undated policy titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigation Policy, states, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation of theft/misappropriation of resident's property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Allegations of abuse or result in serious bodily injury must be reported immediately but no later than two hours. The facility submitted a five day report indicating on 07/09/22, Resident (R)1 alleged she was sexually abused by the Activities Assistant (AA) sometime during Memorial Day Weekend. Review of the investigative file showed the incident was not reported to the State Agency until 07/14/22. During an interview with Licensed Practical Nurse (LPN)1 on 07/15/22 at 10:15 AM, she stated R1 had told her on Memorial Day weekend, AA had sexually abused her. R1 stated she did not say anything because she felt ashamed, and she did not think anybody would believe her. LPN1 stated she reported the incident to her supervisor and the supervisor immediately contacted the Director of Nursing (DON). LPN1 stated she also reported the incident on 05/31/22 to her supervisor who contacted the DON. During an interview with the DON on 07/15/22 at 10:00 AM, she stated the allegations of abuse on R1 was reported to her on 07/09/22 involving R1 and the allegations were reported to Administrator, who is the Abuse Coordinator immediately. DON stated R1 was assessed by nursing with no concerns. R1 was provided a psychosocial followup by Social Services. A Psych evaluation is scheduled for R1 on 07/18/22. The AA was suspended, pending investigation and the Abuse policy review was done by regional staff leadership. DON stated that the allegations of abuse were not reported to State Agency during the timeframe of 2 hours, it was reported 5 Days later. During an interview with the Administrator on 07/15/22 at 11:45 AM, he stated the allegations that were made on Memorial Day weekend were investigated, but was not reported to State Agency.

Based on record review and interview the facility failed to assess or provide treatment to a wound for Resident #48, and failed to provide treatments as ordered for Resident #48 and #5, 2 of 7 reviewed for pressure ulcers. The findings included: The facility admitted Resident #48 on 6/18/19 with [DIAGNOSES REDACTED]. On 8/5/19 at 12:40 PM, record review revealed an order dated 7/2/19 for a hydrogel treatment to the bilateral buttocks with a border dressing daily. Review of the wound documentation in the EHR (electronic health record) revealed no documentation of an assessment or measurement of the wounds. During wound care observation on 8/7/19 at 10:06 AM, two wounds were observed, one on the right buttock and one on the left buttock. During the wound care, the wound on the left buttock was measured at 4.4 x 3.7 cm (centimeters). A small open area on the right buttock was not measured. The RN stated the wound had deteriorated since the week before. The RN placed a [MEDICATION NAME] dressing on the left buttock after cleaning the wound and no dressing or treatment to the right buttock. The only order noted for the buttocks was to apply zinc twice a day. Following the procedure, documentation of the assessments and measurements of the wounds was requested from the wound nurse. The Wound Care Nurse had no documentation in her/his book and stated that s/he would have to obtain that information. When asked where s/he would look for that information, the nurse stated s/he would look in the computer. During an interview immediately following the wound care, the nurse confirmed that s/he did not measure the wound on the right buttock. Review of the TAR (Treatment Administration Record) revealed wound care was not provided to the buttocks on 07/11/19 and 07/19/19. Review of the facility's policy, Dressing, Dry/Clean Competency, revealed Verify that there is a physician's order for this procedure. (Note: This may be generated from a facility protocol.) During an interview on 08/08/19 at 02:45 PM, the Director of Nursing (DON) confirmed the lack of assessments of the wounds to the bilateral buttocks. The DON also confirmed the documentation indicated wound care was not provided for 2 days to the buttocks. In addition, the DON confirmed the RN should have applied zinc to the wounds to the buttock and that, at the time of the dressing change, there was no order for a [MEDICATION NAME] dressing. The DON stated the RN obtained an order from the physician after the procedure was completed. The facility admitted Resident # 5 with [DIAGNOSES REDACTED]. Record review of Resident #5's treatment sheet on 8/6/19 at approximately 2:30 PM, revealed an order dated 7/25/19, Clean left outer ankle with wound cleanser apply skin prep to wound border, apply hydrogel and manooka honey to wound bed only, secure with border gauze every day shift for wound care. During an observation of wound care on 8/7/19 at approximately 8:40 AM, RN #1 failed to apply hydrogel as ordered. RN #1 applied manooka honey to the would bed of the left outer ankle and covered with a dated border gauze. During an interview on 8/7/19 at approximately 9:48 AM, RN #1 checked the left outer ankle wound order for resident #5 and stated that s/he had not applied hydrogel.

Based on record review and interview the facility failed to implement/develop a care plan with resident specific interventions for Resident #48, 1 of 7 residents reviewed for pressure ulcers. The findings included: The facility admitted Resident #48 on 6/18/19 with [DIAGNOSES REDACTED]. On 8/7/19 at 1:54 PM, review of Resident #48's care plan dated 06/19/18 revealed a problem area identified as I am at risk for Alteration in my skin integrity related to s/p (status [REDACTED]. Interventions and approaches included, but not limited to, assist me with repositioning and toileting needs as needed and provide me with protective measures but were not resident specific. During an interview at 9:40 AM on 8/9/19, MDS (Minimum Data Set) Coordinator #1 confirmed the care plan interventions were not resident specific. The MDS Coordinator stated s/he did not know if the resident got out of bed or had a pressure relieving device in her/his chair and confirmed.

Based on review of facility files and interview, the facility failed to implement written policies and procedures related to reporting an allegation of abuse for Resident #346, 1 of 8 residents reviewed for abuse. The findings included: The facility admitted Resident #346 on 05/24/19 with [DIAGNOSES REDACTED]. On 08/06/19 at 03:24 PM, review of the Initial 2/24-Hour Report revealed the facility was notified of Resident #346's spouse's allegation of neglect at 1430 (02:30 PM) on 05/25/19. Further review revealed the facility alleged the report was submitted to the State Agency on 05/25/19 but there was no confirmation that the facsimile was sent to the Agency. Review of the report received by the state agency revealed it was received on 05/25/19 at 05:19 PM and not within the required 2 hour reporting time frame. During an interview on 08/06/19 at 05:15 PM, the Nursing Home Administrator confirmed the report was not submitted timely to the State Agency and that the policy was not followed related to reporting.

Based on record review and interview, the facility failed to prevent verbal abuse and neglect of Resident #27, 1 of 8 residents reviewed for abuse and/or neglect. The findings included: Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #27's medical record revealed the Annual MDS (Minimum Data Set) dated 2/25/19 and the Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact for daily decision-making. On 08/08/19, review of the Initial 2/24-Hour Report dated 5/26/19 revealed Resident #27 made an allegation of verbal abuse and neglect from CNA (Certified Nursing Assistant) #1. The facility's report indicated the incident occurred on 5/26/19 at 3:05 PM. Review of the Social Service Progress Notes revealed a note dated and timed 5/31/2019 at 08:50 AM Social Services followed up with resident about the incident on Sunday 5/26 with the CN[NAME] Resident stated that (s/he) is still shook up about it and that (s/he) is fearful that the CNA will try to harm (her/him). (S/he) stated that (s/he) stayed up all night worried that the CNA would come into (her/his) room and harm (her/him) or try to shoot (her/him) through (her/his) window. Review of a facility timeline attached to the Five-Day Follow-Up Report revealed the CNA came into Resident #27's room at 08:00 AM in response to the resident's call light and told the resident the staff was in the middle of passing out breakfast trays and that s/he would return. The aide returned at 10:45 AM and provided pericare and brief change but no AM care. The CNA told Resident #27 s/he would return in 2 hours. The resident called for assistance when the CNA failed to return in 2 hours and finally got a response at 3:00 PM. A verbal altercation ensued and LPN #4 asked CNA #1 to leave the room. The statement indicated the facility substantiated neglect. CNA #1's facility obtained statement dated 05/26/19 indicated at 03:05 s/he saw Resident #27's light on. S/he went in to change her/him and the resident was upset, yelling, cussing, and screaming, saying 4 CNAs walked past her/his room and ignored the call light. The statement indicated the CNA told the resident s/he had no control over the other aides but that s/he would change her/him. The resident was still yelling and s/he asked a second shift CNA to come into the residents room along with LPN #4. The statement indicated the CNA explained that s/he was busy with other residents and did not know the resident waited an hour for help. In a telephone interview on 08/08/19 at 02:14 PM, CNA #1 confirmed her/his statement was accurate. The CNA stated the resident was changed at approximately 08:45 in the morning. S/he further stated the resident was to have vital signs taken every 2 hours because she had been running a fever and that s/he changed Resident #27 every time s/he took her/his vital signs and stated that it was documented on the ADL sheet. Review of Resident #27's Physician order [REDACTED]. Further review of the Follow-Up Report revealed statements from other staff members who witnessed the altercation. LPN #4's statement dated 05/26/19 indicated Resident #27 was upset and crying; stated her/his light had been on a long time and no one answered it. The Resident reported CNA #1 hadn't checked on her/him between 7 AM and 11:00 AM when s/he was finally changed and she smelt (sic) like fish. (CNA #1) said Yeah, I know, because I washed you. The resident started raising her/his voice, and LPN #4 told CNA #1 to leave the room [ROOM NUMBER] times before s/he finally left, slamming the door behind her. CNA #2's statement dated 05/26/19 stated the first shift CNA asked for help to change Resident #27. The resident was complaining to LPN #4 about the first shift CN[NAME] CNA #1 and Resident #27 began yelling at each other. CNA #2's statement indicated Resident #27 said CNA #1 had only changed her/him at 8:00 AM. The statement also stated the CNA (#1) walked up to resident very angry and pointed (her/his) finger at resident. They were arguing back and forth. (LPN #4) asked CNA (#1) to leave the room. The CNA continued to argue on (her/his) way out and slammed the door. CNA #3's statement dated 05/26/19 indicated s/he went into the room and that the LPN and two CNAs were in the room. CNA #3 indicated s/he saw and heard Resident #27 complaining about the morning shift care from her/his CN[NAME] The resident said the call light was taken away from her/him by CNA #1 and s/he was not changed. Resident #27 said s/he saw CNA #1 walk by and not answer her/his call light and CNA #1 said s/he had to do care for another resident and everybody saw that call light and did not answer. The statement indicated CNA #1 and the resident were arguing about the resident's daily care. CNA #3 indicated the LPN asked CNA #1 to leave the room and CNA #1 continued to argue on her/his way out and slammed the resident's door. RN (Registered Nurse) #3's statement dated 05/26/19 indicated Resident #27 asked CNA #1 to change her/him at 8:00 am. The CNA said trays were there and s/he would return after trays were passed out. S/he returned at 10:45 am, changed Resident #27 and provided peri-care. The resident said her/his son stated there was an odor in the room when he and family arrived. The CNA left and said s/he would return in 2 hours. Resident #27 stated s/he turned her/his light on and it was on for 57 minutes before it was answered. When CNA #1 came in s/he told the resident s/he was on break and that s/he was in the room with another resident. CNA #1 and Resident #27 started hollering at each other. The statement further indicated Patient states (s/he) held (her/his) hand back as if (s/he) was going to hit (her/him) and that the CNA threw the diaper and brief on the bed and left the room, slamming the door. The CNA came back with LPN #4, CNA #2, and CNA #3. Another confrontation started between Resident #27 and CNA #1.

