Every finding on record at Peachtree Centre

Based on observation, interview, document review and record review, the facility failed to ensure that the planned menu was followed to meet the nutritional needs of five of five residents (R)2, R151, R108, R168, and R37) reviewed for nutrition. Specifically, the Dietary Aide (DA)2 served smaller portions to R2, R151, R108, R168 and R37 than the portion size the menu indicated. In addition, the residents on one of four floors (third floor) were served a different vegetable that what was indicated on the menu.Findings include:Review of the facility's menu titled Optima Solutions Ahava 2026 s/s Menus Week:1 revealed the baked chicken portion size should be three ounces. 1.Review of R2' electronic medical record (EMR) admission Record located under the Profile tab revealed R2 was admitted on [DATE] with diagnoses of paraplegia, stage IV pressure ulcer, and malnutrition. Review of R2's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/26 indicated a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated R2' cognition was moderately impaired. Review of R2' Nutrition/Dietary Note dated 4/21/26 in the EMR under the –Progress Note tab revealed R2 had a history of significant weight loss and multiple wounds. The Registered Dietitian (RD) noted that weight gain was beneficial until multiple wounds are healed and adjusted supplements (Med Pass and fortified juice) to improve intake.During an interview on 04/29/26 at 9:46 AM, R2 stated he did not get enough food and that he only received a chicken leg portion for the lunch meal yesterday. During an interview on 05/01/26 at 2:29 PM, the Registered Dietitian (RD) confirmed R2 was ordered to have a regular diet with double portions at all meals due to significant weight loss and high protein needs for wound healing. The RD stated, I would have been hungry too if I only received one chicken leg for lunch. 2. During an interview and observation on 04/28/26 at 12:45 PM, R151's lunch plate had one chicken leg. Her meal ticket read Diet: regular texture, regular liquids. R151 stated she was still hungry. At the time of the observation, Licensed Practical Nurse 1/Unit Manager (LPN1/UM) validated R151 received only one small chicken leg, while other residents at her table received chicken breasts. During an interview on 05/01/26 at 2:34 PM, the RD stated one small chicken leg was not an adequate portion of protein. The RD stated that R151 should get three ounces of protein, which would be a thigh and leg. There was not enough protein in only a wing or a leg. Depending on the size of the chicken leg, residents should have gotten two chicken legs. 3. During an interview and observation on 04/28/26 at 12:47 PM, R108's lunch plate had one chicken wing. Her diet ticket read, Diet Regular low concentrated sweets/no added salt (LCS/NAS). R108 stated that he was still hungry. During an interview on 05/01/26 at 2:41 PM, the RD stated that one chicken wing did not meet her nutritional needs. There was no resident in the building on a small portion diet. 4. During an interview and observation on 04/28/26 at 12:49 PM, R168's lunch plate had one chicken thigh. Her diet ticket read Diet- regular low concentrated sweets. R168 stated that she was still hungry. During an interview on 05/01/26 at 2:42 PM, the RD stated [R168] was on a low concentrated sweet, regular texture diet, with no supplements. She was not on a small portion diet. 5. During an interview and observation on 04/28/26 at 12:52 PM, R37's lunch plate had one small chicken leg. Her diet ticket read Diet regular texture, regular liquids. At the time of the observation, R37 stated that she was still hungry. During an interview on 04/28/26 at 1:06 PM, with DA2, who had served during the lunch meal the chicken to R2, R151, R108, and R168, stated for portion sizes, I know my residents. If I give them a big piece, they aren't going to eat it., I give them a smaller piece instead and they will eat it. During an interview on 05/01/26 at 9:15 AM, the Dietary Manager (DM) stated, we do not serve the same portion size for each person when serving chicken. I can't control that some people get a breast and some only receive a wing or a thigh. All other portions I can control, but not chicken portions. 6. Review of a document provided by the facility titled Optima Solutions.Menus.Week 1. indicated the menu for the lunch meal included: chicken with lemon and pepper, fluffy steamed rice, peas and carrots, dinner roll, fruited Jello, and margarine. Review of a document provided by the facility without a titled and date indicated a Main Course and Alternate which was referred to as an alternate menu items failed to contain information on the substitutions that were to be posted on 04/28/26. During an observation on 04/28/26 at 12:13 PM, the steam table on the third floor, residents were served corn instead of peas and carrots. The menu for the week was posted and did not indicate alternative menu items. During an interview on 05/01/26 at 9:18 AM, the DM stated that kitchen staff were to post the alternates for menu items, so the residents were aware of the substitution.

Based on observation, interview, document review and policy review, the facility failed to ensure personal protective equipment (PPE) was available for laundry staff in one of one laundry rooms to use while sorting soiled resident clothing and bed linens. This failure had the potential to infect the staff and/or all residents with pathogens which could potentially lead to the development of infectious diseases.Findings include: Review of an undated document by the American Healthcare Association indicated, . Use Personal Protective Equipment (PPE) when handling linens.To protect all staff including nursing and housekeeping from contaminants during laundry operations, they must use PPE.Wear tear-resistant gloves when handling and laundering soiled linens. If there is risk of splashing (e.g., if laundry is washed by hand) when laundering soiled linens, staff should in addition to gowns and gloves always wear face protection (e.g., face shield, goggles) . Review of a facility's policy titled Laundry undated indicated .The facility launders and clothing in accordance with current CDC [Centers for Disease Control] guidelines to prevent transmission of pathogens .The facility's laundry area will provide .PPE Interview and observation of the facility's laundry room on 05/01/26 at 9:09 AM, Laundry Aide (LA)1 stated that she did not have access to PPE (gowns and industrial strength gauntlet gloves) when handling soiled facility linens and residents' clothing. LA1 stated she only had access to disposable gloves. During this interview, the Infection Preventionist (IP) stated she did not come to the laundry room area very often. LA1 walked into the soiled laundry shoot area and again there was no PPE available. LA1 and the IP verified this. During an interview on 05/01/26 at 9:33 AM, the Director of Nursing (DON) stated her expectations were for the laundry staff to have access to PPE to prevent cross contamination.

Based on observation, interview, and policy review, the facility failed to maintain a safe, clean, comfortable, and homelike environment on two of the four floors (first and third floors). Specifically, the floor in the dining/activity area and hallways on the third floor were observed to be sticky. Additionally, four tables on the third-floor dining/activity area were chipped and exposed the wood underneath. The sticky floor posed a potential risk for residents who ambulate, as it could contribute to loss of balance of falls. The chipped condition of the tables had the potential to create an infection control issue. Findings include:Review of the facility's undated policy titled Safe and Homelike Environment indicated, .In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment.The facility will create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting.Report any furniture in disrepair to Maintenance promptly.Report any unresolved environmental concerns to the Administrator. 1. During an observation on 04/28/26 at 12:13 PM, staff were passing out meals for the residents present in the dining/activity area on the third floor. The staff present had their shoes sticking to the floor which also made squeaking sounds. During an observation on 04/29/26 at 6:55 AM, the main dining/activity area, on the third floor, had four dining tables pushed together. Each table had heavy chipping of the paint. The floor was sticky and made a squeaky sound. During an observation on 04/29/26 at 8:02 AM, there were multiple staff present and as each staff member walked this area, their shoes would get stuck on the floor, in the dining/activity area of the third floor. 2. Observation on 04/28/26 at 10:00 AM and 12:15 PM; on 04/29/26 at 8:00 AM; 04/30/26 at 9:15 AM; on 05/01/26 at 9:40 AM and 1:40 PM, revealed the first-floor hallways, dining room, and activity room floors were sticky and squeaked when staff and residents walked on the floors. During an interview on 04/29/26 at 8:39 AM, the Housekeeping Supervisor (HS) stated that she spoke with the chemical company's Sales Representative last week regarding the condition of the floor on the third floor. The HS stated that the sticky floors have been an on-going issue and the facility was aware of this issue. During an interview on 04/30/26 at 2:59 PM, the Licensed Practical Nurse/Unit Manager (LPN3/UM) said she did not know why the floors were sticky. During an interview on 04/29/26 at 8:53 AM, the Sales Representative stated that he was unaware that the floors were sticky and no one from the facility contacted him in an attempt to get the sticky floor issue resolved. During an interview on 04/29/26 at 8:58 AM, the Administrator stated that they had an older machine to clean the floors. The Administrator stated she contacted the chemical vender in the last few months and would look for the work orders. The Administrator did not provide any work orders prior to survey exit. During an observation on 04/29/26 at 11:48 AM, staff were entering the third-floor dining/activity area, and the staff present had their shoes making sticky/squeaking sounds.

Based on record review, interview, and policy review, the facility failed to develop person-centered, comprehensive care plans with measurable goals and interventions for two residents (Resident (R) 110 and R73) of two residents reviewed for care plans out of a sample of 54 residents. Specifically, the failure placed R110 at risk for unmet nutritional needs and for R73's unmet mental health treatment needs. These failures placed the residents at risk for unmet care needs, and the inability meet their maximum practicable level of functioning. Findings include:Findings include: Review of the facility's undated Comprehensive Care Plans policy, provided by the DON, noted It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Review of R110's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 02/15/22 with a diagnosis of a vitamin deficiency. Review of a document titled Care Plan dated 02/16/22 provided by the facility indicated that the resident was at nutritional risk due to a vitamin deficiency, gastroesophageal reflux, and hyperlipidemia. The care plan failed to address that the resident had a recent significant weight loss with registered dietitian (RD) recommendations. Review of R110's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/26 located in the EMR under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of six out of 15 which revealed the resident was severely cognitively impaired. The MDS indicated that the resident did not sustain a significant weight loss/gain. Under the Care Area Assessment (CAA) indicated that the resident triggered nutrition and directed the clinical staff to develop a care plan. Review of R110's EMR Nutrition/Dietary Note located under the Prog (Progress) notes dated 02/02/26 indicated the resident was identified with a significant weight loss from 118 to 98 pounds. The Nutrition/Dietary Note indicated that the resident was on a regular diet and would eat 26 to 50 percent of her meals and would snack throughout the day. The note indicated that the resident was provided with a nutritional treat at each lunch and dinner meal. The goal was to halt weight loss with a secondary goal to regain some weight. The note indicated that staff were to continue to monitor the resident's weight along with monitoring her meal and fluid intake. During an interview conducted on 04/30/26 at 10:37 AM, the MDS Coordinator (MDSC)2 stated that the Registered Dietician (RD) does not create the care plans for the residents who were at risk of weight loss. R110's care plan dated 02/16/22 was reviewed during this interview. The MDSC2 stated the resident typically will eat her dessert instead of the main meal and she needs lots of encouragement. MDSC2 stated none of the current recommendations were present in the resident's nutritional care plan. 2.Review of R73's admission Record located under the Profile tab in the EMR revealed the resident was admitted on [DATE] with diagnoses that included anxiety disorder; bipolar disorder, current episode depressed, severe, without psychotic features. Review of R73's quarterly MDS assessment, with an ARD of 02/18/26 and located under the MDS tab in the EMR with a BIMS score of 12 out of 15 which indicated R73's had moderate cognitive impairment. Review of R73's EMR Orders under the Orders tab revealed Topiramate 25 milligram (mg) (an anti-convulsant medication, used off label to treat binge eating), ordered 12/04/25. Review of R73's Care Plan dated 07/28/25 and located in the Care Plan tab of the EMR did not address the behavior of gorging on food and the use of the medication Topiramate as a treatment for the behavior. During an interview on 04/30/26 at 3:00 PM, the Licensed Practical Nurse/Unit Manager (LPN1/UM) stated that R73 had significant issues with gorging on food and drinking four or more energy drinks in a day. LPN1/UM confirmed that R73's behavior of gorging on food had not been entered on the care plan with specific interventions. During an interview on 05/01/26 at 12:31 PM, the Director of Nursing (DON) stated that her expectation for the development of a resident's care plan was to direct the staff on how to provide care to a resident. The DON stated that R110's care plan should have been updated and more individualized to address the resident being at risk for weight loss. During an interview on 05/01/26 at 2:52 PM, the DON stated that we should have had R73's specific behaviors and interventions identified on the care plan.

Based on observation, interview, and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming. Specifically, the facility failed to provide nail care for one of one resident (R)109) in the sample of 54 residents who was observed with long, dirty fingernails. This deficient practice has the potential to affect the resident's quality of life Findings include: Review of R109's electronic medical record (EMR) admission Record under the Profile tab revealed resident was admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebrovascular disease and diabetes mellitus. Review of the Medicare 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/05/26 with a Brief Interview for Mental Status (BIMS) score of eight out of 15 which indicated R109's cognition was moderately impaired. The MDS indicated that R109 required the assistance of another person to complete ADLs. Review of R109's care plan in the EMR under the Care Plan tab revealed that R109 required maximum assistance of one for personal hygiene due to a stroke and right hip fracture dated 01/02/26. On 04/28/26 at 1:15 PM, R109 was observed to have long fingernails on both hands with visible dark substance underneath. On 05/01/26 at 10:31 AM, the resident was observed in bed with long fingernails. Interview at the time of this observation, revealed R109 stated that he wanted his finger nails cut. During an interview on 05/01/26 at 11:03 AM, Licensed Practical Nurse/Unit 4 Mgr. (LPN8/UM) validated that the resident's nails were approximately 0.5 inches long on both hands. LPN8/UM stated that because the resident was diabetic, a nurse must perform nail care on shower days. During an interview on 05/01/26 at 11:06 AM, Certified Nurse Aide (CNA)7 stated that R109 does not refuse care and that his shower days are Tuesdays and Fridays. During an interview on 05/01/26 at 11:32 AM, the Director of Nursing (DON) stated her expectation was that nails should be cut on shower days or whenever needed.

Based on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure one out seven residents (Resident (R) 46) out of a survey sample 54, by failing to cover a heavily scraped painted wall by R46's bed, who had a history of putting non-food items in her mouth. The resident had the potential for choking, gastrointestinal issues, and toxic exposure.Findings include:Review of a facility policy titled Accidents and Supervision undated indicated . The resident environment remains as free of accident hazards as is possible; and each resident receives supervision and assistive devices to prevent accidents. The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Review of R46's electronic medical record (EMR) admission Record located under the Profile tab indicated that the facility admitted the resident on 03/14/25 with a diagnosis of late onset of Alzheimer's disease. Review of a document provided by the facility for R46 titled Care Plan dated 06/11/25 indicated that the resident had a history of intentionally placing non-food items in her mouth such as blankets, socks, and clothing. Review of a document provided by the facility titled Safety Data Sheet 06/16/22 indicated . PRO[DATE] Zero VOC Interior Latex Flat.Liquid. Was to be kept out of reach of children. Review of R46's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/30/25 located under the MDS tab indicated that the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated that the resident had no impairments of her bi-lateral extremities. During an interview conducted on 04/28/26 at 1:59 PM, Certified Nurse Aide (CNA)2 and CNA3 entered R46's room and when asked about the large, scratched wall (which exposed the dry wall under the blue paint) at the head of the resident's bed, both staff stated that the resident would peel and then eat the paint off the wall. Both CNA2 and CNA3 stated that they have reported this to the nurses on the floor. During an interview on 04/28/26 at 2:22 PM, Licensed Practical Nurse (LPN)4 stated she was not aware that R46 did peel and eat the paint off the wall in her room. LPN4 stated that the CNA staff have not reported this to her. During an interview on 04/28/26 at 2:27 PM, LPN5 stated she was not aware that R46 peeled and ate the paint off the wall in her room. LPN5 stated that the resident had a history of placing all sorts of items in her mouth and would chew on anything, such as the socks off her feet. During an interview conducted on 04/28/26 at 2:28 PM LPN1 who was also a Unit Manager (LPN1/UM) stated that she was aware that R46 would peel the paint off the wall in her room but was unaware that the resident would eat the paint. During an interview conducted on 04/28/26 at 2:38 PM, LPN4 stated that she had heard R46 would peel the paint off the wall in her room and stated that the resident did place items in her mouth. LPN4 stated that the staff keep the resident on the outside of her room to keep an eye on her. During an interview conducted on 04/29/26 at 6:18 AM, CNA1 stated that she was aware that R46 would peel and eat the paint off of her wall in her room. CNA1 entered the resident's room and there was now a plexiglass cover over the heavily peeled area located on the wall close to the resident's head of her bed. CNA1 stated that this cover must have been recently placed there since she had not seen it on previous occasions. During an interview conducted on 04/29/26 at 7:37 AM, the Maintenance Director stated he was asked to place the plexiglass cover over the peeled paint area on R46's wall yesterday. The Maintenance Director stated no one had mentioned this area of disrepair prior to 04/28/26. During an interview conducted on 04/29/26 at 10:43 AM, the Clinical Consultant, Director of Nursing (DON), and the Administrator all stated that they were unaware of R46's behavior of peeling and then eating the paint. The Clinical Consultant stated that R46 does have a history of placing non-food items in her mouth. The Administrator stated that there was a current system in place for staff to reports environmental issues and this was not done.

Based on record review, observations, interviews and policy review, the facility failed to ensure a medication error rate of less than five percent (5%). Two errors out of a total of 28 opportunities for error related to two (Residents (R) 18 and R82) of six residents observed during medication administration, resulting in a medication error rate of 7.14%. The facility's failure to ensure a medication error rate of less than five percent created the potential for residents to experience negative physical and/or psychosocial effects related to medication errors. Findings include: Review of the facility's undated policy titled, Medication Administration indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Administer medications as ordered and in accordance with manufacturer's specifications. b. Provide appropriate amount of fluid. Review of R18's admission Record dated 05/01/26 in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia, congestive heart failure (CHF) and protein-calorie malnutrition. Review of R18's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/26 in the EMR under the MDS tab with a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated the resident was severely cognitively impaired. Review of R18's Physician's Order Set dated 04/29/26 in the EMR under the Orders tab revealed an order with an original order date of 04/29/26, for the resident to receive Enteric Coated Aspirin 81 milligrams (MG) daily for CHF. R18 was observed receiving his medication from Licensed Practical Nurse (LPN)7 on 04/30/26 at 9:32 AM. LPN7 administered chewable aspirin 81 MG to the resident instead of the ordered enteric coated aspirin. During an interview with LPN7 on 04/30/26 at 10:29 AM, she confirmed she was aware of the difference between chewable and Enteric Coated aspirin and stated she missed the designation for enteric coated on the resident's Medication Administration Record (MAR). Review of R82's admission Record dated 05/01/26 in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of left radius (arm) fracture, bipolar disorder and malnutrition. Review of R82's admission MDS with an ARD of 04/11/26 in the EMR under the MDS tab revealed a BIMS score of 10 out of 15, which indicated the resident was moderately cognitively impaired. Review of R82's Physician's Order Set dated 04/30/26 in the EMR under the Orders tab revealed an order with an original order date of 04/02/26, for the resident to receive Miralax (a stool softener) 17 grams mixed in 4 – 6 ounces of fluid one time per day every other day. R82 was observed receiving his medication from Registered (RN)3 on 04/29/26 at 8:42 AM. The resident's Miralax powder was poured into a five-ounce cup, and two to three ounces of water was then added to the cup to mix the Miralax. RN3 then administered the Miralax to R82. No additional fluid was provided during the medication pass. During an interview with RN3 on 04/29/26 at 8:59 AM, she stated she thought Miralax needed to be mixed with eight ounces of water. She stated she thought the cup used to add fluid and mix the medication for administration held eight ounces of water. During an interview with Licensed Practical Nurse/Unit Manager (LPN8/UM) on 04/29/26 at 9:11 AM, she stated Miralax needed to be given in at least four ounces of fluid and confirmed the cups available on the medication carts were not big enough to accommodate that much liquid. She stated larger cups were available in the facility. During an interview with the Director of Nursing (DON) on 05/01/26 at 12:30 PM, she confirmed her expectation was correct medication, correct dose and correct route should be verified prior to administration and Miralax, we expect to be administered in at least four to six ounces of water to ensure effectiveness of the medication.

Based on observation and interview, the facility failed to store and dispense food and ice under sanitary conditions for one of four nourishments rooms (second-floor nourishment room). This failure had the potential to cause residents' food borne illness. Findings include: Observation on 04/28/26 at 11:29 AM revealed an ice scoop was stored directly inside the ice chest, in the second-floor nourishment room. Certified Nursing Assistant (CNA)9 validated the observation at 11:30 AM, stating the scoop was not supposed to be stored inside the chest. Observation on 04/28/26 at 11:33 AM revealed inside the second-floor nourishment room refrigerator, was a broken thermometer. The refrigerator contained several expired and unlabeled items, including a plastic-wrapped salad dated 04/15/26, one opened carton of 2% milk, and a water bottle containing an unidentified milky white substance with no name, label, or date. Further inspection revealed an egg carton with four eggs remaining that had a best by date of [DATE], and a box of renal supplement with a use by date of 02/18/26. The second shelf of the refrigerator was covered in red, blue, and white food debris. The door to the refrigerator was observed to be gouged. Observation and interview on 05/01/26 at 11:47 AM, Licensed Practical Nurse (LPN)9 used the broken thermometer and stated the temperature of the refrigerator was 48 degrees Fahrenheit (F). LPN9 noted that the thermometer was broken. LPN9 stated that the eggs should be thrown away because residents could get food poisoning. The Licensed Practical Nurse 1/Unit Manager (LPN1/UM) stated at this time that it was dietary's job to clean the bottom of the fridge. During an interview on 04/28/26 at 12:35 PM, the Dietary Manager stated the fridge door shelf was gouged and could cause cross contamination; the ice scoop should not be stored inside the machine; food should be labeled and dated and thrown out after three days.

Based on record review and interviews, the facility failed to ensure resident assessments were accurately documented for two (2) residents (R)42 and R100. The findings include: Review of R42's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Psychosis [a mental disorder characterized by a disconnection with reality], cognitive communication deficit, major depressive disorder, and anxiety disorder. R42 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. A review of the Physician's Order dated 8/27/24, for R42 read, Hydroxyzine HCl Oral Tablet [an antianxiety medication] 10mg [milligram], give 10mg by mouth at bedtime for sleep. Order Type: Antianxiety Orders. A review of R42's Annual Minimum Data Set (MDS) assessment, dated 2/5/25, revealed the resident was not coded for taking an antianxiety medication, which was considered a high-risk medication [medications that when used in error can cause significant harm and require careful monitoring] on the MDS. A review of R100's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, diabetes mellitus, osteoporosis, and a cognitive communication deficit. R100 had a BIMS score of seven (7), which indicated moderate cognitive impairment. A review of the Physician's Order, dated 11/7/24, for R100 read, Admit to [Name of Hospice Agency]. The Quarterly MDS assessment, dated 2/14/25, for R100, revealed the resident was not coded for receiving Hospice services under Special Treatments, Procedures, and Programs. During an interview, on 3/27/25 at 11:08 a.m., the MDS Coordinator (MDSC) reviewed the Annual MDS dated [DATE] for R42 and confirmed that the assessment for high-risk medications was not accurate. The MDSC stated, It should have been coded 'yes' under the antianxiety [medication] class on the MDS. [sic] The MDSC reviewed the Physician's Order, dated 8/27/24, and confirmed that R42 was prescribed an antianxiety medication during the Annual MDS assessment. For R100, the MDSC confirmed that Hospice was not coded on the Quarterly MDS assessment, dated 2/14/25. The MDSC stated, [R100 name] was on Hospice at the time of the Quarterly MDS assessment. S/he should have been coded for Hospice, but s/he wasn't. I'll have to modify the MDS. The MDSC confirmed that there was no facility policy for MDS assessments. The MDSC stated, I have the MDS 3.0 User's Manual, but I also use the online version of RAI [Resident Assessment Instrument] linked to the medical record, due to the constant updates. [sic] During an interview, on 3/27/25 at 12:42 p.m., the Administrator confirmed that resident assessments needed to be accurate on the MDS. The Administrator stated, I expect the assessments to be reported accurately when signing and submitting them. We don't have a policy for MDS or RAI, we use the online manual linked to the medical record.

Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure that respiratory equipment was appropriately stored according to professional standards of practice for one (1) of one (1) resident sampled for respiratory care, Resident (R)54. The findings include: Review of the undated facility policy titled, Oxygen Administration, noted: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. d. If applicable, change nebulizer tubing and delivery devices every 72 hours or per facility policy and as needed if they become soiled or contaminated. e. Keep delivery devices covered in a plastic bag when not in use. [sic] A review of R54's clinical record revealed that the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease [a group of lung diseases that block airflow and make it difficult to breathe], Dementia, and malignant neoplasm of the nasal cavity [a cancerous tumor of the nasal cavity]. R54's Brief Interview for Mental Status (BIMS) score was nine (9), which indicated moderate cognitive impairment. Review of the Physician's Order for R54, dated 11/20/24, read, Albuterol Sulfate Nebulization Solution [medication used in nebulizers to deliver medication into the lungs in the form of a fine mist] (2.5MG [milligram]/3ML [milliliter]) 0.083% [percent], 3ml inhale orally via nebulizer every 6 hours as needed for Shortness of Breath. [sic] During an observation, on 3/25/25 at 11:36 a.m., R54 was lying in his/her bed, awake. There was a nebulizer device on the right front corner of the nightstand against the wall to the right of the resident's bed. The nebulizer tubing was connected to the nebulizer device, uncovered and hanging down over the nightstand, and coiled up on the floor. The nebulizer mouthpiece was detached from the nebulizer tubing and laying on the nightstand uncovered. There was no nebulizer equipment storage container observed at the bedside or in R54's room. During an observation, on 3/26/25 at 1:45 p.m., R54 was lying in bed awake. There was a nebulizer device on the right front corner of the nightstand against the wall to the right of the resident's bed. The nebulizer tubing was connected to the nebulizer device, uncovered and hanging down over the nightstand, and coiled up on the floor. The nebulizer mouthpiece was detached from the nebulizer tubing and laying on the nightstand uncovered. There was no nebulizer equipment storage container observed at the bedside or in R54's room. During an interview, on 3/26/25 at 1:49 p.m., R54 stated, that's my breathing treatment equipment (pointing to the nebulizer device and equipment on the nightstand). I don't use it very often. I use it when I can't breathe. I haven't used it for a while. During an interview, on 3/26/25 at 1:50 p.m., Licensed Practical Nurse (LPN)3 entered R54's room and stated, Oh, that tubing shouldn't be on the floor like that. It needs to be in a bag when not in use. The mouthpiece shouldn't be left out like that. After a breathing treatment, the staff should rinse the container out and put it back in the bag with the tubing. The bag should be dated. We change the tubing and mouthpiece weekly on Sundays and as needed. I'm going to throw the tubing and mouthpiece away because it's contaminated. I'm not sure if s/he even needs the treatments anymore. [sic] During an interview, on 3/27/25 at 12:40 p.m., the Director of Nursing (DON) confirmed that nebulizer tubing should not be on the floor and that the nebulizer mouthpiece and tubing should be in a storage container when not in use to prevent contamination. The DON stated, the expectation is that the nebulizer tubing and mouthpiece be kept in a plastic bag when not in use. We change it out each week on Tuesdays, I think, and as needed. I don't require the staff to date the bag or tubing because we are consistent with changing the bag and supplies out each week. [sic]

Based on observation, interview, record review, review of the Food Code U.S. Food and Drug Administration, manufacturer's guidance and facility policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner and sanitation practices were in place to prevent the potential spread of food borne illness to 92 out of 93 residents (one resident received nutrition via a feeding tube). Specifically, dietary carts, buckets, garbage can had a heavy accumulation of food or grime; a plastic basin, located under the handwashing sink had an accumulation of dirt and green tinged water within the basin; shelves for the storage of clean pots were rusted; plastic bags of leftovers were in the refrigerator were not labeled with the food item in the bag or the date the food was placed in the refrigerator; the cook used unlabeled undated leftover food as alternates on the steam table; the dietary aide was not aware of the amount of time to immerse the pots and pans in the third compartment sink sanitizer solution; and the cook directly touched the rolls with a gloved hand that had been contaminated by touching other surfaces in the kitchen while adding the roll to the resident's plate during a meal observation. Findings include: The facility policy for glove use in the dietary department was requested on 12/28/23. No policy for glove use was provided. Review of the undated facility's policy titled, Handwashing Guidelines for Dietary Employees revealed, Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses . Frequency of handwashing: Dietary employees shall clean their hands . after engaging in any activity that may contaminate the hands . Review of the undated facility's policy titled, Sanitation Inspection provided by the facility revealed, All food service areas shall be kept clean, sanitary, . Sanitation inspections will be conducted in the following manner: a. Daily: Food service staff shall inspect refrigerators/coolers, freezers, . daily . b. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. Review of the Food Code U.S. Food and Drug Administration dated 2022, 3-6 Food Identity, Presentation, and on Premises Labeling, 3-602 page 102, revealed, Food Labels. (A) Food packaged . Label information shall include: (1) the common name of the food . Review of the Manufacturer's Quick San 10 Specification Sheet found at https://support.sunburstresults.com/wp-content/uploads/sites/2/2018/09/Quick-San-10_Spec-Sheet_V11_Haz.pdf, revealed the food contact surface sanitizing performance time requirement was one minute. 1. During the initial kitchen inspection on 12/27/23 from 9:38 AM through 10:05 AM, the following concerns noted: a. A small utility cart with bottom and upper shelves was observed to be heavily soiled with accumulated food and beverage residue covering approximately one third of the surface of both the upper and lower shelves. Boxes and opened cans of food were observed on the cart. The cart was in the pot washing area. b. Two shelves, located near the pot washing area, were observed to be rusted along the edges and surfaces of the shelves. There were inverted pots and pans resting directly on the rusted surfaces. c. A plastic basin located on the floor underneath the handwashing sink. It was heavily soiled with black grime and residue. d. The garbage can lid for the garbage can in the handwashing sink area was heavily soiled with food spills, splatters, and accumulated grime and dust. e. A plastic bucket located on the floor under the pot washing sinks that was heavily soiled with black residue on the interior and exterior surfaces. f. Observation and interview with Cook1 revealed, Cook1 was preparing lunch and there were several Ziploc bags with leftovers on the counter. Cook1 stated these were going to be the alternates for lunch today. One of the bags contained noodles and Cook1 stated it was chicken noodle casserole. There was no label on the bag indicating what the contents were or when it had been placed in the walk-in or when the use-by date was. Cook1 verified there was no date on the bag and stated she thought it had been in the walk-in a few days. Cook1 stated it should have been labeled with the food item and date. g. Inside the walk-in refrigerator, there was a food storage container in which diced red peppers in liquid were observed. The date on the container was 12/17/23. h. There was a full-sized steamtable pan with cubed chicken in broth covered with plastic wrap. There was a large chunk of ham that had been opened and had been wrapped in plastic wrap on top of the plastic wrap. The ham had fallen into the solution of chicken and broth. The ham was partially submerged in the chicken and broth. 2. A follow up kitchen inspection was conducted on 12/28/23 from 11:28 AM through 12:25 PM with the Dietary Manager (DM) present, and the following concerns were noted: a. A plastic basin, located under the handwashing sink, was observed with accumulated dirt, and green tinged water within the basin. b. The utility cart observed on 12/27/23 continued to be heavily soiled with the same food residue covering approximately one third of the horizontal surfaces. There were boxes and opened cans with the food contents removed from the cart. The DM stated the cart was used to transport garbage. The cart was in the pot washing area. c. The rusted shelves in the pot washing area continued to be rusted and had inverted pots and pans touching the rusted surfaces. The DM stated contact paper had been applied but had worn though. The DM verified the pots and pans were sitting directly on the rusted surface and that a rusted surface could not be adequately cleaned. d. The soiled plastic basin continued to be located under the handwashing sink. The DM stated the sink had leaked at one time and although it no longer leaked, the basin had not been removed. e. The garbage can lid for the garbage can in the handwashing area continued to be heavily soiled with food, beverage residue and grime. The DM stated it needed to be cleaned. f. The container of diced red peppers dated 12/17/23 remained in the walk-in refrigerator. The DM stated all leftovers should be identified by the name of the food and there should be two dates documented, the date it was placed in the walk-in and the date it should be used by. The DM stated leftover should be used within three days. g. The interior of the microwave oven was observed to have a significant amount of rust along the inside seams. This was verified by the DM. h. Dietary Aide (DA)1 initiated washing pots and pans using the three compartment sink, wash, rinse, and sanitize method. DA1 washed utensils, pots, and pans for several minutes by washing in the first sink, dunking in the second rinse sink, and dunking in the third sanitizer sink. DA1 stated on 12/28/23 at 12:22 PM, that there was no requirement to immerse the pots and pans in the sanitizer solution for any specific period. DA1 continued to wash pots and pans for several more minutes using the same procedure until the DM was interviewed. The DM stated at 12:25 PM, that pots and pans should sit in the sanitizer solution for a minute or two; however, there was no specific time requirement regarding how long was necessary to adequately sanitize. 3. During an observation on 12/28/23 from 12:40 PM through 1:10 PM, the first-floor steam table meal service was observed for 24 residents who resided on the first floor. Cook1 plated all the foods onto residents' plates from the steamtable which included chicken, broccoli, yams, and rolls. There was no utensil to serve the rolls. Cook1 served all the rolls with a gloved hand. With the same gloved hand, she touched the utensil handles, paper tray cards, plates, counter, and other surfaces in between touching each roll. In addition, Cook1 touched pieces of chicken with the same gloved hand to center them on the plates. The rolls and chicken were ready to eat food items. At the end of tray line meal service at approximately 1:10 PM, Cook1 was interviewed and verified she touched the rolls and multiple other things (scoops, tray cards, etc.) with the same gloved hand and this created the potential for cross contamination. The DM was interviewed and verified there was no utensil for serving the rolls observed on the tray line and stated tongs should be used for serving the rolls. During an interview on 12/28/23 at 1:11 PM, the Registered Dietitian (RD) stated ready to eat foods such as rolls should be served using tongs, if the same gloves touched other objects besides the rolls. The RD stated she had conducted inspections in the kitchen for sanitation occasionally when she had time. The RD further stated she had identified sanitation concerns in the dietary department which she had documented in her reports. During a follow up interview on 12/29/23 at 1:01 PM, the RD stated she had observed sanitation issues in the kitchen on her inspections including unclean equipment, areas of grime and dirt, and issues with labeling and dating foods. The RD stated leftovers should be discarded within three days after being placed in the walk-in refrigerator. The RD verified rust was not a cleanable surface and that microwaves had been discarded on the nursing units due to being rusted inside. Review of the RD's Consultant Dietitian Report dated 06/28/23 and provided by the facility revealed correction was needed for cleanliness of the stove, floor, shelves, walk-in refrigerator, walls, fans/vent/ducts, and ice machine. Additionally, the report revealed bacon was not dated and foods should be labeled when opened. Review of the undated Kitchen Cleaning Schedule provided by the facility revealed the carts should be deep cleaned once a week; the walk-in refrigerator dates and labels should be checked daily; the trash cans and lids should be cleaned once a week; carts should be cleaned weekly; and the kitchen should be swept and mopped daily. Review of the Kitchen Cleaning Schedule for November 2023 and December 2023 (through 12/28/23) revealed the sign off assignments was completed approximately half of the time in November and two thirds of the time in December 2023. The remaining assignments were blank. During an interview on 12/28/23 at 5:20 PM, the Administrator stated there had been issues with dietary staff completing the cleaning schedules/cleaning in kitchen. The Administrator stated the December cleaning schedule was still incomplete.