Based on review of facility files and interview, the facility failed to prohibit neglect of residents. Resident #19 was transferred by CNA #1 using a stand up lift and the resident was assessed as a stand-pivot transfer. CNA #1 stated s/he heard a pop during the transfer and Resident #19 was noted to have a fracture after the incident. One of one resident reviewed for neglect. The findings included: The facility reported an allegation of neglect to the State Agency on 6/1/16 for Resident #19 and CNA #1. Review of the facility's Five-Day Follow-Up Report dated 6/6/16 indicated upon completion of a thorough investigation they concluded Resident #19 was transferred by CNA #1 via the stand assist lift and his/her injury was the result of his/her body shifting while the lift was in use. Review of the care plan revealed self care deficit was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to assist with transfers using stand-pivot transfers and notify nurse/MD/Th of any decline in self-performance. Review of the Nurse Aide's Information Sheet for Resident #19 revealed s/he was an assist x 1 with a gait-belt and stand-pivot. Review of the Nurses' Notes dated 5/31/16 at 7:30 PM revealed the resident's left elbow was [MEDICAL CONDITION]. S/he was able to do range of motion on command. An order was received for left elbow x-ray with 3 views. Review of the Nurses' Notes dated 5/31/16 at 8 PM revealed the left elbow x-ray was done. Resident #19 did express pain during the process. Review of the Nurses' Notes dated 5/31/16 at 9 PM indicated the nurse was called to the resident's room by the CNA who stated the resident complained of pain to his/her left arm. Resident #19's left elbow had increased [MEDICAL CONDITION] and discoloration. The nurse called the on call nurse practitioner and received orders to send the resident to the ER for evaluation and treatment. Review of the Radiology Report dated 5/31/16 revealed Resident #19 had an acute olecranon fracture. LPN #2's facility-obtained statement dated 5/31/16 indicated s/he was told by the 7-3 nurse that Resident #19 complained of pain to his/her left elbow but was not certain what caused the pain. The resident was able to elevate arm and also able to propel him/herself in the wheelchair. At bedtime the resident was in pain, his/her left elbow was with increased [MEDICAL CONDITION] and discoloration. CNA #2's facility-obtained statement dated 5/31/16 indicated CNA #1 ran out of the shower room on 5/31/16 at approximately 2:30 PM saying s/he needed CNA #4. CNA #2 followed CNA #1 and CNA #4 into the shower room. CNA #1 stated that s/he was doing Resident #19 on the stand up lift to change him/her and s/he moved the wrong way and heard his/her left arm pop and that's when the resident started yelling and crying saying his/her left arm hurt. CNA #2 and CNA #4 told CNA #1 s/he needed to get the nurse. CNA #1 pushed the resident out of the shower room into the hall way and went to get RN #1. RN #1 told the resident to move his/her arms up and down and during that time the resident did not complain about any pain. RN #1's facility-obtained statement dated 6/1/16 indicated the CNA reported to him/her that s/he was transferring Resident #19 on and off the toilet with a stand lift. The CNA stated at some point in the transfer process the resident was holding on the handle of the lift with both hands. The CNA asked the resident to move his/her left hand to the left handle. The resident did not move his/her hand so the CNA asked him/her to move it a second time and the resident did then hold on to the left handle with his/her left hand. The CNA stated at some point during the transfer s/he heard some sort of sound but was not able to determine the source of the sound. The CNA stated the resident did not bump his/her left arm on anything and there was no trouble with the lift straps. Upon assessment the resident's left elbow appeared swollen without redness, bruising or open area. Resident #19 was able to extend his/her arm and able to hang his/her arm down to the side and propelled him/herself in the wheelchair. The resident initially complained of pain in his/her elbow but a few minutes later stated it feels ok. The elbow was assessed about 10-15 minutes later and swelling appeared to have lessened with still no bruising or redness. In an interview with the surveyor on 7/20/16 at approximately 9:35 AM, the Administrator stated Resident #19 was being provided peri-care by CNA #1 and was transferred with a stand assist lift. During the process, the CNA said s/he heard a pop. S/he lowered the resident to his/her w/c and sent for another CNA. That CNA said you need to get the nurse. The nurse assessed the resident and said I think s/he's ok we will just watch him/her. Nothing else was done. The nurse did not notify the Unit Manager, MD, Director Of Nursing - anybody. One of the CNAs who went in worked 2nd shift also that day. S/he went and looked at the resident's arm that night and noticed a lot of swelling and the resident was grimacing. S/he notified the nurse and the nurse notified the DON and MD and they obtained x-rays. The x-ray came back positive for fracture. The CNA was suspended because s/he did not follow the care card which stated the resident was a stand and pivot transfer. The Administrator stated s/he asked the CNA why s/he used a lift. The CNA knew the resident was a stand and pivot. The CNA stated s/he used the lift because it was faster. RN #1 did not fill out an incident report until the next day. S/he did not complete a nurses note. Both the Director Of Nursing and the Administrator stated they would expect the incident to be documented in the nurses' notes. CNA #1's facility-obtained statement dated 6/1/16 indicated s/he had Resident #19 in the shower room and s/he was on the stand up lift going to be cleaned. While s/he was lifting the resident up, s/he started trying to put his/her arms together off of the sling pad and began to move a bit. CNA #1 let the resident down telling him/her to hold on to each arm of the lift. S/he started again and the resident then placed both hands on the right side of the lift and CNA #1 told the resident to hold on to both sides. Resident #19 then moved his/her left arm over and s/he heard a crunch sound. CNA #1 was not sure if it was the lift or the resident. Resident #19 then said oh my arm. CNA #1 let the resident down and went to get help to finish. Resident #19 had a tear and CNA #1 asked him/her what's wrong. Resident #19 stated it was his/her arm. CNA #1 took off the residents geri sleeve on his/her left arm and saw a swollen area under the elbow. CNA #1 then got RN #1 and told him/her what happened.

On the days of the survey, based on record review, observations and interviews the facility failed to follow physician orders [REDACTED]. Resident # 12 did not receive pain relieving medication (Biofreeze) as ordered by the physician. Additionally, Resident #'s 1 did not receive prune juice as ordered by the physician. The findings included: The facility admitted Resident #12 with the [DIAGNOSES REDACTED]. During an individual interview with Resident #12 on 8/22/13 at approximately 9 AM, he/she expressed concerns about not getting bio freeze for his/her legs and feet. He/She stated s/he had been receiving it but currently was not. "I have been having pain for past week, all they want to do is give me pain medication. Pain medication constipates me. I informed the staff of my concern, they responded -we have to get more." Review of Resident #12's medical record revealed a physician's orders [REDACTED]. On 8/12/13 the order was changed to "Biofreeze to feet every night and bid (twice daily) as needed." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the Director of Nursing on 8/22/13 at approximately 10:10 AM he/she verified that the resident did not receive the Biofreeze as ordered. S/he further stated "Biofreeze does not come from the pharmacy and I have not placed an order yet for it. Biofreeze was given to us from therapy on 8/19/13 until ours come in." The facility admitted Resident #1 with the [DIAGNOSES REDACTED]. Record review on 8/19/13 at approximately 2:30 P.M revealed the physician's orders [REDACTED].M." On 8/20/13 and 8/21/13 during observation of breakfast, Resident #1 did not receive prune juice as ordered. During an interview with the Assistant Director of Nursing on 8/21/13 at approximately 3:15 PM, he/she stated "Dietary is responsible for providing prune juice to the residents with their meals." During an interview with the Certified Dietary Manager on 8/21/13 at 3:55 PM she/he confirmed that Resident #1 did not receive prune juice in A.M. as the resident "often refuses to drink it."