Based on observations, interview, record review, and facility policy review, the facility failed to ensure food was palatable for 9 out of 93 residents (Residents (R)76, R36, R38, R91, R89, R60, R69, and two residents who received pureed diets R59 and R44). Specifically, the vegetables for the regular diet were faded and soggy in appearance and residents did not receive salt, pepper, or margarine for their rolls. The pureed food was bland, pasty and lacked flavor. Residents reported the food was not served hot, the vegetables were overcooked, and condiments and margarine were not served. Findings include: Review of the facility's policy titled, Standardized Menus dated 2020 revealed, The facility shall provide nourishing, palatable meals to meet the nutritional need of the residents . The facility will make reasonable efforts to provide food that is appetizing . 1. Residents and/or families expressed concerns regarding the palatability of the food: a. During an interview on 12/27/23 at 1:36 PM, R76 stated the food did not taste good and was not hot. Review of R76's 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/23 in the electronic medical record (EMR) under the MDS tab revealed R76 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. b. During an interview on 12/27/23 at 1:50 PM, a family member who wished to remain anonymous stated R36 received pureed foods, and the food was bland. Review of R36's admission MDS with an ARD of 11/29/23 in the EMR under the MDS tab revealed a BIMS score of 6 out of 15 which indicated the resident's cognition was severely impaired. c. During an interview on 12/27/23 at 12:30 PM, R91 stated the vegetables were soggy. R89 who was also present stated on 12/27/23 at 12:30 PM that the vegetables were too soft. Review of R91's admission MDS with an ARD of 11/24/23 in the EMR under the MDS tab revealed R91 was intact in cognition with a BIMS score of 15 out of 15. Review of R89's admission MDS with an ARD of 10/20/23 in the EMR under the MDS tab revealed R89 was intact in cognition with a BIMS score of 15 out of 15. 2. Review of the Resident Council Meeting Minutes dated 11/22/23 and provided by the facility revealed, Residents states when get food, it [sic] not warm. 3. Review of the Daily Spreadsheet, Week 2 Wednesday provided by the facility revealed lunch on 12/27/23 consisted of spaghetti noodles with meat sauce, Italian blend vegetables, dinner roll, margarine, brownie, and condiments (1 each packet of salt and pepper). During observations of the lunch meal service on the third floor on 12/27/23 from 12:06 PM -12:40 PM revealed, the Italian vegetables were faded in color with a soggy appearance. All menu items, consisting of spaghetti with meat sauce, Italian vegetables, dinner roll, were served on the same plate. Residents were not served margarine with their dinner rolls and only three residents were served salt and pepper. Thirty-two residents were noted having lunch on the third floor. During an interview on 12/27/23 at 12:15 PM, R60, who was eating in the dining room, stated if he wanted salt and pepper, he had to ask for it and R60 then verified he was not offered margarine with his roll but would eat it if offered. Review of R60's quarterly MDS with an ARD of 12/07/23 in the EMR under the MDS tab revealed R60 was moderately impaired in cognition with a BIMS score of 9 out of 15. During an interview on 12/27/23 at 12:17 PM, R69, who was eating in the dining room, stated the staff did not offer salt and pepper or margarine. Review of R69's admission MDS with an ARD of 12/15/23 in the EMR under the MDS tab revealed R69 was moderately impaired in cognition with a BIMS of 12 out of 15. During an interview on 12/27/23 at 12:17 PM, R38 stated although she liked margarine with rolls, she was used to not having it. R38 stated it would be nice if they offered it (margarine). 4. Review of the Daily Spreadsheet, Week 2 Thursday provided by the facility revealed lunch on 12/28/23 consisted of roasted chicken, baked sweet potatoes, broccoli, dinner roll, margarine, sugar cookie, and condiments (one each). During observations of meal service on 12/28/23 from 12:40 PM - 1:24 PM on the first floor. The meal consisted of baked chicken, broccoli, yams, and roll, all served on the same dinner plate. The broccoli was faded and soggy in appearance, residents were not offered margarine, salt, or pepper with their meals. During an interview on 12:28/23 at 1:05 PM, R76 stated that her meal was hot today, which was unusual. She further stated there was no margarine offered and she would use it if she had it. On 12/28/23 at 1:15 PM a test tray of a regular diet and pureed diet was evaluated with the Dietary Manager (DM). The following was observed: The roll on the regular diet test tray was soggy/doughy due to the liquid on the plate from the broccoli. The broccoli was mushy and not flavorful. The DM stated the broccoli was overcooked and verified the roll was soggy. The pureed foods consisting of pureed chicken, pureed broccoli, and pureed yams were faded in color from the colors of the regular foods and were shiny in appearance. Each of the pureed foods lacked flavor of the original foods and were bland and unappetizing. The DM verified the observations of the pureed test tray and the taste of the food. The DM stated that too much thickener might have been added to the pureed foods. The DM stated the dietary staff did not use many seasonings when cooking. The DM verified neither salt, pepper, nor margarine had been served to residents on the first floor. She stated there were salt and pepper packets available and showed the Surveyor a container where they were stored in the dining room. The DM stated the dietary staff were supposed to send up individual margarine packets for the rolls, but she could not find any. The DM stated the nursing staff were supposed to serve the salt and pepper packets. Review of the quarterly MDS dated [DATE] in the EMR under the MDS tab revealed R59's BIMS score of 5 out of 15 indicating R59 had severely impaired cognition. Review of the Diet Orders report provided by the facility revealed R59 was prescribed a pureed diet. Review of the quarterly MDS dated [DATE] in the EMR under the MDS tab revealed R44's BIMS score of 0 out of 15 indicating R44 had severely impaired cognition. Review of the Diet Orders report provided by the facility revealed R59 was prescribed a pureed diet. During an interview on 12/28/23 at 1:24 PM, Certified Nursing Assistant (CNA)5 stated the CNAs only passed out salt and pepper packets to residents if the residents asked for them. Review of the Registered Dietitian (RD)'s Consultant Dietitian Report dated 06/28/23, provided by the facility revealed an identified concern which indicated: Consider vegetables in small bowl or roll served separately; dinner roll soggy due to broccoli. During an interview on 12/29/23 at 9:03 AM, CNA4, who worked on the third floor, stated she passed out salt and pepper packets to residents at meals only if they asked for them. CNA4 stated they did not offer or serve margarine with bread. During an interview on 12/29/23 at 1:01 PM, the RD stated concerns with food temperatures had come to her attention and issues with the availability of nursing staff to serve had been identified. The RD stated she received palatability complaints and worked with individual residents and dietary staff to address their preferences. The RD further stated she had made a recommendation for the dietary staff to serve bread/rolls on a separate plate or in a manner so the rolls would not become soggy from the water with the vegetables. The RD concluded that everything on the menu directed to be served including margarine packets, salt and pepper packets should be included on each resident's tray.

Based on interview, record review and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure three of three residents (Resident (R)7, R52, and R78) reviewed for no Minimum Data Set (MDS) assessment in over 120 days had a quarterly assessment successfully transmitted and accepted within the allotted time frame as stated in the RAI manual. Findings include: Review of the October 2019 RAI page 2-20 revealed: The MDS must be transmitted (submitted and accepted into the . system) electronically no later than 14 calendar days after the care plan completion date . Page 2-33 revealed: The Quarterly assessment is an . non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous . assessment of any type. The ARD . must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. Page 5-5 revealed: Fatal Record Errors result in rejection of individual records by the . system. The provider is informed of Fatal Record Errors on the Final Validation Report. Rejected records must be corrected and resubmitted, unless the Fatal Error is due to submission of a duplicate assessment. Review of R7's electronic medical record (EMR) MDS tab revealed the last processed MDS was dated 07/20/23. A quarterly MDS with an Assessment Reference Date of 10/17/23, history showed the assessment was rejected on 11/06/23 and 11/28/23. Review of R52's EMR MDS tab revealed the last processed MDS had an ARD of 07/19/23. A quarterly MDS with an ARD of 10/17/23, history showed it was rejected on 11/06/23 and 11/28/23. Review of R78's EMR MDS tab revealed the last processed MDS had an ARD of 07/23/23. A quarterly MDS with an ARD 10/18/23 history showed it was rejected on 11/06/23 and 11/28/23. During an interview on 12/28/23 at 3:07 PM, the MDS Coordinator (MDSC) reviewed the three rejected MDS assessments on the 11/06/23 and 11/28/23 Final Validation Report and stated the Regional MDSC reviews the rejection reports and emails her what needs to be fixed and she would fix it, but she was not notified of the three assessments referenced. The MDSC confirmed the three MDS assessments did not have an accepted status and they are late. During an interview on 12/29/23 at 3:16 PM, the Director of Nursing (DON) expressed an expectation that MDS assessments should be completed within the time guidelines. When asked if any MDS assessments should be over 120 days between assessments, the DON responded Oh no.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to provide an accurate resident assessment regarding a Level II screening of a Pre-Admission Screening and Resident Review (PASRR) on an admission Minimum Data Set (MDS) assessment for 1 of 2 residents (Resident (R) 28) reviewed for PASRR. Findings include: Review of the October 2019 RAI Manual, page A-22 and A-23 revealed: Coding Instructions .Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, ., Level II Preadmission Screening and Resident Review (PASRR) Conditions. Review of R28's printed Admission Record in the electronic medical record (EMR) under the Profile tab showed an admitted [DATE] with medical diagnoses including but not limited to: bipolar disorder and major depressive disorder. Review of R28's EMR Misc (Miscellaneous) tab showed a level I PASRR completed on 02/16/21; and a Level II PASRR that was also completed on 02/16/21. Review of the annual MDS from the EMR MDS tab showed the comprehensive assessment reference dates (ARD) of 03/05/23 which indicated, A1500. Preadmission Screening and Resident Review (PASRR), Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The question was coded No which disabled the next question as to R28's mental health needs. During an interview on 12/28/23 at 4:26 PM regarding R28's MDS dated [DATE] and the Level II PASRR screening question and response, the MDS Coordinator (MDSC) confirmed she was the one that completed section A. The MDSC reviewed R28's Level II PASRR, and stated, I didn't know he had a level II [PASRR] and confirmed the PASRR II should have been coded accurately on the MDS. During an interview on 12/29/23 at 3:16 PM regarding the Level II PASRR, the Director of Nursing (DON) stated, I expect assessments to be accurate, and that if there is a PASRR II, that it is coded accurately on the MDS.

Based on record review, review of facility policy, review of the Resident Assessment Instrument (RAI) Manual and interviews, the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and plans for 1 of 27 residents reviewed for care plans. Specifically, the facility failed to develop a care plan that addressed cognition/dementia health problems for Resident (R)76. Failure to develop the care plan could result in the resident not receiving care and services. Findings include: Review the undated facility policy titled, Comprehensive Care Plans provided by the facility indicated . The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. Review of the Minimum Data Set (MDS) 3.0 RAI Manual , dated 10/19, indicated, . The Care Area Assessment (CAA) process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident . Specific components of the CAA process include: - Care Area Triggers (CATs) are specific resident responses for one or a combination of MDS elements. The triggers identify residents who have or are at risk for developing specific functional problems and require further assessment .it is a preliminary assessment to identify potential resident problems, strengths, and preferences. Care Areas are triggered by MDS item responses that indicate the need for additional assessment based on problem identification, known as 'triggered care areas,' which form a critical link between the MDS and decisions about care planning . Review of a document provided by the facility titled Admission Record for R76 indicated the resident was admitted to the facility on [DATE]. Review of R76's electronic medical record (EMR) titled admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/23 indicated the R76 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R76 was moderately cognitively impaired. Under the Care Area Assessment (CAA) the resident triggered for cognition/dementia and directed the clinical staff to develop a care plan. Review of R76's Care Plan provided by the facility, failed to contain evidence the resident was care planned for cognition/dementia. During an interview on 12/29/23 at 8:33 AM, the MDS Coordinator confirmed she did not develop a care plan for cognition/dementia for R76. During an interview on 12/29/23 at 8:39 AM, the Administrator, Regional Director of Clinical Services and the Director of Nursing stated it was their expectation to develop a care plan if the area was triggered on the resident's CAA.

Based on observation, interview, record review and review of facility policy, the facility failed to ensure 1 (Resident (R)88) of 4 dependent residents reviewed for activities of daily living (ADL), was provided with adequate nail care. Findings include: Review of the undated facility policy titled Activities of Daily Living (ADLs) revealed: Policy Explanation and Compliance Guidelines .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . During an observation and interview on 12/27/23 at 4:07 PM, R88 stated he has asked the staff to trim his fingernails. Observation of R88's hands revealed the fingernails were approximately 1/4 inch past the tips of his fingers. Review of R88's printed Care Plan from the electronic medical record (EMR) Care Plan tab revealed, ADL Care Plan: Focus: [R88's name] requires assist with ADLS R/T [related to] cognition, recent CVA [stroke] .Goal: Resident will have ADL needs met daily with appropriate assist through next review. Interventions: . Resident needs mod [moderate] assist of 1 for personal hygiene . During an observation and interview on 12/29/23 at 10:57 AM, R88's fingernails remained long and R88 stated he needed his fingernails trimmed. During an observation and interview on 12/29/23 at 11:00 AM, Certified Nurse Aide (CNA)3 looked at R88's fingernails and confirmed they were long. CNA3 stated, He's hospice. They do the showers and clean his nails. During an interview on 12/29/23 at 11:04 AM, Licensed Practical Nurse (LPN)4 stated, We do it and they do it. I know I asked him last Friday [12/22/23], and he refused care. During an observation and interview on 12/29/23 at 11:10 AM, LPN4 was trimming R88's left hand and stated, They need to be cut. During an interview on 12/29/23 at 11:50 AM, the Administrator stated an expectation that nail care was provided as needed and the facility had no specific policy on nail care. During an interview on 12/29/23 at 1:53 PM, the hospice team coordinator stated, I verified this with the Clinical Supervisor that we do not do that here. We are supplemental care and that nail trimming would be the facility's or family's responsibility. During an interview on 12/29/23 at 3:18 PM, the Director of Nursing (DON) stated, He came in with those nails. We expect that nail care is provided and if refused, staff should walk away and go back to attempt again.