On the days of the Recertification Survey and Extended Survey, based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled "Glucometer" and "Cleansing and Disinfecting Diagnostic Equipment", facility nursing staff failed to ensure that expired Gluco-Chlor disinfecting wipes were not used to clean multiple-resident use glucometer's prior to use. Concerns were identified with ten of ten sampled residents with ordered blood glucose monitoring, Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15 received Finger Stick Blood Sugars (FSBS) from 5/1/11 through 9/13/11. The findings included: Cross refer to F441 as it relates to facility nursing staff failure to ensure that expired Gluco-Chlor disinfecting wipes were not used to clean multiple-resident use glucometer's prior to use. Observation of the facility Medication Room on 9/13/11 at 7:45 AM revealed expired Gluco-Chlor (Sodium Hypochlorite) towelettes in boxes and in 2 red caddies that had "D20EXP0411" imprinted on the wrappers. The caddies also contained alcohol pads but no other disinfecting wipes. During an interview on 9/13/11 at 8:10 AM, Licensed Practical Nurse (LPN) #2 verified the Gluco-Chlor wipes had expired. When asked, she stated there were no other glucometer cleaning supplies in the building. During an interview on 9/13/11 at 9:10 AM, LPN #2 was asked about the process used to check a blood sugar. As she explained the process, she stated she would clean the glucometer off with the glucometer cleaning wipes in the red lab tote. When asked, she stated she did not check the glucometer cleaning wipes for an expiration date and thought they were still good because they were in the red totes to be used. When asked who was responsible for checking to make sure the Gluco-Chlor wipes had not expired she stated the night shift nurse was supposed to check, but she was not sure if they did. She stated the night shift nurse had a list of duties and one was to check for expiration dates. LPN #2 was shown the box of Gluco-Chlor wipes again and asked what "exp date 0411" meant to her. She stated that it meant the wipes were not to be used after April 2011. When asked if there might be any more glucometer cleaning wipes anywhere else in the facility, she stated the Director of Nursing (DON) might keep some in her office. She was asked if she had used the Gluco-Chlor wipes recently and stated she had not. She was asked which residents on her hall received FSBS and stated that Resident #14 had FSBS ordered daily on Mondays, Wednesdays, and Fridays at 4:30 PM. During an interview on 9/13/11 at 9:20 AM, LPN #1 was shown the box of Gluco-Chlor wipes in the medroom and asked what "exp date 0411" meant to her. She stated that the wipes were not to be used after April 2011. LPN #2 was also asked the process used to check a blood sugar. She stated that she took the red bucket (the one in the medicine room with the expired wipes) into the resident's room and used the Gluco-Chlor wipes to clean the glucometer before and after it was used. She stated that she did not check the wipes for an expiration date because she assumed since they were in the red bucket they were not expired. When asked if she had done any FSBS recently, LPN #2 stated she had and stated Residents #7, #8, #9, #10, #11, #12, and #13 all received FSBS on her hall. During an interview on 9/13/11 at 9:50 AM, Registered Nurse (RN) #1 stated she had ordered more Gluco-Chlor wipes and they were on their way to the facility. RN #1 provided the facility policy entitled "Glucometer" which included information that the "Glucometer would be maintained per manufacturers' recommendation". Under step #8 the policy stated that the glucometer should be disinfected with a germicidal wipe, however, there was nothing to indicate nursing staff should check the germicidal wipe for an expiration date. During an interview on 9/13/11 at 10:23 AM, LPN #1 and #2 were present. According to both nurses, there were 2 glucometer's that were used by nursing staff, one on each medicine cart. The glucometer on each cart is used for any residents that need a FSBS on that hall. Prior to medpass observation on 9/13/11 at approximately 11:30 AM, LPN #1 stated she was waiting on the Gluco-Chlor wipes to arrive so she could do the scheduled 11:30 AM FSBS for Resident #7. On 9/13/11 at 11:54 AM, LPN #1 performed a FSBS on Resident #7. She checked the expiration date on the wipe prior to cleaning the glucometer. She stated that these were the new disinfectant wipes that had just arrived. The Gluco-Chlor wipe used to clean the glucometer expired October 2011. During an interview on 9/14/11 at 4:55 PM, the DON stated she was responsible for ordering medical supplies. She said her ADON, who had been on leave for a long while had been responsible for checking the medroom for expired medical supplies. She stated the night nurse was mainly responsible to check for expired medications and not medical supplies. She was not aware of any policy the facility had on who was supposed to check or even if there was one for checking items like the Gluco-Chlor wipes to see if the were expired. She stated they were presently working on a plan to decide who would be responsible and that it probably would be her. Chart reviews on Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 revealed they had received FSBS after the disinfectant wipes used to clean the multiple resident use glucometer's had expired on 4/30/11. The expired Gluco-Chlor wipes were the only disinfectant wipes used to clean glucometer's available in the facility on the morning of 9/13/11. The facility admitted Resident #15 on 6/30/10. Review of September 2011 Medication Administration Records on 9/13/11 revealed Resident #15 had been receiving FSBS. Record review on 9/14/11 at approximately 1:45 PM revealed Diabetes Monitoring Records for June, July, August, and September of 2011 which documented entries for a "Fingerstick blood sugar once a week on Wednesday". The entries had been initialed and resulted as having been done weekly at 6:30 AM as ordered from 6/1/11 through 9/7/11. Review of the May 2011 Diabetes Monitoring Record revealed Resident #15 had Finger Stick Blood Sugars documented and initialed as having been done twice daily from 5/1/11 through 5/9/11. Documentation revealed Resident #15 had received FSBS from 5/1/11 through 9/7/11 after the date the disinfectant wipes used to clean the glucometer's had expired. Resident # 10 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:30 AM. Resident # 11 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 12 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 13 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. The facility admitted Resident #5 on 11/24/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Further record review of the Medication Administration Records and/or Diabetes Monitoring Records indicated Fingerstick Blood Sugars (FSBS) readings were done three times per week during May, June, August, and September 2011. The facility admitted Resident #7 on 2/12/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the Diabetes Monitoring Records and/or Medication Administration Records indicated FSBS readings were done four times daily during May, June, July, August, and September 2011. The facility admitted Resident #8 on 9/09/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Physician's Telephone Orders revealed an order dated 9/13/11 to change FSBS to two times per day at 6:30 AM and 4:30 PM. The facility admitted Resident #9 on 7/28/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. The facility admitted Resident #14 on 3/28/04 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. The order was changed to FSBS daily on 9/13/11. Immediate Jeopardy was determined to exist on 9/13/11 at 12:01 PM after expired Gluco-Chlor wipes used to clean multiple-resident use glucometer's were found. The Gluco-Chlor wipes had expired on 4/30/11. Based on nursing staff interviews, the wipes were the only ones in the facility that had been used to clean the glucometer's which placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. CFR 483.20 F-281 was identified at a scope and severity of "K". Facility Licensed staff failed to follow standard precautions related to blood borne pathogens and failed to appropriately clean Glucometer's used for multiple residents with an appropriate cleansing agent. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing. First Follow Up Visit (9/28/2011) The findings included: On 9/28/11 an unannounced follow-up visit was made to evaluate the facility's Credible Allegation of Compliance for the Immediate Jeopardy identified during a Recertification Survey. Actions to remove the immediacy of the Jeopardy included removing expired products intended for resident care use (specifically Gluco-Chlor wipes), education of all facility staff related to checking for expiration dates (including any agency staff working in the facility), all licensed nursing staff were to be re-educated concerning facility policy for Cleaning and Disinfecting Diagnostic Equipment and reviewing expiration Dates on all products used in this procedure, all night shift nurses had their list of duties enhanced on 9/14/11 to include checking for expiration dates on all products, all nurses were required to review and sign an acknowledgement form of the inservices related to checking expiration dates, and all residents involved in the Jeopardy were reviewed for possible infections resulting from the use of expired wipes. During the unannounced onsite visit on 9/28/11 at 10:20 AM, it was determined based on observations that the product available and in use for resident care (Dipatch Hospital Cleaner disinfectant towels with bleach) for disinfecting Glucometer's was an acceptable product and had not expired. Expiration date(s) were verified as 2/15/2012. Interviews/actual observations were conducted with employees which verified the in-service training had been conducted and staff were knowledgeable in the procedure of cleaning multi-resident use Glucometer's. Review of facility documentation also confirmed in-services had been conducted as stated and Agency staff informed via a letter of the mandated policy for cleaning Glucometer's. No infections for Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15 were identified related to glucometer use. It was determined by the State Agency on the First Follow-up visit on 9/28/2011 that the Allegation of Compliance submitted by the facility on 9/27/11 had been implemented by the facility and was in practice as of 9/20/11, removing the immediacy of the deficient practice. The citations at F-281, F-441, and F-490 remained but were lowered in scope and severity to an "E". The facility will be in compliance with F-281, F-441, and F-490 when an acceptable Plan of Correction is submitted and a second follow up visit is conducted to determine that the facility has implemented their Plan of Correction.

On the days of the survey, based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled "Glucometer" and "Cleansing and Disinfecting Diagnostic Equipment", the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure wipes used to disinfect glucometers between each resident use were not expired. Concerns were identified with 10 of 10 sampled residents who received Fingerstick Stick Blood Sugar (FSBS) monitoring from 5/1/2011 through 9/13/11. Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 were identified with these concerns. The findings included: Observation of the facility Medication Room on 9/13/11 at 7:45 AM revealed two red caddies on the counter each with a handful of Gluco-Chlor (Sodium Hypochlorite) towelettes that had "D20EXP0411" imprinted on the wrappers. The caddies also contained alcohol pads but no other disinfecting wipes. There was one unopened box of 100 Gluco-Chlor towelettes along with a partial box of 57 towelettes in an upper cabinet in the medroom. Printing on the boxes revealed "exp date 0411". Imprinted on the individual towelettes in the boxes was "D20EXP0411". During an interview on 9/13/11 at 8:10 AM, Licensed Practical Nurse (LPN) #2 verified the Gluco-Chlor wipes had expired. When asked, she stated there were no other glucometer cleaning supplies in the building. During an interview on 9/13/11 at 9:10 AM, LPN #2 was asked about the process used to check a blood sugar. As she explained the process, she stated she would clean the glucometer off with the glucometer cleaning wipes in the red lab tote. When asked, she stated she did not check the glucometer cleaning wipes for an expiration date and thought they were still good because they were in the red totes to be used. When asked who was responsible for checking to make sure the Gluco-Chlor wipes had not expired she stated the night shift nurse was supposed to check, but she was not sure if they did. She stated the night shift nurse had a list of duties and one was to check for expiration dated. LPN #2 was shown the box of Gluco-Chlor wipes again and asked what "exp date 0411" meant to her. She stated that it meant the wipes were not to be used after April 2011. When asked if there might be any more glucometer cleaning wipes anywhere else in the facility, she stated the Director of Nursing (DON) might keep some in her office. She was asked if she had used the Gluco-Chlor wipes recently and stated she had not. She was asked which residents on her hall received FSBS and stated that Resident #14 had FSBS ordered daily on Mondays, Wednesdays, and Fridays at 4:30 PM. During an interview on 9/13/11 at 9:20 AM, LPN #1 was shown the box of Gluco-Chlor wipes in the medroom and asked what "exp date 0411" meant to her. She stated that the wipes were not to be used after April 2011. LPN #2 was also asked the process used to check a blood sugar. She stated that she took the red bucket (the one in the medicine room with the expired wipes) into the resident's room and used the Gluco-Chlor wipes to clean the glucometer before and after it was used. She stated that she did not check the wipes for an expiration date because she assumed since they were in the red bucket they were not expired. When asked if she had done any FSBS recently, LPN #2 stated she had and stated Residents #7, #8, #9, #10, #11, #12, and #13 all received FSBS on her hall. During an interview on 9/13/11 at 9:50 AM, Registered Nurse (RN) #1 was brought to the medication room and verified the expiration dates on the boxes of Gluco-Chlor wipes as 4/11. She stated that Central Supply was usually responsible for checking medical supplies for expiration dates but since this was not her building she would need to find out. RN #1 asked the Administrator who stated they did not have a Central Supply. The Administrator did not know if there were any other Glucometer cleaning wipes in the building but stated she would find out. According to RN #1, she had ordered more Gluco-Chlor wipes and they were on their way to the facility. When asked if there were any Gluco-Chlor wipes in the DON's office, the Administrator stated she did not know. RN #1 provided the facility policy entitled "Glucometer" which included information that the "Glucometer would be maintained per manufacturers' recommendation". Under step #8 the policy stated that the glucometer should be disinfected with a germicidal wipe, however, there was nothing to indicate nursing staff should check the germicidal wipe for an expiration date. During a phone interview on 9/13/11 at 10:22 AM, the DON stated she did not think she had any Gluco-Chlor wipes in her office. She stated there were some Caveat wipes in the storage closet in the small Day Room. When asked if the nursing staff used the Caveat wipes to clean glucometers she stated that they could, but usually did not. When asked who was responsible for checking for expired medical supplies she stated that either she or her Assistant Director of Nursing (ADON)was responsible. She stated that her ADON was presently on leave but had been checking the medicine rooms for expired supplies. She stated that the 3rd shift night nurse was also responsible for checking for expired things. When asked if the night shift nurse would check the glucometer cleaning wipes, she stated she should. During an interview on 9/13/11 at 10:23 AM, LPN #1 and #2 were present. According to both nurses, there are 2 glucometers that are used by nursing staff, one on each medicine cart. The glucometer on each cart is used for any residents that need a FSBS on that hall. When asked if she knew what Caveat wipes were, LPN #1 shook her head "no". LPN #1 and LPN #2 both shook their heads "no" when asked if they used Caveat wipes to clean the glucometers. LPN #1 was asked to accompany the surveyor to the small Day Room. Observation of the storage closet there revealed 10 containers of Micro-Kill Deodorizing Cleaning Wipes. LPN #1 shook her head "no" when asked if she knew that the wipes were there or what they were used for. During an interview on 9/14/11 at 2:42 PM, the Physical Therapist in the small Day Room stated the wipes in the storage cabinet were used to clean therapy equipment after each resident use. During a phone interview on 9/13/11 at 11:30 AM, a representative form Medtrol (the company that manufactured the Gluco-Chlor towelettes) was asked about the expiration date imprinted on the wrapper of the Gluco-Chlor towelette"D20EXP0411". She stated that the "D20" meant the product was packaged April 20th. She stated that by EPA (Environmental Protection Agency) standards, the product expired 12 months from the package date which would be 4/11. She stated the "EXP0411" meant the product expired in April 2011 and should not be used after that date. According to information provided by Medtrol and reviewed on 9/15/11 entitled "Lot Number (Batch Record) and Expiration Date", the expiration date on the Gluco-Chlor disinfecting wipes "...is determined by shelf life studies documented for each EPA Registered product. EPA Registered products expire when the strength of the active ingredient (i.e. sodium hypochlorite-bleach) drops below the strength stated on the product label. Therefore, the Expiration Date on the Gluco-Chlor and Super-Chlor packets means "do not use" after the Expiration Date". Prior to medpass observation on 9/13/11 at approximately 11:30 AM, LPN #1 stated she was waiting on the Gluco-Chlor wipes to arrive so she could do the scheduled 11:30 AM FSBS for Resident #7. On 9/13/11 at 11:54 AM, LPN #1 performed a FSBS on Resident #7. She checked the expiration date on the wipe prior to cleaning the glucometer. She stated that these were the new disinfectant wipes that had just arrived. The Gluco-Chlor wipe used to clean the glucometer expired October 2011. During a phone interview on 9/13/11 at 12:40 PM, the Medical Director was told of the concern with the expired Gluco-Chlor sanitizing wipes. He stated he did not think there was a policy in place related to the wipes. He stated it never occurred to him that the wipes even expired. When asked if the Pharmacy Consultant had responsibility for checking the expiration dates on the wipes, the Medical Director stated he did not expect the pharmacy to check for that since the wipes were not considered a medication. When asked if he would expect nursing staff to check the wipes before they were used to see if they were expired, he stated it was reasonable for someone to check the expiration date, but that he did not expect the nurse to check each wipe before it's used. When asked if any or what type of outcomes could result from using expired disinfectant wipes on the glucometer, the Medical Director stated he didn't think there was any chance of harm. He stated a sterile needle was used to get the blood and the blood was placed on a new test strip. He did not think there was any chance of cross-contamination. He stated there was no risk to the resident since it wasn't like they were touching the patient with it (glucometer). During an interview on 9/13/11 at 12:50 PM, the Pharmacy Consultant stated she comes once a month to check the narcotic box and do the residents' chart reviews. She stated they used to check the medroom quarterly for expired medications, but since they are under new ownership the full medroom check had not been done recently. She stated they usually did not check medical supplies for expiration dates, only medications. Review of the the Consultant Pharmacist's Medication Regimen Review on 9/14/11 revealed no concerns related to expired medical supplies. Review of the "BWNC Night Nurse Assignment Sheet" on 9/14/11 revealed the night nurse (11-7 shift) was responsible for cleaning and checking the glucometer nightly and checking all refrigerated medications for expiration and date of opening weekly. There was nothing to indicate the night nurse was responsible for checking for expired medical supplies. Review of the "Consulting Services Overview" provided by the facility listed the responsibilities of the consultant pharmacy revealed the pharmacy was responsible for random sampling of medication storage/carts and emergency kit audits. There was nothing to indicate the pharmacy was responsible for checking for expired medical supplies. The facility provided a copy of the "User's Guide" for the "[MEDICATION NAME]" glucometer which revealed on page 41 information related to "Caring For Your Monitor". Under "Cleaning Your Monitor", it stated "...Healthcare professionals: Acceptable cleaning solutions include 10% bleach, 70% alcohol, or 10% Ammonia". On 9/14/11 the Nurse Consultant provided a policy entitled "Cleaning and Disinfecting Diagnostic Equipment" which detailed the procedure used to clean resident care equipment such as glucometers. It stated that "Diagnostic equipment such as blood glucose meters and PT/INR machines are designed and developed to prevent blood specimens from entering the machine. Therefore, any gross blood found on a machine should be disinfected immediately with a bleach wipe". According to the policy, the procedure for cleaning and disinfecting the glucometer should be repeated between each resident usage and at the end of each shift. The surveyor had requested an invoice of when the Gluco-Chlor wipes had been delivered, however, per the Nurse Consultant they could not obtain this information since the supply company they had used to get the wipes no longer had this information. During an interview on 9/14/11 at 4:55 PM, the DON stated she was responsible for ordering medical supplies. She said her ADON, who had been on leave for a long while had been responsible for checking the medroom for expired medical supplies. She stated the night nurse was mainly responsible to check for expired medications and not medical supplies. She was not aware of any policy the facility had on who was supposed to check or even if there was one for checking items like the Gluco-Chlor wipes to see if the were expired. She stated they were presently working on a plan to decide who would be responsible and that it probably would be her. Inservice information provided by the facility on 9/13/11 and reviewed by surveyor(s) on 9/13/11 and 9/14/11 revealed an "Inservice Attendance sheet" which listed nursing staff who had attended the inservice given by the DON on 9/13/11. According to the documentation provided, some of the nursing staff who were not present were educated by phone or left messages. Included in the inservice was the policy for "Cleansing and Disinfecting Diagnostic Equipment" which detailed the steps to cleaning the glucometer. As stated above, the steps did not include checking the disinfectant wipes for an expiration date. Also included in the inservice was information from the Centers for Disease Control (CDC) related to "Recommended Infection Control and Safe Injection Practices to Prevent Patient-To-Patient Transmission of Bloodborne Pathogens". Under "Diabetes Care Procedures & Techniques" information stated that "Environmental surfaces such as glucometers should be decontaminated regularly and anytime contamination with blood or body fluids occurs or is suspected...If a glucometer that has been used for one patient must be reused for another patient, the device must be cleaned