Based on observation, interview, and manufacturer's instructions for use (MIFU), the facility failed to ensure a medication administration error rate under five percent, with 2 errors for 2 (Residents (R)11 and R68) out of a possible 25 opportunities. This resulted in an error rate of 8 percent (%). Specifically, 2 Licensed Practical Nurses (LPN)1 and LPN2 failed to prime (to remove any bubbles from the needle and cartridge to ensure that the pen is working correctly so the insulin given is not too much or too little) insulin injection pens prior to the administration of the insulin. Findings include: Review of the MIFU for the glargine insulin pen documented: .STEP 3. PERFORM A SAFETY TEST Dial a test dose of 2 Units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the test 2 more times. If there is still no insulin coming out, use a new needle and do the safety test again. Always perform the safety test before each injection. Never use the pen if no insulin comes out after using a second needle . Review of the MIFU for the Novolog documented: .Priming your NovoLog FlexTouch Pen: Step 7: Turn the dose selector to select 2 units Step 8: Hold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. Step 9: Hold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter show 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. If you still do not see a drop of insulin, change the needle, and repeat steps 7 to 9. During a medication administration observation on 12/29/23 at 8:38 AM, LPN1 was observed to attach a needle to R11's insulin glargine (a long-acting modified form of medical insulin, used in the management of type I and type II diabetes) and dialed a 24-unit dose without priming the insulin injection pen. Review of the Order Summary from the electronic medical record (EMR) Reports tab showed a physician's order dated 10/18/23 for insulin glargine 24 unit of a 100 unit/milliliter solution twice a day for diabetes. During an interview on 12/29/23 at 8:44 AM, LPN1 stated, No, I don't prime. There are no air bubbles [showed insulin pen to surveyor] so I don't have to prime. During an observation of medication administration on 12/29/23 at 11:30 AM, LPN2 attached a needle to R68's Novolog (a fast-acting insulin used to manage blood sugar levels in adults with type 1 or type 2 diabetes) insulin pen and dialed a six-unit dose for a blood glucose of 354 without priming the insulin pen. Review of the Order Summary from the EMR Reports tab showed a physician's order, dated 04/12/23, for Novolog 100 units/milliliter solution with a sliding scale that showed for a blood glucose level of 354, six units Novolog should be administered for a diagnosis of diabetes. During an interview on 12/29/23 at 11:45 AM, LPN2 stated, I thought these were single use, the needle engages and when it's released it becomes a safety needle. So, I don't know how you would do that. LPN3, who was at the medication cart next to LPN2's medication cart stated, she means prime like this and dialed two units and depressed insulin pen injection button. When asked if the facility had taught her this, LPN3 stated, No, I knew that from another facility. It was verified with both LPNs, the facility had not instructed either LPN on priming insulin pen prior to use. During an interview on 12/29/23 at 3:20 PM, the Director of Nursing (DON) stated an expectation that staff follow manufacturer's instructions.

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 2 of 5 residents reviewed for pneumonia vaccinations (Resident (R) 21 and R60) and/or their representatives, the opportunity to be vaccinated in accordance with nationally recognized standards. Specifically, the facility failed to offer R21 and R60 the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Prevnar 20 (PCV 20) in accordance with nationally recognized standards. The failed practice had the potential to increase the risk for these residents to contract pneumonia. Findings include: Review of the Center of Disease Control website under the link titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, last reviewed 01/24/22, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older. The tables below provide detailed information . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV23 [pneumococcal polysaccharide vaccination] one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 is used, a dose of PPSV23 is NOT indicated . For adults [AGE] years or older who have only received a PPSV23, CDC recommends you . May give 1 dose of PCV15 or PCV20 . The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended. For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete . The CDC guidelines went into effect on 10/21/21 per recommendations from the Advisory Committee on Immunization Practices (ACIP). Review of the facility's undated policy titled Pneumococcal Vaccine (Series) indicated, .It is our policy to offer our residents . immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations.The type of pneumococcal vaccine (PCV13, PPSV23/PPSC) offered will depend upon the resident's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations . 1. Review of a document provided by the facility titled Admission Record, indicated R21 was admitted to the facility on [DATE]. The resident was [AGE] years of age at the time of admission. Review of a document provided by the facility titled Immunization Report indicated R21 received PPSV23 on 01/06/20. There was no evidence the resident was offered either the PCV15 or PCV20. 2. Review of a document provided by the facility titled Admission Record indicated R60 was admitted to the facility on [DATE]. The resident was [AGE] years of age at the time of admission. Review of a document provided by the facility titled Immunization Report indicated R21 received PPSV23 on 10/23/20. There was no evidence the resident was offered either the PCV15 or PCV20. During an interview on 12/28/23 at 3:37 PM, the Medical Director stated he was not aware of the current CDC recommendations regarding pneumococcal vaccinations. During an interview with the Infection Preventionist (IP), Administrator, and Director of Nursing on 12/29/23 at 1:00 PM, the IP stated she was not aware of the current CDC recommendations for the pneumococcal vaccine.

Based on review of facility policy, interview and record review, the facility failed to implement interventions outlined in a care plan for 1 of 4 residents. Specifically, Resident (R)1's Care Plan included an intervention for fall mats. R1 experienced a fall from the bed, with the absence of fall mats, resulting in R1 suffering injuries. Findings include: Review of the undated facility policy titled Care Plans -- Comprehensive revealed, The nurse supervisor uses the care plans to complete the CNA's daily work assignment sheets and/or flow sheets. Review of the undated facility policy titled Fall Prevention Program revealed, Each resident . will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Review of R1's Face Sheet revealed, R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, major depressive disorder, anxiety, and dementia. Review of R1's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/22 revealed, the resident required extensive assistance for toilet use and personal hygiene with one person to assist. Review of R1's General Orders dated 09/10/21 revealed, fall mats with low bed for safety. Review of R1's Care Plan dated 09/09/21 revealed, R1 was care planned for fall risks related to impaired cognition, mobility, and dizziness. The Care Plan included the intervention, fall mats to bilateral sides of bed. Review of a facility document titled [R1] Fall Timeline (Incident Date 11/8/22) revealed, R1 fell on [DATE] at approximately 12:30 PM during routine incontinence care. Nursing staff assessed the resident and sent her to the emergency room at 1:14 PM. At 3:04 PM, a computed tomography (CT) scan indicated R1 sustained multiple cervical fractures. Review of Certified Nursing Assissant (CNA)1's Investigation Statement, taken by the facility on 11/08/22 revealed, CNA1 was changing R1 and stripping R1's bed. CNA1 attempted to turn the resident to clean her back side. While cleaning her, R1 started to roll forward away from the CNA. CNA1 attempted to catch her but the resident rolled off the bed. R1 hit her head and hands. Review of a document titled Interview with [CNA1] conducted by the Director of Nursing (DON) on 11/11/22 at 2:44 PM revealed, there were no floor mats on the floor or in the room. Review of Registered Nurse (RN)1's Investigation Statement, taken by the facility on 11/08/22 revealed, RN1 observed the resident lying supine (lying horizontally with the face and torso facing up) on the floor, with a V-shaped laceration to her left frontal scalp and redness to her forehead. Review of Licensed Practicing Nurse (LPN)1's Investigation Statement, taken by the facility on 11/08/22 revealed, she observed the resident lying on the floor with a V-shaped laceration in the center of her forehead with blood loss noted. In an interview with CNA1 on 05/11/23 at 12:17 PM revealed, CNA1 did not know the resident was supposed to have fall mats at the time of the incident. Normally, the resident's Kardex would include the intervention, but since CNA1 was agency staff, nursing would normally inform her ahead of time what interventions are required for residents she was unfamiliar with. CNA1 confirmed that R1 fell during incontinence care, R1 hit her head and began bleeding. Review of R1's Progress Notes dated 11/08/2022 at 12:53 PM revealed, Resident had V shaped laceration to forehead. Resident provided care and assisted to bed x 3 Hoyer lift. At that time resident began having emesis. 911 in route Hall nurse stayed at residents' bedside. resident had discoloration noted to right side of face after EMS transferred to stretcher. Review of R1's Progress Notes dated 11/11/22 at 5:48 PM, revealed, R1 was status post fall and hospitalization and that the resident had been diagnosed with a cervical fracture. Review of R1's CT Cervical Spine Without Contrast with a study date 11/08/22 revealed, R1 had an acute appearing nondisplaced fracture of the anterior arch of C1, posterior arches of C1, and left lateral mass of C2. The report also revealed the resident had a nondisplaced type2 odontoid fracture as well as a minimally displaced spinous process fracture of C6. Review of R1's Ortho Spine Consult Note with date of service 11/10/22 revealed, the resident's assessment of acute nondisplaced fractures of anterior arch of C1, posterior arches of C2, and left lateral mass of C2. The plan of care was for R1 to use an Aspen collar (a cervical collar to immobilize the neck) and to follow up with the office in 2 weeks. In an interview with the Administrator on 05/11/23 at approximately 12:00 PM revealed, the findings of the facility's investigation into the incident was the failure to put fall mats in place as ordered. The facility does not use side rails, and R1 was a one-person assist for toileting. During the survey multiple attempts were made to contact RN1 and LPN 1 with no success. The facility implemented the following corrections: On 11/08/2022 at 4:15 PM, the Staff Development Coordinator (SDC) began education for nurses and CNAs. The SDC performed 1:1 education with CNA1. The Director of Nursing (DON) printed Kardexes for review by Guardian Angel staff. On 11/09/2022 at 9:00 AM - 12:00 PM, the Kardex audit was initiated by Guardian Angel staff. The SDC continued with education of nursing staff. On 11/09/2022 at 12:00 PM - 4:00 PM, the Guardian Angels returned audits to the DON. The DON and MDS Coordinators reviewed audits and began necessary corrections to care plans and Kardexes. On 11/10/2022 at 10:00 AM - 12:00 PM, the DON and MDS coordinator reviewed corrected Kardexes for accuracy. On 11/10/2022 at 12:00 PM - 4:00 PM, the Guardian Angels reconciled Kardexes and in-room equipment. The SDC continued with education to nursing staff. On 11/11/2022 at 10:00 AM - 12:00 PM, the DON and MDS coordinators reviewed Guardian Angel round sheets and made further corrections to Kardexes. On 11/11/2022 at 12:00 PM - 3:00 PM, the Guardian Angels rounded with Kardexes. The SDC education continued with nursing staff.

Based on review of facility policy, interview and record review, the facility failed to protect 1 of 4 residents from a fall resulting in injury. Specifically, Resident (R)1 fell while receiving incontinence care which resulted in R1 suffering from neck fractures and hospitalization . Findings include: Review of the undated facility policy titled Fall Prevention Program revealed, Each resident . will receive care and services in accordance with the level of risk to minimize the likelihood of falls. Review of R1's Face Sheet revealed, R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, major depressive disorder, anxiety, and dementia. Review of R1's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/22 revealed, the resident required extensive assistance for toilet use and personal hygiene with one person to assist. Review of R1's General Orders dated 09/10/21 revealed, fall mats with low bed for safety. Review of R1's Care Plan dated 09/09/21 revealed, R1 was care planned for fall risks related to impaired cognition, mobility, and dizziness. The Care Plan included the intervention, fall mats to bilateral sides of bed. Review of a facility document titled [R1] Fall Timeline (Incident Date 11/8/22) revealed, R1 fell on [DATE] at approximately 12:30 PM during routine incontinence care. Nursing staff assessed the resident and sent her to the emergency room at 1:14 PM. At 3:04 PM, a computed tomography (CT) scan indicated R1 sustained multiple cervical fractures. Review of Certified Nursing Assissant (CNA)1's Investigation Statement, taken by the facility on 11/08/22 revealed, CNA1 was changing R1 and stripping R1's bed. CNA1 attempted to turn the resident to clean her back side. While cleaning her, R1 started to roll forward away from the CNA. CNA1 attempted to catch her but the resident rolled off the bed. R1 hit her head and hands. Review of a document titled Interview with [CNA1] conducted by the Director of Nursing (DON) on 11/11/22 at 2:44 PM revealed, there were no floor mats on the floor or in the room. Review of Registered Nurse (RN)1's Investigation Statement, taken by the facility on 11/08/22 revealed, RN1 observed the resident lying supine (lying horizontally with the face and torso facing up) on the floor, with a V-shaped laceration to her left frontal scalp and redness to her forehead. Review of Licensed Practicing Nurse (LPN)1's Investigation Statement, taken by the facility on 11/08/22 revealed, she observed the resident lying on the floor with a V-shaped laceration in the center of her forehead with blood loss noted. In an interview with CNA1 on 05/11/23 at 12:17 PM revealed, CNA1 did not know the resident was supposed to have fall mats at the time of the incident. Normally, the resident's Kardex would include the intervention, but since CNA1 was agency staff, nursing would normally inform her ahead of time what interventions are required for residents she was unfamiliar with. CNA1 confirmed that R1 fell during incontinence care, R1 hit her head and began bleeding. Review of R1's Progress Notes dated 11/08/2022 at 12:53 PM revealed, Resident had V shaped laceration to forehead. Resident provided care and assisted to bed x 3 Hoyer lift. At that time resident began having emesis. 911 in route Hall nurse stayed at residents' bedside. resident had discoloration noted to right side of face after EMS transferred to stretcher. Review of R1's Progress Notes dated 11/11/22 at 5:48 PM, revealed, R1 was status post fall and hospitalization and that the resident had been diagnosed with a cervical fracture. Review of R1's CT Cervical Spine Without Contrast with a study date 11/08/22 revealed, R1 had an acute appearing nondisplaced fracture of the anterior arch of C1, posterior arches of C1, and left lateral mass of C2. The report also revealed the resident had a nondisplaced type2 odontoid fracture as well as a minimally displaced spinous process fracture of C6. Review of R1's Ortho Spine Consult Note with date of service 11/10/22 revealed, the resident's assessment of acute nondisplaced fractures of anterior arch of C1, posterior arches of C2, and left lateral mass of C2. The plan of care was for R1 to use an Aspen collar (a cervical collar to immobilize the neck) and to follow up with the office in 2 weeks. In an interview with the Administrator on 05/11/23 at approximately 12:00 PM revealed, the findings of the facility's investigation into the incident was the failure to put fall mats in place as ordered. The facility does not use side rails, and R1 was a one-person assist for toileting. During the survey multiple attempts were made to contact RN1 and LPN 1 with no success. The facility implemented the following corrections: On 11/08/2022 at 4:15 PM, the Staff Development Coordinator (SDC) began education for nurses and CNAs. The SDC performed 1:1 education with CNA1. The Director of Nursing (DON) printed Kardexes for review by Guardian Angel staff. On 11/09/2022 at 9:00 AM - 12:00 PM, the Kardex audit was initiated by Guardian Angel staff. The SDC continued with education of nursing staff. On 11/09/2022 at 12:00 PM - 4:00 PM, the Guardian Angels returned audits to the DON. The DON and MDS Coordinators reviewed audits and began necessary corrections to care plans and Kardexes. On 11/10/2022 at 10:00 AM - 12:00 PM, the DON and MDS coordinator reviewed corrected Kardexes for accuracy. On 11/10/2022 at 12:00 PM - 4:00 PM, the Guardian Angels reconciled Kardexes and in-room equipment. The SDC continued with education to nursing staff. On 11/11/2022 at 10:00 AM - 12:00 PM, the DON and MDS coordinators reviewed Guardian Angel round sheets and made further corrections to Kardexes. On 11/11/2022 at 12:00 PM - 3:00 PM, the Guardian Angels rounded with Kardexes. The SDC education continued with nursing staff.

Based on observation, interview, record review, and review of facility policy, facility clinical staff failed to ensure one (1) of 17 residents received treatment and services to promote the healing and prevent the development of pressure ulcers (Resident #3). Facility staff failed to complete required assessments; failed to follow physician's orders [REDACTED]. As a result, Resident #3's Stage IV pressure ulcer to the right posterior lateral heel was slow to heal, and on 12/5/19, through Surveyor intervention, a deep tissue injury was discovered to the resident's posterior left heel. The findings included: Review of the facility's policy titled Wound Care Management dated 12/2017 noted each resident receives the care and services necessary to retain or regain in optimal skin integrity to the extent possible. Each resident is evaluated by the interdisciplinary team to determine his or her risk for skin compromise or the presence of wounds and/or pressure ulcers. A plan of care is developed and implemented based on this evaluation with ongoing review. If skin compromise occurs, evaluation is conducted by the interdisciplinary team to ensure appropriate measures are in lace to minimize the further compromise and aid in healing to extent possible . A. General Guidelines (1) The Director of Nursing and the Interdisciplinary Team are responsible for coordination of an interdisciplinary approach to managing the process for prediction, assessment, treatment, management and tracking of pressure ulcers . (3) Risk factors for Pressure Ulcers: impaired/decreased mobility and decreased functional ability .co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease or diabetes . a previous ulcer that has healed .B. Reporting (2) Report other information in accordance with facility policy and professional standards of practice; and (3) care plan accordingly. C. Procedure (2) Residents identified as at risk for development of pressure ulcers will have a plan and interventions included in the care plan to address each resident specific risk factor; (3) All residents will be checked from head to toe skin assessment t least weekly by a licensed nurse to identify any new pressure ulcers or other types of skin concerns. The licensed nurse will document the results of weekly skin checks in resident's medical record. (4) When a pressure ulcer is identified, the licensed nurse will document the wound in the Weekly Wound Assessment (WWA). Documentation to include size, stage, location, drainage, odor and pain. Notify MD and obtain treatment orders, initiate the care plan and notification of the interdisciplinary team utilizing the 24-hour report process . (6) Residents with newly identified or known pressure ulcers will be assessed by the interdisciplinary team upon notification and weekly thereafter, and a care plan will be developed, implemented, evaluated, and re-evaluated to treat actual pressure ulcers and reduce further pressure ulcers. This will include but not limited to review of lab results, risk factors, positions, etc. Review of the facility's policy titled Charting and Documentation: Nurse's Notes dated 10/17 noted the policy was to maintain a complete account of the resident's care, treatment, response to care, signs, symptoms, etc., as well as the progress of the resident's care. To provide caregivers with clear, concise guidelines for documentation of an assessment and care given. An assessment will be done on each resident upon admission and at regular intervals, as appropriate, thereafter. Purpose - To ensure that all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. General Guidelines - (1) All observations, medications administered, services performed, etc., must be documented in the resident's clinical records . Resident #3 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired having scored six (6) out of 15 on the Brief Interview for Mental Status (BI[CONDITION]) assessment. According to the assessment, the resident exhibited physical behavioral symptoms one (1) to three (3) days during the assessment period. In addition, Resident #3 was administered antianxiety medication for one (1) day during the assessment period. Resident #3 required the extensive assistance of two staff persons for bed mobility, transfers, dressing, and personal hygiene. The resident required the extensive assistance of one staff for toileting and was always incontinent of bowel and bladder. The MDS indicated the resident was at risk for the development of pressure ulcers and was assessed to have a Stage IV pressure ulcer at the time of the assessment. Review of Resident #3's comprehensive care plan initiated 10/23/18 revealed the following care plan areas: 1. Resident #3 is at risk for impaired skin integrity related to incontinent episodes, history of impaired skin, use of equipment that may cause pressure and decreased mobility. See wound report. Community acquired. One (1) Stage four (4) Pressure Ulcer - Right posterior lateral heel (initiated 2/7/19). Interventions included: Assess resident for verbal and nonverbal pain and if noted report to nurse (8/1/19); Easy boots bilateral feet at all times. May remove for hygiene/transfers (initiated 2/4/19); Encourage/provide fluids with meals and in between as tolerated (2/7/19); Ensure proper body alignment when in bed or a chair (initiated 2/7/19); Float heels while in bed (initiated 10/3/19); Head-to-toe skin assessment weekly and PRN (as needed) (8/1/19); Keep bed linen clean, dry and free of wrinkles (initiated 2/7/19); Observe skin with daily care and while in the shower/bath (initiated 2/7/19); Provide incontinence care for episodes of incontinence (2/7/19); RD (Registered Dietician) to assess as needed (2/7/19); Staff will report changes to MD as needed and obtain treatments as ordered as indicated (initiated 2/7/19); Supplements will be administered as ordered (2/7/19); and therapy to screen an evaluate for modalities for wound healing (initiated [DATE]). 2. Resident #3 has impaired circulation related to HLD (Hypersensitivity Lung Disease), [MEDICAL CONDITION] Embolism, and [MEDICAL CONDITION] (initiated 8/1/19). Interventions included: Assess fingers and toes for warmth and color. Report if noted (initiated 8/1/19); Elevate legs when resting (initiated 8/1/19); Inspect foot/ankle/calf skin for changes: maceration (white, wrinkly, moist), redness, purple tinge, blue, rust coloring, weeping, [MEDICAL CONDITION], puffiness, tenderness, areas with no sensation (initiated 8/1/19); Observe vital signs as ordered (initiated 8/1/19); and report abnormalities in pedal pulses. If abnormality noted report to MD PRN (initiated 8/1/19). Review of Resident #3's Skin Weekly Review dated 2/4/19 completed when Resident #3 returned from the hospital with a 4 x 1 cm pressure ulcer to the right heel. The assessment did not include staging of the ulcer. Review of Resident #3's physician's orders [REDACTED]. 2/4/19 (discontinued) - [MEDICATION NAME] to posterior right heel on Tuesday, Thursday and Saturday and cover with [MEDEQUIP] 2/4/19 - Easy boot bilateral feet at all times may remove for hygiene and transfers every day and every night shift for pressure relief. 2/5/19 - Skin prep to left heel every shift. 2/9/19 - Weekly body audits. 5/22/19 - Patient to tolerate 20-30 mmHg compression thigh high stocking on left lower extremity when OOB (out of bed) for [MEDICAL CONDITION] management. 8/1/19 - Up OOB as tolerated with feet elevated every shift. [DATE] - Limit sitting to [AGE] minutes every shift. 10/3/19 - Float heels while in bed every shift for wound. 11/17/19 - Wound: right posterior lateral heel; clean with wound cleanser/NS (normal saline) apply iodsorb gauze packing strips ½ inch and superabsorbent pad with border gauze, apply skin prep to periwound one time a day for wound. [DATE] - (duplicate order) Wound: right posterior lateral heel; clean with wound cleanser/NS (normal saline) apply iodsorb gauze packing strips ½ inch and superabsorbent pad with border gauze, apply skin prep to periwound one time a day for wound. Review of Resident #3's Wound Evaluation and Management Summary dated 11/14/19 noted the resident had a Stage IV pressure wound of the right posterior, lateral heel which had been present for more than 314 days. Exam on this date revealed the resident had mild [MEDICAL CONDITION] to bilateral lower extremities (feet) and the pedal pulse was positive in both lower extremities. On this date the wound measured 2.8 x 1.5 x 0.2 cm with maceration, moderate serous and 100% slough. Dressing plan treatment was as follows: Primary Dressing - Gauze packing strips ([MEDICATION NAME]) ½ inch apply once daily for 30 days; superabsorbent w/o bdr (without border) apply once daily for 30 days. Secondary Dressing - Gauze island (with border) apply once daily for 15 days. Peri Wound Treatment - Skin prep apply once daily for 15 days. The physician performed a surgical excisional debridement procedure of the wound and documented the following recommendations: Reposition per facility policy; Dietician consult; protein supplementation; Off-load wound; Limit sitting to [AGE] minutes; [MEDICATION NAME]; Float heels in bed. The summary further noted: Coordination of Care - Data and history pertinent to this patient's care were obtained via nursing staff. This patient's care was discussed with another health care provider Nursing Staff member during this visit. The clinical documentation for this consultation was made available to the referring physician. This documentation is also made available to the skilled nursing facility at any time and for placement in the skilled nursing facility record. Follow-up in seven (7) days. Review of Resident #3's Wound Evaluation and Management Summary dated 11/21/19 reviewed the resident's pressure ulcer to the left heel. The resident had mild [MEDICAL CONDITION] and positive pedal pulses to bilateral lower extremities. On this date, the wound measured 2.5 x 1.7 x 0.4 cm with heavy serous and 100% slough. The summary noted This wound is in [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of a biofilm. The wound was again debrided. The wound care treatment orders and recommendations from the physician were unchanged from the orders and recommendation noted in the 11/14/19 Wound Evaluation and Management Summary. Follow-up by wound care specialist in eight (8) to 14 days with further intervention as indicated. Review of Resident #3's Podiatry Services Progress Notes revealed the following: 4/19/19 - resident seen for mycotic nail care. The Podiatrist assessed the resident's bilateral feet with +3 capillary filling time (time taken for color to return to an external capillary bed after pressure is applied to cause blanching). The skin texture to both feet was noted to be thin, shiny, dry, friable and atrophic. According to the assessment, the resident's dorsalis pedis pulse and posterior tibial pulse were non-palpable and the resident had non-[MEDICAL CONDITION] to bilateral lower extremities and a right heel ulcer. Follow-up in two (2) - three (3) months. 7/26/19 - resident seen for DM foot care. The doctor noted history of right heel ulcer current concern and feet are in prevalon boots. The resident had a +3 capillary fill time to both extremities and skin texture was noted to be thin, shiny, dry, friable and atrophic. Non-palpable dorsalis pedis and posterior tibial pulses. The Podiatrist noted to defer to primary team for right heel wound care. Review of Resident #3's Podiatry Exam dated [DATE] revealed Patient present for diabetic foot care . has covered right heel ulcer . Non-palpable dorsalis pedal pulse and non-palpable posterior tibial pulse to bilateral feet and ankles. Capillary refill time +3. Skin texture thin, shiny, dry and friable with non-[MEDICAL CONDITION] to both feet. The Assessment/Plan noted the resident have to daily foot checks; defer to primary team for right heel ulcer, dressing was not removed today; and follow-up with the Podiatrist in two (2) to three (3) months. The consult further documented should the Primary Care Physician not agree with the medical necessity of both care delivered and the proposed plan of care (podiatrist) is to be notified immediately. Review of Resident #3's Monthly ICF Summary dated 11/12/19 noted under the section titled Cardiovascular System it was noted the resident had a regular heart rate. The area to address the resident's peripheral pulses was blank. Review of Resident #3's Weekly Wound Observation/Measurement revealed assessments were completed on these dates: -8/1/19, 8/15/19 and 8/29/19 (no weekly assessment between 8/15/19 and 8/29/19 - two (2) weeks between assessments) -[DATE], 9/12/19, [DATE] and 9/26/19 -10/17/19 and 10/24/19 (no weekly assessment between 9/26/19 and 10/17/19 - three (3) weeks between assessments) -[DATE], 11/21/19 and 11/28/19 (no weekly assessment between 10/24/19 and [DATE] - two (2) weeks in between assessments; and no weekly assessment between [DATE] and 11/21/19 - 13 days in between assessments). The Weekly Wound Observation/Measurement noted the following: [DATE] - right posterior heel Stage III pressure ulcer acquired on 12/2/18 measuring at 2.3 x 1.8 x 0.2 cm with granulation present and moderate serosanguinous fluid and odor present. Current treatment plan Dakins. 11/28/19 - right posterior lateral heel (not staged) and admitted with ulcer acquired on 12/20/18. The wound measured 2.5 x 1.5 x 0.4 cm with granulation and slough tissue present and a small amount of serosanguinous fluid present. Current treatment plan idoform packing daily. [DATE] - left lateral foot - unopened area - pressure. The document noted the resident was admitted with the wound acquired on [DATE]. The wound measured 1.4 x 0.8 cm with necrotic and dry tissue present. First observation - current treatment plan - skin prep. There were no Weekly Wound Observation/Measurement assessments completed between 2/4/19 and 7/31/19. Review of the resident's Skin Weekly Review reports between 2/4/19 and 7/18/19 revealed the form allowed for documentation of pressure ulcers (site, type, length, width, depth and stage). There were 24 assessments completed between 2/4/19 and 7/18/19, and of the 24 weekly skin reviews, 18 of them documented no new areas noted, as the only information on the assessment. The report on 6/6/19 documented Stage IV pressure ulcer to right lateral heel measuring 3.2 x 3.6 x 0.6; and the report on [DATE] documented Stage IV pressure ulcer to right posterior heel measuring 3.2 x 4 x 0.3 cm. Of the 24 assessments, the two (2) assessments dated 6/6/19 and [DATE] were the only reviews that measured the resident's right heel wound. Review of the Resident #3's Weekly Skin Assessments revealed the resident was assessed by licensed nursing staff on: -8/2/19, 8/9/19, 8/15/19 and 8/30/19 (no assessment for two (2) weeks between 8/15/19 and 8/30/19) -9/13/19 and 9/23/19 (no assessment for two (2) weeks between 8/30/19 and 9/13/19 and 10 days between 9/13/19 and 9/23/19). -[DATE] and 10/25/19 (no assessment for 24 days between [DATE] and 10/25/19). -[DATE], 11/15/19 and [DATE] (no assessment for two (2) weeks between 10/25/19 and [DATE]) Observation on 12/3/19 at 11:13 AM revealed Resident #3 was in the common area dining room on the unit. The resident was wearing a red long sleeve sweatshirt and was sitting in a broda chair with a blanket laying over the resident's bilateral lower extremities. The resident's feet were not covered by the blanket and the resident's right leg was observed to have significant [MEDICAL CONDITION]. The right foot had no sock and on Resident #3's left foot was what appeared to be a regular sock. Resident #3's legs were not elevated while the resident sat in the broda chair and the resident was not wearing boots to bilateral feet. When Surveyor attempted interview, the resident did not respond. Observation on [DATE] at 10:25 AM revealed Resident #3 was again sitting in the common area dining room on the unit. Resident #3 was wearing the same red long sleeve sweatshirt he/she was observed wearing on 12/3/19. The resident sat in the broda chair without his/her feet being elevated and without wearing bilateral boots. On Resident #3's left foot was a sock (no shoe) and the right foot did not have on a sock or shoe. [MEDICAL CONDITION] to the resident's right foot appeared to be approximately 2+. Resident #3 sat in the dining room area along with five (5) other facility residents. There were no staff present during this observation. Observation on 12/4/10 at 12:00 PM revealed Resident #3 was in his/her room and lying in bed in a supine position. The resident's legs were not elevated, and the resident was not wearing boots while in bed. Review of resident MD orders for treatment dated [DATE] revealed Wound; right posterior lateral heel; Clean with wound cleanser/Normal saline (NS), apply iodsorb gauze packing strips one-half (1/2) inch and a superabsorbent pad with border gauze, apply skin prep to peri wound (tissue surrounding the wound). Nurse reviewed the orders to verify that she had recently changed order from one quarter (¼) inch iodsorb gauze to one-half (½) inch gauze. Wound Care observation on [DATE] at 1:25 PM for Resident #3 revealed the following: The WCN used hand sanitizer prior to setting up wound supplies (wound cleanser with normal saline (NS), 4 by (x) 4 gauze, alcohol wipes, superabsorbent pad and ½ inch iodsorb packing strip). The WCN pulled over two (2) inches of iodsorb packing strip out of the bottle and left it hanging over the side of the bottle. The excess packing strip touched the bare top of the dressing cart thereby contaminating the iodsorb packing strip. The nurse then cut the desired length of iodsorb gauze and placed it in a medication cup (this included the piece of gauze that was touching the outside of the bottle and top of dressing cart. After gathering her wound care supplies, the WCN created a clean field at the resident's bedside to perform the resident's wound care. Both the WCN and CNA #15 performed hand hygiene and donned a clean pair of gloves. While CNA #15 elevated Resident #3's right foot the WCN removed the dressing dated [DATE] which contained a small amount of greenish drainage. The heel ulcer had a small amount beige colored slough at the 12 o'clock position on the wound; the rest of the wound had red granulating tissue. The resident's foot was swollen, dark in color with black splotches on top of his foot. The WCN removed her gloves, performed hand hygiene and donned a clean pair of gloves. The nurse cleaned the heel ulcer with a moistened 4x4 gauze going from cleanest part of the ulcer to the dirtiest part (from clean to dirty). The WCN repeated the motion with another clean moistened 4x4 gauze. The WCN removed her gloves, performed hand hygiene and donned a clean pair of gloves and proceeded to pack the heel ulcer with ¼ inch iodsorb packing strip. After the wound was packed the WCN reached her uniform pocket with her gloved hand and pulled a out a pair of scissors to cut the dressing. The WCN failed to apply the skin prep around the wound area before applying the dressing. The WCN finished dressing the heel ulcer and dated the dressing. During the wound care the WCN stated the resident transferred from Unit I approximately two (2) months ago with the heel ulcer. The WCN stated it was a Stage III ulcer that was healing. The resident is seen weekly by the Wound Care Physician. The WCN confirmed the resident's foot was swollen and that it was possibly two (2) plus [MEDICAL CONDITION]. The WCN was unable to palpate the resident's pedal pulse, however she was able to palpate the post tibial pulse in the resident's right foot. The WCN stated even though the resident had [MEDICAL CONDITION] in his lower extremities especially his feet she had never checked for the pedal or post tibial pulse before. The WCN was asked about the resident's left foot and she responded to her knowledge the resident did not have any problems with his left foot. The resident was wearing a normal white sock instead of the compression stocking as ordered. The WCN was asked to examine the resident's left foot. Removal of the white sock revealed the resident's left leg and foot were [MEDICAL CONDITION] and the sock had left an indentation in the resident's leg due to the swelling. The resident's foot was [MEDICAL CONDITION] with white dry flaky skin peeling. On the outer side of the resident's left foot was a discolored area that measured approximately one (1) inch in length. Both the WCN and the CNA confirmed they had never seen the area before. The WCN confirmed that it was a deep tissue injury (DTI). The WCN was able to palpate both the pedal and post tibial pulses on the resident's left foot. An interview with the WCN immediately after the wound care observation revealed the that when the staff identify a skin concern, they should notify the WCN, Physician and the resident's responsible party. The WCN would immediately start treatment for [REDACTED]. During the interview the WCN was made aware of the observation of her contaminating the iodsorb packing strip on the medication cart and the failure to apply the skin prep around the ulcer on the resident's right heel. The WCN stated that she was not aware that she had committed those errors and agreed that it was not an acceptable practice. Interview on [DATE] at 1:53 PM with LPN #4 revealed licensed nursing staff were responsible for completing residents' body audits and the aides were to observe residents' skin for skin tears or injuries when providing daily hygiene and showers. When asked how licensed staff ensured that residents' personal hygiene and showers were being completed, LPN #4 said if staff tells us it's done (we) believe them. The nurse continued and stated aides were to notify licensed nursing staff of any observed injuries to residents' skin and the nurse, in turn, completes an assessment and documentation (i.e. incident report). Interview on [DATE] at 3:05 PM with the facility's Wound Nurse (WN) revealed the nurse had been employed with the facility since October 2019 and became responsible for completing the Weekly Wound Observations/Measurements around 10/21/19. The nurse confirmed an assessment was not completed for the week of 11/15/19. During a telephone interview on [DATE] at 3:30 PM with Resident #3's Wound Doctor (WD) revealed that not using the compression stockings and not elevating legs while out of bed could be a contributing factor to the delay in healing to Resident #3's right heel pressure ulcer. The doctor stated there could be other co-morbidities contributing to the slow rate of healing to the ulcer. The doctor confirmed that normal socks were not a substitute for using compression stockings. When asked further about the use of the compression stocking, the WD stated that the resident could not tolerate compression stockings and instead should be using [MEDICATION NAME] because they were not as intolerable for the resident. Interview on [DATE] at 4:09 PM, the facility's WN said a pair of compression socks had been placed in the resident's second drawer. The nurse confirmed that before Surveyor intervention on [DATE], the resident did not have the stockings. Follow-up interview on 12/5/19 at 2:35 PM with the WD revealed the doctor was not aware of an order for [REDACTED].#3 had a [DIAGNOSES REDACTED]. During continued interview, the WD again confirmed the resident's legs should be elevated while wearing bilateral boots to promote healing of the resident's pressure ulcer to right heel. When the WD was asked about Resident #3's pedal pulse and whether nursing staff should be assessing the presence of it on a routine basis, the WD said there was no need to do pedal pulse of all residents and that the absence of a pedal pulse would indicate that the resident should be sent to the emergency room . When asked about an individualized plan of care for Resident #3 in reference to his/her pedal pulse being routinely assessed, the WD again stated there was no need for nursing staff to assess the resident's pedal pulse. The WD said he/she assessed Resident #3 on this date and the pedal pulse was present. The WD stated he/she was not aware of the resident's Podiatrist assessing the resident's pedal pulse being non-palpable in April 2019, July 2019, and November 2019. The WD confirmed there should be communication between medical disciplines (like podiatry) to ensure the coordination of the resident's care. It was the expectation of the WD that the facility would mediate that communication. During a congruent interview on 12/5/19 at 2:35 PM with the facility's DON, the nurse said that the order for the resident's compression stockings were ordered by therapy services, but nursing did not access the order in the new electronic system. Continued interview revealed assessment information and recommendations from Resident #3's podiatry visits should be moved forward and communicated to the resident's wound doctor and primary care physician. When asked about nursing staff completing the Cardiovascular Assessment section of the Monthly ICF Nursing Summary, the DON this section should be completed with documentation of the assessment of the resident's pedal pulse.