and disinfected..." On 9/14/11 interviews were conducted with nursing staff working the 3-11 shift. At 6:20 PM, LPN #4 was asked to explain the process used to obtain a FSBS. She stated she would take a bleach wipe and clean the glucometer before using it. She did not mention that she would check the expiration date on the wipe. When asked if she had received an inservice on the glucometers, she stated she had an inservice last week on cleaning the glucometers. When asked specifically if she had been inserviced that day or the day before on cleaning the glucometers, she stated she had not been inserviced that day or the day before. On 9/14/11 at 6:25 PM, LPN #3 was asked what she would do to check a FSBS. She stated she would get a meter and strip, wipe the finger with alcohol and prick the resident's finger. She did not mention that she would clean the meter first with a disinfectant wipe or check for an expiration date on a wipe. She was asked what she should do with the glucometer before she even started to prick the resident's finger and was even prompted by the surveyor asking if the glucometer should be cleaned to which she responded that she did not clean the glucometer prior to resident use since the nurse who used it last should have cleaned it. She stated she cleaned the glucometer after she did the FSBS. When questioned by the surveyor as to how she knew that the nurse before her really cleaned the glucometer after a FSBS she stated "So I need to wipe it before I start". When asked what she did before she opened the chlorine sanitizer wipe, she did not know to check the expiration date on the wipe. When asked if she had received an inservice today or yesterday she stated she had been inserviced yesterday on the proper cleaning of the glucometer. When asked if she was told to check the expiration date on the wipe she stated she did not remember that. Chart reviews on Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 revealed they had received FSBS after the disinfectant wipes used to clean the multiple resident use glucometers had expired on 4/30/11. The expired Gluco-Chlor wipes were the only disinfectant wipes used to clean glucometers available in the facility on the morning of 9/13/11. The facility admitted Resident #15 on 6/30/10. Review of September 2011 Medication Administration Records on 9/13/11 revealed Resident #15 had been receiving FSBS. Record review on 9/14/11 at approximately 1:45 PM revealed Diabetes Monitoring Records for June, July, August, and September of 2011 which documented entries for a "Fingerstick blood sugar once a week on Wednesday". The entries had been initialed and resulted as having been done weekly at 6:30 AM as ordered from 6/1/11 through 9/7/11. Review of the May 2011 Diabetes Monitoring Record revealed Resident #15 had Finger Stick Blood Sugars documented and initialed as having been done twice daily from 5/1/11 through 5/9/11. Documentation revealed Resident #15 had received FSBS from 5/1/11 through 9/7/11 after the date the disinfectant wipes used to clean the glucometers had expired. The facility admitted Resident #5 on 11/24/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the September 2011 Diabetes Monitoring Record indicated fingerstick blood sugar (FSBS) readings were done Monday, Wednesday, and Friday. In addition, further record review of the Medication Administration Records and/or Diabetes Monitoring Records indicated FSBS readings were done three times per week during May, June, and August 2011. The facility admitted Resident #7 on 2/12/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the September 2011 Diabetes Monitoring Record indicated FSBS readings were done daily at 6 AM, 11:30 AM, 4:30 PM, and 8 PM. Further record review of the Diabetes Monitoring Records and/or Medication Administration Records indicated FSBS readings were done four times daily during May, June, July, and August 2011. The facility admitted Resident #8 on 9/09/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 Medication Administration Record indicated FSBS readings were done four times per day at 6 AM, 11:30 AM, 4:30 PM, and 9 PM with Insulin administered per sliding scale. Review of the Physician's Telephone Orders revealed an order dated 9/13/11 to change FSBS to two times per day at 6:30 AM and 4:30 PM. The facility admitted Resident #9 on 7/28/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the Medication Administration Records for July 2011 and August 2011 indicated FSBS readings were done four times daily, and the September 2011 Diabetes Monitoring Record revealed FSBS readings were done twice daily during September. The facility admitted Resident #14 on 3/28/04 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the Medication Administration Records for May, June, July, August, and September 2011 indicated FSBS were done three times per week. The order was changed to FSBS daily on 9/13/11. Resident # 10 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:30 AM. Resident # 11 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 12 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 13 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Immediate Jeopardy was determined to exist on 9/13/11 at 12:01 PM after expired Gluco-Chlor wipes used to clean multiple-resident use glucometers were found. The Gluco-Chlor wipes had expired on 4/30/11. Based on nursing staff interviews, the wipes were the only ones in the facility that had been used to clean the glucometers which placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. CFR 483.65 F-441 was identified at a scope and severity of "K". The findings related to the Immediate Jeopardy were identified related to the facility failure to assure that Glucometer's used for multiple residents were appropriately cleansed and disinfected with an appropriate cleansing agent between use to prevent the transmission of blood borne pathogens. The cleansing agent used by the facility had an manufacturer expiration date of April 2011. On 9/13/2011 at 11:30 AM it was verified with the Manufacturer that the product was not to be used after 4/30/2011. There were 10 of 37 residents residing in the facility who required ongoing blood glucose testing with the use of the Glucometer. The systemic failure of the facility to effectively clean the Glucometer's placed the residents at risk at for serious harm. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.

On the days of the Recertification and Extended Survey, based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled "Glucometer" and "Cleansing and Disinfecting Diagnostic Equipment", the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure wipes used to disinfect glucometers between each resident use were not expired. Concerns were identified with 10 of 10 sampled residents who received Fingerstick Stick Blood Sugar (FSBS) monitoring from 5/1/2011 through 9/13/11. Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 were identified with these concerns. The findings included: Observation of the facility Medication Room on 9/13/11 at 7:45 AM revealed two red caddies on the counter each with a handful of Gluco-Chlor (Sodium Hypochlorite) towelettes that had "D20EXP0411" imprinted on the wrappers. The caddies also contained alcohol pads but no other disinfecting wipes. There was one unopened box of 100 Gluco-Chlor towelettes along with a partial box of 57 towelettes in an upper cabinet in the medroom. Printing on the boxes revealed "exp date 0411". Imprinted on the individual towelettes in the boxes was "D20EXP0411". During an interview on 9/13/11 at 8:10 AM, Licensed Practical Nurse (LPN) #2 verified the Gluco-Chlor wipes had expired. When asked, she stated there were no other glucometer cleaning supplies in the building. During an interview on 9/13/11 at 9:10 AM, LPN #2 was asked about the process used to check a blood sugar. As she explained the process, she stated she would clean the glucometer off with the glucometer cleaning wipes in the red lab tote. When asked, she stated she did not check the glucometer cleaning wipes for an expiration date and thought they were still good because they were in the red totes to be used. When asked who was responsible for checking to make sure the Gluco-Chlor wipes had not expired she stated the night shift nurse was supposed to check, but she was not sure if they did. She stated the night shift nurse had a list of duties and one was to check for expiration dated. LPN #2 was shown the box of Gluco-Chlor wipes again and asked what "exp date 0411" meant to her. She stated that it meant the wipes were not to be used after April 2011. When asked if there might be any more glucometer cleaning wipes anywhere else in the facility, she stated the Director of Nursing (DON) might keep some in her office. She was asked if she had used the Gluco-Chlor wipes recently and stated she had not. She was asked which residents on her hall received FSBS and stated that Resident #14 had FSBS ordered daily on Mondays, Wednesdays, and Fridays at 4:30 PM. During an interview on 9/13/11 at 9:20 AM, LPN #1 was shown the box of Gluco-Chlor wipes in the medroom and asked what "exp date 0411" meant to her. She stated that the wipes were not to be used after April 2011. LPN #2 was also asked the process used to check a blood sugar. She stated that she took the red bucket (the one in the medicine room with the expired wipes) into the resident's room and used the Gluco-Chlor wipes to clean the glucometer before and after it was used. She stated that she did not check the wipes for an expiration date because she assumed since they were in the red bucket they were not expired. When asked if she had done any FSBS recently, LPN #2 stated she had and stated Residents #7, #8, #9, #10, #11, #12, and #13 all received FSBS on her hall. During an interview on 9/13/11 at 9:50 AM, Registered Nurse (RN) #1 was brought to the medication room and verified the expiration dates on the boxes of Gluco-Chlor wipes as 4/11. She stated that Central Supply was usually responsible for checking medical supplies for expiration dates but since this was not her building she would need to find out. RN #1 asked the Administrator who stated they did not have a Central Supply. The Administrator did not know if there were any other Glucometer cleaning wipes in the building but stated she would find out. According to RN #1, she had ordered more Gluco-Chlor wipes and they were on their way to the facility. When asked if there were any Gluco-Chlor wipes in the DON's office, the Administrator stated she did not know. RN #1 provided the facility policy entitled "Glucometer" which included information that the "Glucometer would be maintained per manufacturers' recommendation". Under step #8 the policy stated that the glucometer should be disinfected with a germicidal wipe, however, there was nothing to indicate nursing staff should check the germicidal wipe for an expiration date. During a phone interview on 9/13/11 at 10:22 AM, the DON stated she did not think she had any Gluco-Chlor wipes in her office. She stated there were some Caveat wipes in the storage closet in the small Day Room. When asked if the nursing staff used the Caveat wipes to clean glucometers she stated that they could, but usually did not. When asked who was responsible for checking for expired medical supplies she stated that either she or her Assistant Director of Nursing (ADON)was responsible. She stated that her ADON was presently on leave but had been checking the medicine rooms for expired supplies. She stated that the 3rd shift night nurse was also responsible for checking for expired things. When asked if the night shift nurse would check the glucometer cleaning wipes, she stated she should. During an interview on 9/13/11 at 10:23 AM, LPN #1 and #2 were present. According to both nurses, there are 2 glucometers that are used by nursing staff, one on each medicine cart. The glucometer on each cart is used for any residents that need a FSBS on that hall. When asked if she knew what Caveat wipes were, LPN #1 shook her head "no". LPN #1 and LPN #2 both shook their heads "no" when asked if they used Caveat wipes to clean the glucometers. LPN #1 was asked to accompany the surveyor to the small Day Room. Observation of the storage closet there revealed 10 containers of Micro-Kill Deodorizing Cleaning Wipes. LPN #1 shook her head "no" when asked if she knew that the wipes were there or what they were used for. During an interview on 9/14/11 at 2:42 PM, the Physical Therapist in the small Day Room stated the wipes in the storage cabinet were used to clean therapy equipment after each resident use. During a phone interview on 9/13/11 at 11:30 AM, a representative form Medtrol (the company that manufactured the Gluco-Chlor towelettes) was asked about the expiration date imprinted on the wrapper of the Gluco-Chlor towelette"D20EXP0411". She stated that the "D20" meant the product was packaged April 20th. She stated that by EPA (Environmental Protection Agency) standards, the product expired 12 months from the package date which would be 4/11. She stated the "EXP0411" meant the product expired in April 2011 and should not be used after that date. According to information provided by Medtrol and