Based on review of facility files and interview, the facility failed to ensure that all alleged violations, including injury of unknown source, are reported immediately to the State Survey Agency. Resident #2 was noted with bruising and swelling of the right upper extremity on 11/14/16, x-ray of the area on 11/18/16 revealed the resident had a [MEDICAL CONDITION] right humerus. Review of the facility's investigation revealed there was no evidence of how the resident's humerus was fractured. Cross-refer to F309 for failure to provide care/services for highest well-being. The findings included: Review of the facility's investigation into the injury of unknown origin for Resident #2 revealed the resident was noted with a bruise and swollen area to his/her right upper arm on 11/14/16. The resident was sent to the emergency roiagnom on [DATE] and returned to the facility on [DATE]. The resident returned from the emergency room with no new orders and a verbal report that there was no blood clot. On 11/18/16, Resident #2 was discussed in morning meeting with the Director of Nursing and Unit Manager. The Unit Manager stated the resident continued to have swelling to the right upper arm and the physician was to be contacted. The physician was contacted and x-rays were ordered. The x-ray report revealed Resident #2 had a [MEDICAL CONDITION] right humerus. In an interview with the surveyor on 1/3/17 at approximately 4:10 PM, RN (Registered Nurse) #1 stated s/he does the investigating and reporting for incidents. RN #1 stated s/he can't say where the resident's fracture came from, cannot definitively answer that. RN #1 stated s/he did not know that fractures of unknown origin needed to be reported to certification. In an interview with the surveyor on 1/3/17 at approximately 6:00 PM, the Director of Nursing stated they have provided RN #1 with the information on reporting. Review of the facility's Resident Abuse, Neglect, Exploitation and Mistreatment Policy and Procedures revealed procedures included any incidents of unknown origin must be reported and investigated. If the incident is of a serious or severe nature, e.g. an unknown injury to a resident DHEC's Division of Certification will be notified within 24 hours of the incident or the next business day. Review of the facility's Investigating Unexplained Injuries revealed should a resident be observed with unexplained injuries (including bruises, abrasions, and injuries of an unknown source), the supervisor on duty must record such information in the resident's clinical record. The policy included to document for 72 hours following all incidents in the Nurses' Notes.

Based on review of facility files and interview, the facility failed to ensure that each resident received the necessary care and services to maintain the highest practicable physical well-being. Resident #2 was noted with bruising and swelling to the right upper arm on 11/14/16. The resident was sent out to the hospital and checked for a blood clot. The resident returned to the facility on [DATE] and continued to have bruising and complaints of pain when touched or turned. The facility ordered x-rays on 11/18/16 and found the resident had a proximal right humerus fracture. Resident #3 complained of pain in the left ankle/foot on 11/15/16 and was not examined until 11/24/16 when s/he was noted to have a left ankle fracture. Cross-refer to F225 for failure to investigate/report allegations. The findings included: Review of the facility's investigation into the injury of unknown origin for Resident #2 revealed the resident was noted with a bruise and swollen area to his/her right upper arm on 11/14/16. The resident was sent to the emergency roiagnom on [DATE] and returned to the facility on [DATE]. The resident returned from the emergency room with no new orders and a verbal report that there was no blood clot. On 11/18/16, Resident #2 was discussed in morning meeting with the Director of Nursing and Unit Manager. The Unit Manager stated the resident continued to have swelling to the right upper arm and the physician was to be contacted. The physician was contacted and x-rays were ordered. The x-ray report revealed Resident #2 had a [MEDICAL CONDITION] right humerus. Review of Resident #2's Nurse's Notes dated 11/14/16 at 2:30 PM revealed a bruise was found on the resident. An order was received for x-ray and ultrasound to rule out fracture and [MEDICAL CONDITION] ([MEDICAL CONDITION]. The Nurse's Note dated 11/14/16 at 4:00 PM indicated the nurse checked the resident and the knot had moved into the resident's chest. The nurse received a new order to send the resident out to the emergency room . The Nurse's Note dated 11/15/16 at 6:15 AM revealed the physician reviewed the paperwork from the emergency room and ordered lab work. The Nurse's Note dated 11/15/16 at 2:20 PM indicated swelling still noted to right upper extremity and sore to the touch. At 6:30 PM a new order was received to recheck lab work on 11/18/16. The Nurse's Note dated 11/16/16 at 10:15 AM revealed the resident's arm remained swollen. The Nurse's Note dated 11/17/16 at 10:20 AM revealed Resident #2's arm remained swollen with no pain voiced until the resident rolled on side to provide incontinent care. The Nurse's Note dated 11/18/16 indicated the resident's right arm remained swollen with no pain complaints until touched or moved onto that side. At 11:00 AM the note indicated a new order was obtained to x--ray Resident #2's shoulder, humerus and elbow on the right side. Review of Resident #2's emergency room paperwork for 11/14/16 revealed the resident's chief complaint was extremity pain. The resident was noted with swelling of the extremity. Resident #2 had a venous duplex for the right upper extremity that revealed no evidence of right upper extremity [MEDICAL CONDITION]. There was no documentation that the resident's arm was x-rayed at the hospital. In an interview with the surveyor on 1/3/17 at approximately 4:10 PM, RN (Registered Nurse) #1 stated s/he does the investigating and reporting for incidents. Resident #2 was discussed in morning meeting on 11/18/16, s/he had continued swelling of the right arm. The nurse called the doctor on 11/18/16 and x-rays were ordered. Results were reported around 1:45 PM on 11/18/16 with fracture. RN #1 stated they did not do any x-rays at the hospital that they could find. Resident #2 had no complaints of pain unless moved or touched on that side. RN #1 stated s/he did not get the hospital paperwork until 11/18/16, during morning meeting. RN #1 stated the paperwork from the hospital came back with the resident. When they reviewed the hospital paperwork and discussed the resident during morning meeting on 11/18/16, they decided the doctor needed to be called. RN #1 stated Resident #2 was not brought up in morning meeting before 11/18/16. The resident should have been brought up the next day after going out to the hospital. RN #1 stated they should go back 3 days (72 hours) prior to an incident to get staff statements. RN #1 stated s/he can't say where the resident's fracture came from, cannot definitively answer that. RN #1 stated s/he did not know that fractures of unknown origin needed to be reported to certification. In an interview with the surveyor on 1/3/17 at approximately 4:55 PM, RN #2 stated s/he is the unit manager for Unit 2. RN #2 stated s/he went with the nurse to look at the area on Resident #2 on 11/14/16, it was deep purple, on the underside of the upper right arm and extended up into the shoulder area. RN #2 sated s/he received no further reports of pain from the nurses after Resident #2 arrived back to the facility on [DATE] until 11/18/16. That day RN #2 was working with the resident and the resident complained of pain when they Hoyer lifted him/her. That is when they got an order for [REDACTED].#2 stated s/he probably would have brought Resident #2 up as having gone out to the hospital and included what s/he had done there. RN #2 stated s/he thinks s/he mentioned that s/he would have expected them to do an x-ray at the hospital. RN #2 would expect the nurses to report to him/her that the resident was still having pain in that area. In an interview with the surveyor on 1/3/17 at approximately 6:00 PM, the Director of Nursing stated they have provided RN #1 with the information on reporting. The Director of Nursing stated s/he would expect Resident #2's pain to have been reported and the physician to be notified. Review of the facility's investigation into the injury of unknown origin for Resident #3 revealed the resident was noted swelling to his/her left ankle and foot on 11/24/16 and was sent to the hospital for evaluation. X-rays at the hospital revealed a fractured left ankle. Review of the investigation into the injury revealed it was reported as an injury of unknown origin. A staff statement from Certified Nursing Assistant (CNA) #1 dated 11/25/16 revealed on 11/15/16, CNA #1 entered Resident #3's room to assist her with changing and Resident #3 stated she should be careful with her foot as it was broken. Per the statement, CNA #1 immediately went and told the nurse working with Resident #3 (Licensed Practical Nurse (LPN) #1) that Resident #3 reported her foot was broken and LPN #1 stated it was gout. In an interview on 01/03/17 at 4:45 PM, CNA #1 confirmed s/he was with Resident #3 on 11/15/16 and Resident #3 had stated his/her foot was broken. CNA #1 stated Resident #3's ankle and foot were swollen more than usual and s/he reported the incident to LPN #1. A staff statement from LPN #1 dated 11/25/16 confirmed Resident #3 had reported foot and ankle pain and was placed on the log for physician's review on 11/15/16. Per the statement LPN #1 then contacted the physician on 11/24/16 to request an x-ray for Resident #3's ankle. Review of the physician's log revealed an entry dated 11/15/16 indicating Resident #3 had swelling in her/his left foot with the notation ? gout. There was no indication on the log of any physician review, exam, or orders until an x-ray was ordered on [DATE]. Review of Resident #3's physician progress notes [REDACTED]. There were no notes between 11/15/16, when the swelling and pain were first noted and 11/24/16 when an x-ray was ordered for Resident #3. Review of Resident #3's Nursing Notes revealed no nursing notes were completed from 11/04/16 until 11/24/16, including no documentation of the swelling noted on 11/15/16 or Resident #3's complaints of a broken foot. In an interview on 01/03/17 at 5:55 PM, the Director of Nursing (DON) confirmed there were no nursing notes for Resident #3 from 11/04/16 through 11/24/16 and the DON would have expected there to be notes since Resident #3 had complained of pain and been placed on the physician's log. The DON also confirmed there was no documentation of any examination of Resident #3 by the physician between 11/15/16 and 11/24/16 and no documentation of any other interventions by any nursing home staff to address Resident #3's complaints of pain and swelling between 11/15/16 and 11/24/16.