reviewed on 9/15/11 entitled "Lot Number (Batch Record) and Expiration Date", the expiration date on the Gluco-Chlor disinfecting wipes "...is determined by shelf life studies documented for each EPA Registered product. EPA Registered products expire when the strength of the active ingredient (i.e. sodium hypochlorite-bleach) drops below the strength stated on the product label. Therefore, the Expiration Date on the Gluco-Chlor and Super-Chlor packets means "do not use" after the Expiration Date". Prior to medpass observation on 9/13/11 at approximately 11:30 AM, LPN #1 stated she was waiting on the Gluco-Chlor wipes to arrive so she could do the scheduled 11:30 AM FSBS for Resident #7. On 9/13/11 at 11:54 AM, LPN #1 performed a FSBS on Resident #7. She checked the expiration date on the wipe prior to cleaning the glucometer. She stated that these were the new disinfectant wipes that had just arrived. The Gluco-Chlor wipe used to clean the glucometer expired October 2011. During a phone interview on 9/13/11 at 12:40 PM, the Medical Director was told of the concern with the expired Gluco-Chlor sanitizing wipes. He stated he did not think there was a policy in place related to the wipes. He stated it never occurred to him that the wipes even expired. When asked if the Pharmacy Consultant had responsibility for checking the expiration dates on the wipes, the Medical Director stated he did not expect the pharmacy to check for that since the wipes were not considered a medication. When asked if he would expect nursing staff to check the wipes before they were used to see if they were expired, he stated it was reasonable for someone to check the expiration date, but that he did not expect the nurse to check each wipe before it's used. When asked if any or what type of outcomes could result from using expired disinfectant wipes on the glucometer, the Medical Director stated he didn't think there was any chance of harm. He stated a sterile needle was used to get the blood and the blood was placed on a new test strip. He did not think there was any chance of cross-contamination. He stated there was no risk to the resident since it wasn't like they were touching the patient with it (glucometer). During an interview on 9/13/11 at 12:50 PM, the Pharmacy Consultant stated she comes once a month to check the narcotic box and do the residents' chart reviews. She stated they used to check the medroom quarterly for expired medications, but since they are under new ownership the full medroom check had not been done recently. She stated they usually did not check medical supplies for expiration dates, only medications. Review of the the Consultant Pharmacist's Medication Regimen Review on 9/14/11 revealed no concerns related to expired medical supplies. Review of the "BWNC Night Nurse Assignment Sheet" on 9/14/11 revealed the night nurse (11-7 shift) was responsible for cleaning and checking the glucometer nightly and checking all refrigerated medications for expiration and date of opening weekly. There was nothing to indicate the night nurse was responsible for checking for expired medical supplies. Review of the "Consulting Services Overview" provided by the facility listed the responsibilities of the consultant pharmacy revealed the pharmacy was responsible for random sampling of medication storage/carts and emergency kit audits. There was nothing to indicate the pharmacy was responsible for checking for expired medical supplies. The facility provided a copy of the "User's Guide" for the "[MEDICATION NAME]" glucometer which revealed on page 41 information related to "Caring For Your Monitor". Under "Cleaning Your Monitor", it stated "...Healthcare professionals: Acceptable cleaning solutions include 10% bleach, 70% alcohol, or 10% Ammonia". On 9/14/11 the Nurse Consultant provided a policy entitled "Cleaning and Disinfecting Diagnostic Equipment" which detailed the procedure used to clean resident care equipment such as glucometers. It stated that "Diagnostic equipment such as blood glucose meters and PT/INR machines are designed and developed to prevent blood specimens from entering the machine. Therefore, any gross blood found on a machine should be disinfected immediately with a bleach wipe". According to the policy, the procedure for cleaning and disinfecting the glucometer should be repeated between each resident usage and at the end of each shift. The surveyor had requested an invoice of when the Gluco-Chlor wipes had been delivered, however, per the Nurse Consultant they could not obtain this information since the supply company they had used to get the wipes no longer had this information. During an interview on 9/14/11 at 4:55 PM, the DON stated she was responsible for ordering medical supplies. She said her ADON, who had been on leave for a long while had been responsible for checking the medroom for expired medical supplies. She stated the night nurse was mainly responsible to check for expired medications and not medical supplies. She was not aware of any policy the facility had on who was supposed to check or even if there was one for checking items like the Gluco-Chlor wipes to see if the were expired. She stated they were presently working on a plan to decide who would be responsible and that it probably would be her. Inservice information provided by the facility on 9/13/11 and reviewed by surveyor(s) on 9/13/11 and 9/14/11 revealed an "Inservice Attendance sheet" which listed nursing staff who had attended the inservice given by the DON on 9/13/11. According to the documentation provided, some of the nursing staff who were not present were educated by phone or left messages. Included in the inservice was the policy for "Cleansing and Disinfecting Diagnostic Equipment" which detailed the steps to cleaning the glucometer. As stated above, the steps did not include checking the disinfectant wipes for an expiration date. Also included in the inservice was information from the Centers for Disease Control (CDC) related to "Recommended Infection Control and Safe Injection Practices to Prevent Patient-To-Patient Transmission of Bloodborne Pathogens". Under "Diabetes Care Procedures & Techniques" information stated that "Environmental surfaces such as glucometers should be decontaminated regularly and anytime contamination with blood or body fluids occurs or is suspected...If a glucometer that has been used for one patient must be reused for another patient, the device must be cleaned and disinfected..." On 9/14/11 interviews were conducted with nursing staff working the 3-11 shift. At 6:20 PM, LPN #4 was asked to explain the process used to obtain a FSBS. She stated she would take a bleach wipe and clean the glucometer before using it. She did not mention that she would check the expiration date on the wipe. When asked if she had received an inservice on the glucometers, she stated she had an inservice last week on cleaning the glucometers. When asked specifically if she had been inserviced that day or the day before on cleaning the glucometers, she stated she had not been inserviced that day or the day before. On 9/14/11 at 6:25 PM, LPN #3 was asked what she would do to check a FSBS. She stated she would get a meter and strip, wipe the finger with alcohol and prick the resident's finger. She did not mention that she would clean the meter first with a disinfectant wipe or check for an expiration date on a wipe. She was asked what she should do with the glucometer before she even started to prick the resident's finger and was even prompted by the surveyor asking if the glucometer should be cleaned to which she responded that she did not clean the glucometer prior to resident use since the nurse who used it last should have cleaned it. She stated she cleaned the glucometer after she did the FSBS. When questioned by the surveyor as to how she knew that the nurse before her really cleaned the glucometer after a FSBS she stated "So I need to wipe it before I start". When asked what she did before she opened the chlorine sanitizer wipe, she did not know to check the expiration date on the wipe. When asked if she had received an inservice today or yesterday she stated she had been inserviced yesterday on the proper cleaning of the glucometer. When asked if she was told to check the expiration date on the wipe she stated she did not remember that. Chart reviews on Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 revealed they had received FSBS after the disinfectant wipes used to clean the multiple resident use glucometers had expired on 4/30/11. The expired Gluco-Chlor wipes were the only disinfectant wipes used to clean glucometers available in the facility on the morning of 9/13/11. The facility admitted Resident #15 on 6/30/10. Review of September 2011 Medication Administration Records on 9/13/11 revealed Resident #15 had been receiving FSBS. Record review on 9/14/11 at approximately 1:45 PM revealed Diabetes Monitoring Records for June, July, August, and September of 2011 which documented entries for a "Fingerstick blood sugar once a week on Wednesday". The entries had been initialed and resulted as having been done weekly at 6:30 AM as ordered from 6/1/11 through 9/7/11. Review of the May 2011 Diabetes Monitoring Record revealed Resident #15 had Finger Stick Blood Sugars documented and initialed as having been done twice daily from 5/1/11 through 5/9/11. Documentation revealed Resident #15 had received FSBS from 5/1/11 through 9/7/11 after the date the disinfectant wipes used to clean the glucometers had expired. The facility admitted Resident #5 on 11/24/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the September 2011 Diabetes Monitoring Record indicated fingerstick blood sugar (FSBS) readings were done Monday, Wednesday, and Friday. In addition, further record review of the Medication Administration Records and/or Diabetes Monitoring Records indicated FSBS readings were done three times per week during May, June, and August 2011. The facility admitted Resident #7 on 2/12/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the September 2011 Diabetes Monitoring Record indicated FSBS readings were done daily at 6 AM, 11:30 AM, 4:30 PM, and 8 PM. Further record review of the Diabetes Monitoring Records and/or Medication Administration Records indicated FSBS readings were done four times daily during May, June, July, and August 2011. The facility admitted Resident #8 on 9/09/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 Medication Administration Record indicated FSBS readings were done four times per day at 6 AM, 11:30 AM, 4:30 PM, and 9 PM with Insulin administered per sliding scale. Review of the Physician's Telephone Orders revealed an order dated 9/13/11 to change FSBS to two times per day at 6:30 AM and 4:30 PM. The facility admitted Resident #9 on 7/28/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the Medication Administration Records for July 2011 and August 2011 indicated FSBS readings were done four times daily, and the September 2011 Diabetes Monitoring Record revealed FSBS readings were done twice daily during September. The facility admitted Resident #14 on 3/28/04 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. Review of the Medication Administration Records for May, June, July, August, and September 2011 indicated FSBS were done three times per week. The order was changed to FSBS daily on 9/13/11. Resident # 10 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:30 AM. Resident # 11 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 12 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 13 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record (MAR) for May 2011, June 2011, July 2011, August 2011, and September 2011 the resident was receiving fingerstick blood sugars as ordered. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Immediate Jeopardy was determined to exist on 9/13/11 at 12:01 PM after expired Gluco-Chlor wipes used to clean multiple-resident use glucometers were found. The Gluco-Chlor wipes had expired on 4/30/11. Based on nursing staff interviews, the wipes were the only ones in the facility that had been used to clean the glucometers which placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. CFR 483.65 F-441 was identified at a scope and severity of "K". The findings related to the Immediate Jeopardy were identified related to the facility failure to assure that Glucometer's used for multiple residents were appropriately cleansed and disinfected with an appropriate cleansing agent between use to prevent the transmission of blood borne pathogens. The cleansing agent used by the facility had an manufacturer expiration date of April 2011. On 9/13/2011 at 11:30 AM it was verified with the Manufacturer that the product was not to be used after 4/30/2011. There were 10 of 37 residents residing in the facility who required ongoing blood glucose testing with the use of the Glucometer. The systemic failure of the facility to effectively clean the Glucometer's placed the residents at risk at for serious harm. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing. First Follow Up Visit (9/28/2011) The findings included: On 9/28/11 an unannounced follow-up visit was made to evaluate the facility's Credible Allegation of Compliance for the Immediate Jeopardy identified during a Recertification Survey. Actions to remove the immediacy of the Jeopardy included removing all expired Gluco-Chlor wipes from the medication room and cleaning and disinfecting all Glucometers in the facility utilizing wipes identified to be within acceptable date range. This was to be completed by the acting Director of Nursing. All facility staff were to be re-educated related to checking for expiration dates and this was to include any agency staff used by the facility. Night shift nurses were assigned the new duty of checking for expiration dates on all products and they were to be inserviced on this new assignment. Residents identified as having potential for infection from the use of expired wipes to clean glucometers were reviewed to determine if any infection occurred from the facility practice. These residents were #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15. During the unannounced onsite visit on 9/28/11 at 10:20 AM, it was determined based on observations that the product available and in use for resident care (Dipatch Hospital Cleaner disinfectant towels with bleach) for disinfecting Glucometer's was an acceptable product and had not expired. Expiration date(s) were verified as 2/15/2012. Interviews/actual observations were conducted with employees which verified the in-service training had been conducted and staff were knowledgeable in the procedure of cleaning multi-resident use Glucometer's. Review of facility documentation also confirmed in-services had been conducted as stated and Agency staff informed via a letter of the mandated policy for cleaning Glucometer's. No infections for Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15 were identified related to glucometer use. It was determined by the State Agency on the First Follow-up visit on 9/28/2011 that the Allegation of Compliance submitted by the facility on 9/27/11 had been implemented by the facility and was in practice as of 9/20/11, removing the immediacy of the deficient practice. The citations at F-281, F-441, and F-490 remained but were lowered in scope and severity to an "E". The facility will be in compliance with F-281, F-441, and F-490 when an acceptable Plan of Correction is submitted and a second follow up visit is conducted to determine that the facility has implemented their Plan of Correction.

On the days of the survey, based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled "Glucometer" and "Cleansing and Disinfecting Diagnostic Equipment", the facility failed to be administered in a manner that ensured staff were trained in the prevention of bloodborne pathogens related to cleaning and disinfecting multiple-resident use glucometers with a disinfectant wipe that had not expired. Concerns were identified with 10 of 10 sampled residents who received Fingerstick Stick Blood Sugar (FSBS) monitoring from [DATE] through [DATE]. Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 were identified with these concerns. The findings included: 1. Cross refer to F441. Based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled "Glucometer" and "Cleansing and Disinfecting Diagnostic Equipment", the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure wipes used to disinfect glucometers between each resident use were not expired. Concerns were identified with 10 of 10 sampled residents who received Fingerstick Stick Blood Sugar (FSBS) monitoring from [DATE] through [DATE]. Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 were identified with these concerns. 2. The facility did not have a policy or procedure in place related to expired medical supplies or to identify who was responsible to ensure that medical supplies were not expired. During a phone interview on [DATE] at 12:40 PM, the Medical Director was told of the concern with the expired Gluco-Chlor sanitizing wipes. He stated he did not think there was a policy in place related to the wipes. He stated it never occurred to him that the wipes even expired. When asked if the Pharmacy Consultant had responsibility for checking the expiration dates on the wipes, the Medical Director stated he did not expect the pharmacy to check for that since the wipes were not considered a medication. When asked if he would expect nursing staff to check the wipes before they were used to see if they were expired, he stated it was reasonable for someone to check the expiration date, but that he did not expect the nurse to check each wipe before it's used. When asked if any or what type of outcomes could result from using expired disinfectant wipes on the glucometer, the Medical Director stated he didn't think there was any chance of harm. He stated a sterile needle was used to get the blood and the blood was placed on a new test strip. He did not think there was any chance of cross-contamination. He stated there was no risk to the resident since it wasn't like they were touching the patient with it (glucometer). During an interview on [DATE] at 4:55 PM, the Director of Nursing (DON) stated she was responsible for ordering medical supplies. She stated that her Assistant Director of Nursing(ADON) who was presently on leave had been responsible for checking the medrooms for expired medical supplies. She was not aware of any policy the facility had on who was supposed to check or even if there was one for checking items like the Gluco-Chlor wipes to see if the were expired. She stated they were presently working on a plan to decide who would be responsible and that it probably would be her. Immediate Jeopardy was determined to exist on [DATE] at 12:01 PM after expired Gluco-Chlor wipes used to clean multiple-resident use glucometers were found. The Gluco-Chlor wipes had expired on [DATE]. Based on nursing staff interviews, the wipes were the only ones in the facility that had been used to clean the glucometers which placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. 483.75 Administration F-490 was identified at a scope and severity level of "K". The facility Administration failed to assure that appropriate polices and procedures were in place and implemented related to the cleaning of Glucometer's used for multiple residents. The systemic failure of the facility to effectively clean the Glucometer's placed the residents at risk at for serious harm. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.

On the days of the Recertification and Extended Survey, based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled "Glucometer" and "Cleansing and Disinfecting Diagnostic Equipment", the facility failed to be administered in a manner that ensured staff were trained in the prevention of bloodborne pathogens related to cleaning and disinfecting multiple-resident use glucometers with a disinfectant wipe that had not expired. Concerns were identified with 10 of 10 sampled residents who received Fingerstick Stick Blood Sugar (FSBS) monitoring from [DATE] through [DATE]. Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 were identified with these concerns. The findings included: 1. Cross refer to F441. Based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled "Glucometer" and "Cleansing and Disinfecting Diagnostic Equipment", the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure wipes used to disinfect glucometers between each resident use were not expired. Concerns were identified with 10 of 10 sampled residents who received Fingerstick Stick Blood Sugar (FSBS) monitoring from [DATE] through [DATE]. Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 were identified with these concerns. 2. The facility did not have a policy or procedure in place related to expired medical supplies or to identify who was responsible to ensure that medical supplies were not expired. During a phone interview on [DATE] at 12:40 PM, the Medical Director was told of the concern with the expired Gluco-Chlor sanitizing wipes. He stated he did not think there was a policy in place related to the wipes. He stated it never occurred to him that the wipes even expired. When asked if the Pharmacy Consultant had responsibility for checking the expiration dates on the wipes, the Medical Director stated he did not expect the pharmacy to check for that since the wipes were not considered a medication. When asked if he would expect nursing staff to check the wipes before they were used to see if they were expired, he stated it was reasonable for someone to check the expiration date, but that he did not expect the nurse to check each wipe before it's used. When asked if any or what type of outcomes could result from using expired disinfectant wipes on the glucometer, the Medical Director stated he didn't think there was any chance of harm. He stated a sterile needle was used to get the blood and the blood was placed on a new test strip. He did not think there was any chance of cross-contamination. He stated there was no risk to the resident since it wasn't like they were touching the patient with it (glucometer). During an interview on [DATE] at 4:55 PM, the Director of Nursing (DON) stated she was responsible for ordering medical supplies. She stated that her Assistant Director of Nursing(ADON) who was presently on leave had been responsible for checking the medrooms for expired medical supplies. She was not aware of any policy the facility had on who was supposed to check or even if there was one for checking items like the Gluco-Chlor wipes to see if the were expired. She stated they were presently working on a plan to decide who would be responsible and that it probably would be her. Immediate Jeopardy was determined to exist on [DATE] at 12:01 PM after expired Gluco-Chlor wipes used to clean multiple-resident use glucometers were found. The Gluco-Chlor wipes had expired on [DATE]. Based on nursing staff interviews, the wipes were the only ones in the facility that had been used to clean the glucometers which placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. 483.75 Administration F-490 was identified at a scope and severity level of "K". The facility Administration failed to assure that appropriate polices and procedures were in place and implemented related to the cleaning of Glucometer's used for multiple residents. The systemic failure of the facility to effectively clean the Glucometer's placed the residents at risk at for serious harm. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing. First Follow Up Visit ([DATE]) The findings included: On [DATE] an unannounced follow-up visit was made to evaluate the facility's Credible Allegation of Compliance for the Immediate Jeopardy identified during a Recertification Survey. Actions to remove the immediacy of the Jeopardy included removing all expired Gluco-Chlor wipes from the medication room and cleaning and disinfecting all Glucometers in the facility utilizing wipes identified to be within acceptable date range. A 100% review of the facility was completed to verify no additional Gluco-Chlor wipes were accessible to be used by any nursing staff working for the facility. All facility staff were to be re-educated related to checking for expiration dates and this was to include any agency staff used by the facility. Night shift nurses were assigned the new duty of checking for expiration dates on all products and they were to be inserviced on this new assignment. Policy on cleaning and disinfecting diagnostic equipment and checking of expiration dates was implemented and licensed staff inserviced. The facility Medical Director was notified of the Immediate Jeopardy and what it involved. All licensed nursing staff were required to sign and complete the acknowledgement form related to the policy implemented and Staffing Agencies were notified by letter of the need to inservice their employees that might be working at the facility. During the unannounced onsite visit on [DATE] at 10:20 AM, it was determined based on observations that the product available and in use for resident care (Dipatch Hospital Cleaner disinfectant towels with bleach) for disinfecting Glucometer's was an acceptable product and had not expired. Expiration date(s) were verified as [DATE]. Interviews/actual observations were conducted with employees which verified the in-service training had been conducted and staff were knowledgeable in the procedure of cleaning multi-resident use Glucometer's. Review of facility documentation also confirmed in-services had been conducted as stated and Agency staff informed via a letter of the mandated policy for cleaning Glucometer's. No infections for Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15 were identified related to glucometer use. It was determined by the State Agency on the First Follow-up visit on [DATE] that the Allegation of Compliance submitted by the facility on [DATE] had been implemented by the facility and was in practice as of [DATE], removing the immediacy of the deficient practice. The citations at F-281, F-441, and F-490 remained but were lowered in scope and severity to an "E". The facility will be in compliance with F-281, F-441, and F-490 when an acceptable Plan of Correction is submitted and a second follow up visit is conducted to determine that the facility has implemented their Plan of Correction.

On the days of the survey, based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled "Glucometer" and "Cleansing and Disinfecting Diagnostic Equipment", facility nursing staff failed to ensure that expired Gluco-Chlor disinfecting wipes were not used to clean multiple-resident use glucometers prior to use. Concerns were identified with ten of ten sampled residents with ordered blood glucose monitoring, Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15 received Finger Stick Blood Sugars (FSBS) from 5/1/11 through 9/13/11. The findings included: Cross refer to F441 as it relates to facility nursing staff failure to ensure that expired Gluco-Chlor disinfecting wipes were not used to clean multiple-resident use glucometers prior to use. Observation of the facility Medication Room on 9/13/11 at 7:45 AM revealed expired Gluco-Chlor (Sodium Hypochlorite) towelettes in boxes and in 2 red caddies that had "D20EXP0411" imprinted on the wrappers. The caddies also contained alcohol pads but no other disinfecting wipes. During an interview on 9/13/11 at 8:10 AM, Licensed Practical Nurse (LPN) #2 verified the Gluco-Chlor wipes had expired. When asked, she stated there were no other glucometer cleaning supplies in the building. During an interview on 9/13/11 at 9:10 AM, LPN #2 was asked about the process used to check a blood sugar. As she explained the process, she stated she would clean the glucometer off with the glucometer cleaning wipes in the red lab tote. When asked, she stated she did not check the glucometer cleaning wipes for an expiration date and thought they were still good because they were in the red totes to be used. When asked who was responsible for checking to make sure the Gluco-Chlor wipes had not expired she stated the night shift nurse was supposed to check, but she was not sure if they did. She stated the night shift nurse had a list of duties and one was to check for expiration dates. LPN #2 was shown the box of Gluco-Chlor wipes again and asked what "exp date 0411" meant to her. She stated that it meant the wipes were not to be used after April 2011. When asked if there might be any more glucometer cleaning wipes anywhere else in the facility, she stated the Director of Nursing (DON) might keep some in her office. She was asked if she had used the Gluco-Chlor wipes recently and stated she had not. She was asked which residents on her hall received FSBS and stated that Resident #14 had FSBS ordered daily on Mondays, Wednesdays, and Fridays at 4:30 PM. During an interview on 9/13/11 at 9:20 AM, LPN #1 was shown the box of Gluco-Chlor wipes in the medroom and asked what "exp date 0411" meant to her. She stated that the wipes were not to be used after April 2011. LPN #2 was also asked the process used to check a blood sugar. She stated that she took the red bucket (the one in the medicine room with the expired wipes) into the resident's room and used the Gluco-Chlor wipes to clean the glucometer before and after it was used. She stated that she did not check the wipes for an expiration date because she assumed since they were in the red bucket they were not expired. When asked if she had done any FSBS recently, LPN #2 stated she had and stated Residents #7, #8, #9, #10, #11, #12, and #13 all received FSBS on her hall. During an interview on 9/13/11 at 9:50 AM, Registered Nurse (RN) #1 stated she had ordered more Gluco-Chlor wipes and they were on their way to the facility. RN #1 provided the facility policy entitled "Glucometer" which included information that the "Glucometer would be maintained per manufacturers' recommendation". Under step #8 the policy stated that the glucometer should be disinfected with a germicidal wipe, however, there was nothing to indicate nursing staff should check the germicidal wipe for an expiration date. During an interview on 9/13/11 at 10:23 AM, LPN #1 and #2 were present. According to both nurses, there were 2 glucometers that were used by nursing staff, one on each medicine cart. The glucometer on each cart is used for any residents that need a FSBS on that hall. Prior to medpass observation on 9/13/11 at approximately 11:30 AM, LPN #1 stated she was waiting on the Gluco-Chlor wipes to arrive so she could do the scheduled 11:30 AM FSBS for Resident #7. On 9/13/11 at 11:54 AM, LPN #1 performed a FSBS on Resident #7. She checked the expiration date on the wipe prior to cleaning the glucometer. She stated that these were the new disinfectant wipes that had just arrived. The Gluco-Chlor wipe used to clean the glucometer expired October 2011. During an interview on 9/14/11 at 4:55 PM, the DON stated she was responsible for ordering medical supplies. She said her ADON, who had been on leave for a long while had been responsible for checking the medroom for expired medical supplies. She stated the night nurse was mainly responsible to check for expired medications and not medical supplies. She was not aware of any policy the facility had on who was supposed to check or even if there was one for checking items like the Gluco-Chlor wipes to see if the were expired. She stated they were presently working on a plan to decide who would be responsible and that it probably would be her. Chart reviews on Residents #5, #7, #8, #9, #10, #11, #12, #13, #14, #15 revealed they had received FSBS after the disinfectant wipes used to clean the multiple resident use glucometers had expired on 4/30/11. The expired Gluco-Chlor wipes were the only disinfectant wipes used to clean glucometers available in the facility on the morning of 9/13/11. The facility admitted Resident #15 on 6/30/10. Review of September 2011 Medication Administration Records on 9/13/11 revealed Resident #15 had been receiving FSBS. Record review on 9/14/11 at approximately 1:45 PM revealed Diabetes Monitoring Records for June, July, August, and September of 2011 which documented entries for a "Fingerstick blood sugar once a week on Wednesday". The entries had been initialed and resulted as having been done weekly at 6:30 AM as ordered from 6/1/11 through 9/7/11. Review of the May 2011 Diabetes Monitoring Record revealed Resident #15 had Finger Stick Blood Sugars documented and initialed as having been done twice daily from 5/1/11 through 5/9/11. Documentation revealed Resident #15 had received FSBS from 5/1/11 through 9/7/11 after the date the disinfectant wipes used to clean the glucometers had expired. Resident # 10 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record [REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:30 AM. Resident # 11 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record [REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 12 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record [REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. Resident # 13 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Per the physician orders [REDACTED]. Per review of the Medication Administration Record [REDACTED]. The resident received a fingerstick blood sugar on 9/13/11 at 6:00 AM. The facility admitted Resident #5 on 11/24/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. The facility admitted Resident #7 on 2/12/09 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. The facility admitted Resident #8 on 9/09/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 Medication Administration Record [REDACTED]. Review of the Physician's Telephone Orders revealed an order dated 9/13/11 to change FSBS to two times per day at 6:30 AM and 4:30 PM. The facility admitted Resident #9 on 7/28/11 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. The facility admitted Resident #14 on 3/28/04 with [DIAGNOSES REDACTED]. Review of the medical record on 9/13/11 revealed the September 2011 physician's orders [REDACTED]. The order was changed to FSBS daily on 9/13/11. Immediate Jeopardy was determined to exist on 9/13/11 at 12:01 PM after expired Gluco-Chlor wipes used to clean multiple-resident use glucometers were found. The Gluco-Chlor wipes had expired on 4/30/11. Based on nursing staff interviews, the wipes were the only ones in the facility that had been used to clean the glucometers which placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. CFR 483.20 F-281 was identified at a scope and severity of "K". Facility Licensed staff failed to follow standard precautions related to blood borne pathogens and failed to appropriately clean Glucometer's used for multiple residents with an appropriate cleansing agent. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.