Based on observation, record review, interview, and review of the pharmacy policies entitled "Storage and Expiration of Medications, Biologicals, Syringes, and Needles" and "Insulin Storage Recommendations (Last Revised 9-29-14)" , the facility failed to ensure that 4 of 7 sampled residents reviewed for expired insulin on 2 of 2 medication carts on Unit 2 (1 of 3 Units) were free of significant medication errors. Residents #18, #51, #85, and #103 received multiple insulin doses after discard/expired dates when the facility failed to label 7 vials of insulin with appropriately calculated discard dates based on dates the vials were opened. The findings included: Cross Refer CFR 483.60(c)(1) Drug Regimen Review, F-428 related to the pharmacist's failure to identify and report irregularities in medication labeling for insulin vials in current use. Failure to identify and report 7 mislabeled vials of insulin to the facility for correction contributed to medication being administered after the expiration date to Residents #18, #51, #85, and #103 and resulted in the potential for clinically significant adverse consequences to residents receiving ongoing treatment for [REDACTED].#5, #95, and #197) identified with mislabeled medication had the potential to be administered Insulin after the actual expiration/discard date. Cross Refer CFR 483.60(e) Storage of Drugs and Biologicals, F-431 related to failure of the facility to ensure that 7 opened/punctures vials of insulin were labeled appropriately and expired medications were not available for administration. Failure to label insulin using current standards of practice resulted in medication being administered after the expiration/discard dates to Residents #18, #51, #85, and #103 and resulted in the potential for clinically significant adverse consequences to residents receiving ongoing treatment for [REDACTED].#5, #95, and #197) identified with mislabeled medication had the potential to be administered Insulin after the actual expiration/discard date. Observation of medication storage in 2 medication carts on Unit 2 on 4-29-15 at approximately 4:13 PM revealed that the handwritten labeling of discard dates on 7 insulin vials was incorrect. During separate interviews on 4-29-15 at approximately 4:20 PM, Licensed Practical Nurses (LPNs) #5 and #7 were asked how the discard dates were determined. Both referred to "the calendar" as a reference on the Medication Administration Record [REDACTED] Review of the reference calendar revealed that multiple types of insulin were listed on the top of the page, with the number of days available for use after opening, according to insulin type. Three (3) dates were listed on each calendar day, representing 28, 42, and 90 days after open date. The nurses could note the date and type of insulin opened, check to see how long it could be used, refer to that date on the calendar, and enter that discard date on the open/discard stickers on the vials. Of the seven mislabeled vials, four (4) residents had expired insulin which had been administered past the actual discard date: (1) Resident #18 had one open 10 milliliter (ml) vial of [MEDICATION NAME] R(egular) 100 units per ml. A sticker applied to the vial stated it had been opened on AM 2-17-15 and was to be discarded on 4-30-15. There were no initials on the sticker to indicate which nurse had miscalculated the discard date. According to the facility reference, [MEDICATION NAME] R "expires 42 days after opening." The insulin should have expired on 3-30-15. Record review revealed physician's orders [REDACTED]. 0-60= If alert, give 4 oz (ounces) sweetened beverage; if not alert, give [MEDICATION NAME] l mg (milligram) IM (intramuscular) or SC (subcutaneous) and notify MD (medical doctor). 01-200 = nothing. 201-250=2 units. 251-300=4 units. 301-350=6 units. 351-400=8 units. > 400=10 units and notify MD." Review of the Medication Administration Record [REDACTED] 4-1-15 BS=238 2 units of insulin were given. 4-2-15 BS=249 2 units of insulin were given. 4-3-15 BS=239 2 units of insulin were given. 4-4-15 BS=262 4 units of insulin were given. 4-5-15 BS=288 4 units of insulin were given. 4-6-15 BS=231 2 units of insulin were given. 4-7-15 BS=281 4 units of insulin were given. 4-8-15 BS=281 4 units of insulin were given. 4-9-15 BS=320 6 units of insulin were given. 4-10-15 BS=242 2 units of insulin were given. 4-11-15 BS=245 2 units of insulin were given. 4-12-15 BS=248 2 units of insulin were given. 4-13-15 BS=252 4 units of insulin were given. 4-14-15 BS=287 4 units of insulin were given. 4-15-15 BS=274 4 units of insulin were given. 4-16-15 BS=321 6 units of insulin were given. 4-17-15 BS=223 2 units of insulin were given. 4-18-15 BS=305 6 units of insulin were given. 4-19-15 BS=277 4 units of insulin were given. 4-20-15 BS=216 2 units of insulin were given. 4-21-15 BS=271 4 units of insulin were given. 4-22-15 BS=266 4 units of insulin were given. 4-23-15 BS=222 2 units of insulin were given. 4-24-15 BS=272 4 units of insulin were given. 4-25-15 BS=213 2 units of insulin were given. 4-26-15 BS=246 2 units of insulin were given. 4-27-15 BS=274 4 units of insulin were given. 4-28-15 BS=260 4 units of insulin were given. 4-29-15 BS=295 4 units of insulin were given. (2) Resident #51 had one open 10 ml vial of [MEDICATION NAME] R 100 units per ml. A green sticker applied to the vial stated it had been opened on 3-11-15 and was to be discarded on 5-18-15. There were initials on the open/discard sticker to indicate LPN #7 had miscalculated the discard date. According to the facility calendar reference, [MEDICATION NAME] R "expires 28 days after opening." The insulin should have expired/been discarded on 4-7-15. Record review revealed physician's orders [REDACTED]. Additionally, [MEDICATION NAME] R Insulin was to be administered per sliding scale. "FSBS at 7 AM and 4 PM. 0-60= If alert, give 4 oz sweetened beverage; if not alert, give [MEDICATION NAME] l mg IM or SC and notify MD. 01-200 = nothing. 201-250=2 units. 251-300=4 units. 301-350=6 units. 351-400=8 units. > 400=10 units and notify MD." Review of the MAR indicated [REDACTED] 4-8-15 BS=258 4 units of insulin were given at 4 PM. 4-9-15 BS=313 6 units of insulin were given at 4 PM. 4-10-15 BS=269 4 units of insulin were given at 4 PM. 4-11-15 BS=371 8 units of insulin were given at 4 PM. 4-12-15 BS=287 4 units of insulin were given at 4 PM. 4-13-15 BS=342 6 units of insulin were given at 4 PM. 4-14-15 BS=221 2 units of insulin were given at 4 PM. 4-15-15 BS=254 4 units of insulin were given at 4 PM. 4-16-15 BS=268 4 units of insulin were given at 4 PM. 4-17-15 BS=282 4 units of insulin were given at 4 PM. 4-18-15 BS=229 2 units of insulin were given at 4 PM. 4-19-15 BS=216 2 units of insulin were given at 4 PM. 4-20-15 BS=261 4 units of insulin were given at 4 PM. 4-21-15 BS=284 4 units of insulin were given at 4 PM. 4-22-15 BS=266 4 units of insulin were given at 4 PM. 4-23-15 BS=230 2 units of insulin were given at 7 AM. 4-23-15 BS=260 4 units of insulin were given at 4 PM. 4-24-15 BS=234 2 units of insulin were given at 4 PM. 4-26-15 BS=236 2 units of insulin were given at 4 PM. 4-27-15 BS=247 2 units of insulin were given at 4 PM. 4-28-15 BS=291 4 units of insulin were given at 4 PM. (3) Resident #85 had one open 10 ml vial of [MEDICATION NAME] 100 units per ml. A green sticker applied to the vial stated it had been opened on 3-24-15 and was to be discarded on 5-4-15. There were initials on the open/discard sticker to indicate LPN #6 had miscalculated the discard date. According to the facility calendar reference, [MEDICATION NAME] "expires 28 days after opening." The insulin should have expired/been discarded on 4-20-15. Record review revealed physician's orders [REDACTED]. Inject 12 units subcutaneously twice daily. "...Expires 28 days after opening.**" Review of the MAR indicated [REDACTED]. . (4) Resident #103 had one open 10 ml vial of [MEDICATION NAME] R Insulin 100 units per ml. A green sticker applied to the vial stated it had been opened on 3-4-15 and was to be discarded on 5-5-15. There were initials on the open/discard sticker to indicate LPN #7 had miscalculated the discard date. According to the facility calendar reference, [MEDICATION NAME] R "expires 42 days after opening." The insulin should have expired/been discarded on 4-14-15. Record review revealed physician's orders [REDACTED].= If alert, give 4 oz sweetened beverage; if not alert, give [MEDICATION NAME] l mg IM or SC and notify MD. 01-200 = nothing. 201-250=2 units. 251-300=4 units. 301-350=6 units. 351-400=8 units. > 400=10 units and notify MD." Review of the MAR indicated [REDACTED] 4-24-15 BS=209 2 units of insulin were given at 4 PM. 4-28-15 BS=207 2 units of insulin were given at 4 PM. During the interview on 4-29-15 at approximately 4:20 PM, when asked how s/he knew if the insulin was in date and appropriate to administer, LPN #7 referred to the sticker on the side of the insulin vial. S/he said, "I go by that date (indicating the handwritten discard date on the sticker). I can give it up to that date." When open dates on the vials were compared to the calendar, LPNs #5 and #7 verified that the discard information on the labels did not match the calendar. After review of the calendar, LPN #7 stated, "I do not know why the dates are wrong." During an interview on 4-29-15 at approximately 4:30 PM, Registered Nurse (RN #1) verified that the discard dates were incorrect on the labeling of the vials. An interview on 4-30-15 at 7:50 AM with LPN #6, who was identified by the Director of Nurses and Administrator as having labeled and miscalculated discard dates on some of the vials of Insulin. When asked to describe the procedure followed when opening and labeling insulin, the nurse stated,"The stickers are in front of the MAR. The stickers have on them an open and discard date. I put the date when opened and when discarded according to the insulin type. I use the calendar in front of the MAR. I go by the calendar and look on it for dates." When asked how s/he thought the stickers could have been incorrectly labeled, LPN #6 stated, "I was thinking it was the next month. I was one month ahead in my thinking when I mislabeled the insulins." On 4-30-15 at approximately 7:30 AM, review of the pharmacy policy entitled "Storage and Expiration of Medications, Biologicals, Syringes, and Needles" with a revision date of 1-1-13 revealed the following: "Facility should ensure that medications and biologicals: 4.1 Have an Expiration Date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines... 5.0 Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 5.1 Facility staff may record the calculated expiration date based on date opened on the medication container." Review of the pharmacy policy entitled "Insulin Storage Recommendations (Last Revised 9-29-14)" revealed that opened and stored at room temperature, [MEDICATION NAME] R Insulin was good for 42 days, [MEDICATION NAME] for 28 days. [MEDICATION NAME] R was noted to be good for 31 days, which was discrepant from the reference tool used by the facility. During an interview on 4-30-15 at approximately 11:30 AM, when asked about concerns related to the administration of expired insulin, the Medical Director stated, "I don't feel there is jeopardy to the patients because blood sugars are monitored daily. There are safety mechanisms in place." When asked about the efficacy of the insulin when administered past the calculated expiration date, s/he stated, "You would have to ask the Pharmacist. I would have to ask the manufacturer for recommendations for the safety." When asked about possible negative outcomes, the physician stated,"That would be that it was not as effective. Blood sugars would go up." When asked about expectations regarding medication administration, s/he stated, "I expect the right medicine to be given at the right time as ordered. Policy should be followed. Follow the manufacturing recommendations of the medicine." On 4-30-2015 at approximately 2:30 PM, review of an email sent from the Pharmacist to the Director of Nurses was as follows: "I am writing to you about your inquiry on administering expired insulin to a resident. As insulin ages, it will potentially lose its potency. When administering insulin that has surpassed its date of expiration, the insulin may not be as effective for the resident." The Allegation of Compliance was submitted, reviewed, and approved on 4-30-15 at 10:30 AM: The Director of Nursing removed seven vials of incorrectly dated insulin from the Unit II med cart on 04/29/15 at approximately 5:30 PM. The replacement vials were labeled and dated appropriately. The Director of Nursing reviewed the four resident's records who could have been negatively affected and completed medication error reports on 04/30/15. The Physician and families were notified. The two nurses responsible for incorrectly dating vials were inserviced individually with return demonstration performed correctly on 04/29/15. An immediate "Quality Assurance Performance Plan" was initiated to prevent recurrence of the problem. Beginning on 04/29/15 and finishing on 04/30/15, all insulin vials on Units I, II, and III were checked by the Unit Supervisor to assure appropriate dates were placed on insulin vials and signed for review and accuracy by two nurses. On 04/29/15 at 6:45 PM, training was initiated by the Staff Education Nurse for all facility licensed nursing staff regarding the appropriate method for dating insulin vials. All current licensed nursing staff employed by the facility will be inserviced by the Staff Education Nurse or designee on correct dating of insulin vials prior to working in the facility. Any newly hired nurses or agency nurses will be inserviced regarding correct dating of insulin vials prior to administering any medications in the facility. A letter was faxed to notify the staffing agencies on 4-30-15 of this requirement. Allegation of Compliance (AOC) date is 04/30/15. Observations, record reviews, and interviews revealed the AOC submitted by the facility on 04/30/15 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. Medication carts were viewed and no expired or mislabeled medications were observed. Documentation indicated that facility nurses were being inserviced on correctly determining expiration dates for insulin and correctly labeling of insulin with the appropriate expiration date. Interviews with facility licensed nursing staff confirmed they were trained on the correct dating of insulin and were able to demonstrate that skill. The Administrator was informed of this on 04/30/15 at approximately 6:00 PM. The Immediate Jeopardy at F-333, F-428, F-431, and F-520 was removed but the citations remained at a lowered scope and severity of "E."

Based on observation, record review, interview, and review of the "Pharmacy Consultant Agreement" and the pharmacy policies entitled "Storage and Expiration of Medications, Biologicals, Syringes, and Needles" and "Insulin Storage Recommendations (Last Revised 9-29-14)" , the pharmacist failed to identify and report irregularities in medication storage on 2 of 2 medication carts on Unit 2, one of three Units in the facility. Seven punctured vials of insulin were labeled with incorrect discard dates based on recorded open dates. Four (4) of the 7 were in current use when the medication carts were checked on 4-29-15. Failure to identify and report the mislabeled insulin to the facility for correction contributed to medication being administered after the expiration date and resulted in the potential for clinically significant adverse consequences to residents receiving ongoing treatment for [REDACTED]. The findings included: Cross Refer CFR 483.25(m)(2) Free of any Significant Medication Errors F-333 related to failure of the facility to ensure that 4 residents were free of significant medication errors. Residents #18, #51, #85, and #103 received multiple insulin doses after discard/expired dates when staff failed to label vials of insulin with appropriately calculated discard dates. Cross Refer CFR 483.60(e) Storage of Drugs and Biologicals, F-431 related to facility failure to ensure that 7 opened/punctures vials of insulin were labeled appropriately and expired medications were not available for administration. Failure to label insulin using current standards of practice resulted in medication being administered after the expiration/discard dates to Residents #18, #51, #85, and #103 and resulted in the potential for clinically significant adverse consequences to residents receiving ongoing treatment for [REDACTED].#5, #95, and #197) identified with mislabeled medication had the potential to be administered Insulin after the actual expiration/discard date. Cross Refer CFR 483.75(o)(2)(ii) Quality Assurance and Assessment, F-520 related to facility failure to identify a concern with mislabeled insulin available for administration past the expiration/discard date, though performance improvement plans related to expired medication had been in place since 12-20-13 for Pharmaceutical Services and since 9-15-14 for Expired Meds. Observation of medication storage in 2 medication carts on Unit 2 on 4-29-15 at approximately 4:13 PM revealed that the handwritten labeling of discard dates on 7 insulin vials was incorrect. Of the seven mislabeled vials, four (4) residents with a [DIAGNOSES REDACTED]. (1) Resident #18 had one open 10 milliliter (ml) vial of Novolin R(egular) 100 units per ml. A sticker applied to the vial stated it had been opened on AM 2-17-15 and was to be discarded on 4-30-15. There were no initials on the sticker to indicate which nurse had miscalculated the discard date. According to the facility reference, Novolin R "expires 42 days after opening." The insulin should have expired on 3-30-15, instead of 4-30-15, as noted on the sticker. Review of physician's orders [REDACTED]. (2) Resident #51 had one open 10 ml vial of Humulin R 100 units per ml. A green sticker applied to the vial stated it had been opened on 3-11-15 and was to be discarded on 5-18-15. There were initials on the open/discard sticker to indicate Licensed Practical Nurse (LPN) #7 had miscalculated the discard date. According to the facility calendar reference, Humulin R "expires 28 days after opening." The insulin should have expired/been discarded on 4-7-15, instead of 5-18-15 as noted on the sticker. Review of physician's orders [REDACTED]. (3) Resident #85 had one open 10 ml vial of Lantus Insulin 100 units per ml. A green sticker applied to the vial stated it had been opened on 3-24-15 and was to be discarded on 5-4-15. There were initials on the open/discard sticker to indicate LPN #6 had miscalculated the discard date. According to the facility calendar reference, Lantus "expires 28 days after opening." The insulin should have expired/been discarded on 4-20-15. Record review revealed physician's orders [REDACTED]. Inject 12 units subcutaneously twice daily. "...Expires 28 days after opening.**" Review of physician's orders [REDACTED]. (4) Resident #103 had one open 10 ml vial of Novolin R Insulin 100 units per ml. A green sticker applied to the vial stated it had been opened on 3-4-15 and was to be discarded on 5-5-15. There were initials on the open/discard sticker to indicate LPN #7 had miscalculated the discard date. According to the facility calendar reference, Novolin R "expires 42 days after opening." The insulin should have expired/been discarded on 4-14-15. Review of physician's orders [REDACTED]. In addition to the four residents who had been given insulin past the expired/discard dates, three other residents also had mislabeled Insulin which had the potential to be administered after the actual expiration/discard date: (1) Resident #5 had one open 10 ml vial of Novolin R Insulin 100 units per ml. A sticker applied to the vial stated it had been opened on 3-24-15 and was to be discarded on 6-21-15. There were initials on the open/discard sticker to indicate LPN #6 had miscalculated the discard date. According to the facility calendar reference, Novolin R "expires 42 days after opening." The label should have had an expired/discard date of 5-4-15. (2) Resident #197 had one open 10 milliliter (ml) vial of Levemir Insulin 100 units per ml. A sticker applied to the vial stated it had been opened on 4-7-15 and was to be discarded on 5-5-15. There were no initials on the sticker to indicate which nurse had miscalculated the discard date. According to the facility reference, Levemir "expires 42 days after opening." The label should have had an expired/discard date of 5-4-15. (3) Resident #95 had one open 10 ml vial of Novolin R Insulin 100 units per ml. A sticker applied to the vial stated it had been opened on 2-28-15 and was to be discarded on 5-10-15. There were initials on the open/discard sticker to indicate LPN #6 had miscalculated the discard date. According to the facility calendar reference, Novolin R "expires 42 days after opening." The insulin should have been labeled with an expired/discard date of 4-10-15. Resident #95 had an order for [REDACTED]. During the interview on 4-29-15 at approximately 4:20 PM, when asked how s/he knew if the insulin was in date and appropriate to administer, LPN #7 referred to the sticker on the side of the insulin vial. S/he said, "I go by that date (indicating the handwritten discard date on the sticker). I can give it up to that date." When open dates on the vials were compared to the calendar, LPNs #5 and #7 verified that the discard information on the labels did not match the calendar. After review of the calendar, LPN #7 stated, "I do not know why the dates are wrong." During an interview on 4-29-15 at approximately 4:30 PM, Registered Nurse (RN #1) verified that the discard dates were incorrect on the labeling of the vials. An interview on 4-30-15 at 7:50 AM with LPN #6, who was identified by the Director of Nurses and Administrator as having labeled and miscalculated discard dates on some of the vials of Insulin. When asked to describe the procedure followed when opening and labeling insulin, the nurse stated,"The stickers are in front of the MAR. The stickers have on them an open and discard date. I put the date when opened and when discarded according to the insulin type. I use the calendar in front of the MAR. I go by the calendar and look on it for dates." When asked how s/he thought the stickers could have been incorrectly labeled, LPN #6 stated, "I was thinking it was the next month. I was one month ahead in my thinking when I mislabeled the insulins." On 4-30-15 at approximately 7:30 AM, review of the pharmacy policy entitled "Storage and Expiration of Medications, Biologicals, Syringes, and Needles" with a revision date of 1-1-13 revealed the following: "Facility should ensure that medications and biologicals: 4.1 Have an Expiration Date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines... 5.0 Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 5.1 Facility staff may record the calculated expiration date based on date opened on the medication container." Review of the pharmacy policy entitled "Insulin Storage Recommendations (Last Revised 9-29-14)" revealed that opened and stored at room temperature, Novolin R and Levemir Insulins were good for 42 days, Lantus for 28 days. Humulin R was noted to be good for 31 days, which was discrepant from the reference tool used by the facility. During an interview on 4-30-15 at approximately 11:30 AM, when asked about concerns related to the administration of expired insulin, the Medical Director stated, "I don't feel there is jeopardy to the patients because blood sugars are monitored daily. There are safety mechanisms in place." When asked about the efficacy of the insulin when administered past the calculated expiration date, s/he stated, "You would have to ask the Pharmacist. I would have to ask the manufacturer for recommendations for the safety." When asked about possible negative outcomes, the physician stated,"That would be that it was not as effective. Blood sugars would go up." When asked about expectations regarding medication administration, s/he stated, "I expect the right medicine to be given at the right time as ordered. Policy should be followed. Follow the manufacturing recommendations of the medicine." On 4-30-2015 at approximately 2:30 PM, review of an email sent from the Pharmacist to the Director of Nurses was as follows: "I am writing to you about your inquiry on administering expired insulin to a resident. As insulin ages, it will potentially lose its potency. When administering insulin that has surpassed its date of expiration, the insulin may not be as effective for the resident." Review of the "Pharmacy Consultant Agreement" on 4-30-15 at approximately 7:30 AM revealed the following: "Required Consultant Services:...5. Consultant shall identify any irregularities as defined in the State Operations Manual .....8. Consultant shall assist Facility in determining that medications are labeled in accordance with federal and state labeling requirements and accepted standards of practice." Review of the "Medication Storage Audit" for Unit 2 on 4-30-2015 at approximately 2:15 PM revealed that a pharmacy representative had checked the medication and treatment carts on 4-13-15. At that time, the representative noted that Insulin was dated and initialed, medication was properly labeled, and medications were in date for both medication carts. Review of the mislabeled Insulin vials revealed that open dates ranged from 2-17-15 to 4-7-15 and were present at the time of the review. Two of the 4 residents (Residents #18 and #51) noted as having received expired medication were receiving insulin that should have already been discarded at the time of this cart audit. On 4-30-2015 at approximately 2:30 PM, review of an email sent from the Consultant Pharmacist to the Director of Nurses (DON) as stated: "I am writing to you about your inquiry on administering expired insulin to a resident. As insulin ages, it will potentially lose its potency. When administering insulin that has surpassed its date of expiration, the insulin may not be as effective for the resident." The Allegation of Compliance was submitted, reviewed, and approved on 4-30-15 at 10:30 AM: The Director of Nursing removed seven vials of incorrectly dated insulin from the Unit II med cart on 04/29/15 at approximately 5:30 PM. The replacement vials were labeled and dated appropriately. The Director of Nursing reviewed the four resident's records who could have been negatively affected and completed medication error reports on 04/30/15. The Physician and families were notified. The two nurses responsible for incorrectly dating vials were inserviced individually with return demonstration performed correctly on 04/29/15. An immediate "Quality Assurance Performance Plan" was initiated to prevent recurrence of the problem. Beginning on 04/29/15 and finishing on 04/30/15, all insulin vials on Units I, II, and III were checked by the Unit Supervisor to assure appropriate dates were placed on insulin vials and signed for review and accuracy by two nurses. On 04/29/15 at 6:45 PM, training was initiated by the Staff Education Nurse for all facility licensed nursing staff regarding the appropriate method for dating insulin vials. All current licensed nursing staff employed by the facility will be inserviced by the Staff Education Nurse or designee on correct dating of insulin vials prior to working in the facility. Any newly hired nurses or agency nurses will be inserviced regarding correct dating of insulin vials prior to administering any medications in the facility. A letter was faxed to notify the staffing agencies on 4-30-15 of this requirement. Allegation of Compliance (AOC) date is 04/30/15. Observations, record reviews, and interviews revealed the AOC submitted by the facility on 04/30/15 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. Medication carts were viewed and no expired or mislabeled medications were observed. Documentation indicated that facility nurses were being inserviced on correctly determining expiration dates for insulin and correctly labeling of insulin with the appropriate expiration date. Interviews with facility licensed nursing staff confirmed they were trained on the correct dating of insulin and were able to demonstrate that skill. The Administrator was informed of this on 04/30/15 at approximately 6:00 PM. The Immediate Jeopardy at F-333, F-428, F-431, and F-520 was removed but the citations remained at a lowered scope and severity of "E."

Based on observation, record review, interview, and review of the "Pharmacy Consultant Agreement" and the pharmacy policies entitled "Storage and Expiration of Medications, Biologicals, Syringes, and Needles" and "Insulin Storage Recommendations (Last Revised 9-29-14)", the facility failed to follow a procedure to ensure that medications were labeled appropriately and expired medications were not available for administration in 2 of 2 medication carts on Unit 2, one of three Units in the facility. Seven punctured vials of insulin were labeled with incorrect discard dates based on recorded open dates. Four (4) of the 7 were in current use on the days of the survey. Failure to label insulin using current standards of practice resulted in medication being administered after the expiration/discard dates to Residents #18, #51, #85, and #103 and resulted in the potential for clinically significant adverse consequences to residents receiving ongoing treatment for [REDACTED]. Also, based on observation, interview, and review of the policy entitled "Inventory Control of Controlled Substances", the facility failed to follow a procedure to reconcile controlled drugs appropriately on 1 of 1 medication cart reviewed for reconciliation. In addition, random observation revealed that (LPN) #4 failed to sign the narcotic book when a drug was removed for use from controlled drug storage for Resident #153. The findings included: Cross Refer CFR 483.25(m)(2) Free of any Significant Medication Errors F-333 related to failure of the facility to ensure that 4 residents were free of significant medication errors. Residents #18, #51, #85, and #103 received multiple insulin doses after discard/expired dates when staff failed to label vials of insulin with appropriately calculated discard dates. Cross Refer CFR 483.60(c)(1) Drug Regimen Review, F-428 related to the pharmacist's failure to identify and report irregularities in medication labeling for insulin vials in current use. Failure to identify and report 7 mislabeled vials of insulin to the facility for correction contributed to medication being administered after the expiration date to Residents #18, #51, #85, and #103 and resulted in the potential for clinically significant adverse consequences to residents receiving ongoing treatment for [REDACTED].#5, #95, and #197) identified with mislabeled medication had the potential to be administered Insulin after the actual expiration/discard date. Observation of medication storage in 2 medication carts on Unit 2 on 4-29-15 at approximately 4:13 PM revealed that the handwritten labeling of discard dates on 7 punctured/open insulin vials was incorrect. During separate interviews on 4-29-15 at approximately 4:20 PM, Licensed Practical Nurses (LPNs) #5 and #7 were asked how the discard dates were determined. Both referred to "the calendar" as a reference on the Medication Administration Record [REDACTED] Review of the reference calendar revealed that multiple types of insulin were listed on the top of the page, with the number of days available for use after opening, according to insulin type. Three (3) dates were listed on each calendar day, representing 28, 42, and 90 days after open date. The nurses could note the date and type of insulin opened, check to see how long it could be used, refer to that date on the calendar, and enter that discard date on the open/discard stickers on the vials. Of the seven mislabeled vials, four (4) residents with a [DIAGNOSES REDACTED]. (1) Resident #18 had one open 10 milliliter (ml) vial of Novolin R(egular) 100 units per ml. A sticker applied to the vial stated it had been opened on AM 2-17-15 and was to be discarded on 4-30-15. There were no initials on the sticker to indicate which nurse had miscalculated the discard date. According to the facility reference, Novolin R "expires 42 days after opening." The insulin should have expired on 3-30-15, instead of 4-30-15, as noted on the sticker. Review of Physician's Orders and the Medication Administration Record [REDACTED]. (2) Resident #51 had one open 10 ml vial of Humulin R 100 units per ml. A green sticker applied to the vial stated it had been opened on 3-11-15 and was to be discarded on 5-18-15. There were initials on the open/discard sticker to indicate Licensed Practical Nurse (LPN) #7 had miscalculated the discard date. According to the facility calendar reference, Humulin R "expires 28 days after opening." The insulin should have expired/been discarded on 4-7-15, instead of 5-18-15 as noted on the sticker. Review of Physician's Orders and the MAR indicated [REDACTED] (3) Resident #85 had one open 10 ml vial of Lantus Insulin 100 units per ml. A green sticker applied to the vial stated it had been opened on 3-24-15 and was to be discarded on 5-4-15. There were initials on the open/discard sticker to indicate LPN #6 had miscalculated the discard date. According to the facility calendar reference, Lantus "expires 28 days after opening." The insulin should have expired/been discarded on 4-20-15. Record review revealed Physician's Orders for "Lantus 100 unit/ml vial-Ins(ulin). Inject 12 units subcutaneously twice daily. "...Expires 28 days after opening.**" Review of Physician's Orders and the MAR indicated [REDACTED]. (4) Resident #103 had one open 10 ml vial of Novolin R Insulin 100 units per ml. A green sticker applied to the vial stated it had been opened on 3-4-15 and was to be discarded on 5-5-15. There were initials on the open/discard sticker to indicate LPN #7 had miscalculated the discard date. According to the facility calendar reference, Novolin R "expires 42 days after opening." The insulin should have expired/been discarded on 4-14-15. Review of Physician's Orders and the MAR indicated [REDACTED]. In addition to the four residents who had been given insulin past the expired/discard dates, three other residents also had mislabeled Insulin which had the potential to be administered after the actual expiration/discard date: (1) Resident #5 had one open 10 ml vial of Novolin R Insulin 100 units per ml. A sticker applied to the vial stated it had been opened on 3-24-15 and was to be discarded on 6-21-15. There were initials on the open/discard sticker to indicate LPN #6 had miscalculated the discard date. According to the facility calendar reference, Novolin R "expires 42 days after opening." The label should have had an expired/discard date of 5-4-15. (2) Resident #197 had one open 10 milliliter (ml) vial of Levemir Insulin 100 units per ml. A sticker applied to the vial stated it had been opened on 4-7-15 and was to be discarded on 5-5-15. There were no initials on the sticker to indicate which nurse had miscalculated the discard date. According to the facility reference, Levemir "expires 42 days after opening." The label should have had an expired/discard date of 5-4-15. (3) Resident #95 had one open 10 ml vial of Novolin R Insulin 100 units per ml. A sticker applied to the vial stated it had been opened on 2-28-15 and was to be discarded on 5-10-15. There were initials on the open/discard sticker to indicate LPN #6 had miscalculated the discard date. According to the facility calendar reference, Novolin R "expires 42 days after opening." The insulin should have been labeled with an expired/discard date of 4-10-15. Resident #95 had an order for [REDACTED]. During the interview on 4-29-15 at approximately 4:20 PM, when asked how s/he knew if the insulin was in date and appropriate to administer, LPN #7 referred to the sticker on the side of the insulin vial. S/he said, "I go by that date (indicating the handwritten discard date on the sticker). I can give it up to that date." When open dates on the vials were compared to the calendar, LPNs #5 and #7 verified that the discard information on the labels did not match the calendar. After review of the calendar, LPN #7 stated, "I do not know why the dates are wrong." During an interview on 4-29-15 at approximately 4:30 PM, Registered Nurse (RN #1) verified that the discard dates were incorrect on the labeling of the vials. An interview on 4-30-15 at 7:50 AM with LPN #6, who was identified by the Director of Nurses and Administrator as having labeled and miscalculated discard dates on some of the vials of Insulin. When asked to describe the procedure followed when opening and labeling insulin, the nurse stated,"The stickers are in front of the MAR. The stickers have on them an open and discard date. I put the date when opened and when discarded according to the insulin type. I use the calendar in front of the MAR. I go by the calendar and look on it for dates." When asked how s/he thought the stickers could have been incorrectly labeled, LPN #6 stated, "I was thinking it was the next month. I was one month ahead in my thinking when I mislabeled the insulins." On 4-30-15 at approximately 7:30 AM, review of the pharmacy policy entitled "Storage and Expiration of Medications, Biologicals, Syringes, and Needles" with a revision date of 1-1-13 revealed the following: "Facility should ensure that medications and biologicals: 4.1 Have an Expiration Date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines... 5.0 Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 5.1 Facility staff may record the calculated expiration date based on date opened on the medication container." Review of the pharmacy policy entitled "Insulin Storage Recommendations (Last Revised 9-29-14)" revealed that opened and stored at room temperature, Novolin R and Levemir Insulins were good for 42 days, Lantus for 28 days. Humulin R was noted to be good for 31 days, which was discrepant from the reference tool used by the facility. During an interview on 4-30-15 at approximately 11:30 AM, when asked about concerns related to the administration of expired insulin, the Medical Director stated, "I don't feel there is jeopardy to the patients because blood sugars are monitored daily. There are safety mechanisms in place." When asked about the efficacy of the insulin when administered past the calculated expiration date, s/he stated, "You would have to ask the Pharmacist. I would have to ask the manufacturer for recommendations for the safety." When asked about possible negative outcomes, the physician stated,"That would be that it was not as effective. Blood sugars would go up." When asked about expectations regarding medication administration, s/he stated, "I expect the right medicine to be given at the right time as ordered. Policy should be followed. Follow the manufacturing recommendations of the medicine." On 4-30-2015 at approximately 2:30 PM, review of an email sent from the Pharmacist to the Director of Nurses was as follows: "I am writing to you about your inquiry on administering expired insulin to a resident. As insulin ages, it will potentially lose its potency. When administering insulin that has surpassed its date of expiration, the insulin may not be as effective for the resident." Review of the "Pharmacy Consultant Agreement" on 4-30-15 at approximately 7:30 AM revealed the following: "Required Consultant Services:...5. Consultant shall identify any irregularities as defined in the State Operations Manual .....8. Consultant shall assist Facility in determining that medications are labeled in accordance with federal and state labeling requirements and accepted standards of practice." Review of the "Medication Storage Audit" for Unit 2 on 4-30-2015 at approximately 2:15 PM revealed that a pharmacy representative had checked the medication and treatment carts on 4-13-15. At that time, the representative noted that Insulin was dated and initialed, medication was properly labeled, and medications were in date for both medication carts. Review of the mislabeled Insulin vials revealed that open dates ranged from 2-17-15 to 4-7-15 and were present at the time of the review. Two of the 4 residents (Residents #18 and #51) noted as having received expired medication were receiving insulin that should have already been discarded at the time of this cart audit. On 4-30-2015 at approximately 2:30 PM, review of an email sent from the Consultant Pharmacist to the Director of Nurses (DON) as stated: "I am writing to you about your inquiry on administering expired insulin to a resident. As insulin ages, it will potentially lose its potency. When administering insulin that has surpassed its date of expiration, the insulin may not be as effective for the resident." On 4-29-15 at approximately 3:13 PM, the narcotic count of controlled substances was observed. Licensed Practical Nurses (LPN) #4 and #5 were performing the controlled substance count at the end of the AM shift. During the observation of the narcotic count, the 2 nurses failed to properly count and compare the narcotics for correct reconciliation of usage. First, LPNs #4 and #5 manually counted the number of unit dose cards to reconcile the number of cards present. Then, LPN #5 started the narcotic count by calling out only the number of the pills left in each of the individual residents' cards. LPN #4 compared that with the number on the narcotic count sheet in the narcotic book. Residents' names and the names of the medications were not spoken. During an interview on 4-29-15 at approximately 3:25 PM, when asked about the process used for counting narcotics, LPN #4 stated, "The outgoing nurse counts with the oncoming nurse by counting the pills and comparing to the narcotic sheet." During observation of the reconciliation, the nurses noted that the count was incorrect for Resident #153. LPN# 4 failed to sign out Roxanol at 2:00 PM for the resident. The nurses stopped the count and LPN #4 signed out the Roxanol During an interview on 4-29-15 at approximately 3:25 PM, LPN #4 confirmed that s/he had not signed out the 2:00 PM Roxanol for Resident #153 when given on 4-29-15. During an interview on 4-29-15 at 6:20 PM, the Director of Nursing and Assistant Director of Nursing stated, "The number of medication cards are counted first resulting in an inventory count first. Then each medication name/strength, and the last name of the resident should be called out to confirm a correct count." On 4-30-15 at approximately 8:29 AM, review of the facility policy entitled "Inventory Control of Controlled Substances (revised 1-1-13)" revealed the following: "1. With respect to Schedule II Controlled Substances: ...1.2 Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on the "Controlled Substance Count Verification/Shift Count Sheet... 1.2.2 Reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification/Shift Count Sheet. 1.2.3 The Facility should routinely reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification/Shift Sheet, to the medication administration record." Clinical Nursing Skills & Techniques 7th Edition page 524 states: "Use a special inventory record each time a narcotic is dispensed. . . Use the record to document the patient's name, date, time of medication administration, name of medication, dose, and signature of nurse dispensing the medication." The Allegation of Compliance related to the Immediate Jeopardy was submitted, reviewed, and approved on 4-30-15 at 10:30 AM: The Director of Nursing removed seven vials of incorrectly dated insulin from the Unit II med cart on 04/29/15 at approximately 5:30 PM. The replacement vials were labeled and dated appropriately. The Director of Nursing reviewed the four resident's records who could have been negatively affected and completed medication error reports on 04/30/15. The Physician and families were notified. The two nurses responsible for incorrectly dating vials were inserviced individually with return demonstration performed correctly on 04/29/15. An immediate "Quality Assurance Performance Plan" was initiated to prevent recurrence of the problem. Beginning on 04/29/15 and finishing on 04/30/15, all insulin vials on Units I, II, and III were checked by the Unit Supervisor to assure appropriate dates were placed on insulin vials and signed for review and accuracy by two nurses. On 04/29/15 at 6:45 PM, training was initiated by the Staff Education Nurse for all facility licensed nursing staff regarding the appropriate method for dating insulin vials. All current licensed nursing staff employed by the facility will be inserviced by the Staff Education Nurse or designee on correct dating of insulin vials prior to working in the facility. Any newly hired nurses or agency nurses will be inserviced regarding correct dating of insulin vials prior to administering any medications in the facility. A letter was faxed to notify the staffing agencies on 4-30-15 of this requirement. Allegation of Compliance (AOC) date is 04/30/15. Observations, record reviews, and interviews revealed the AOC submitted by the facility on 04/30/15 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. Medication carts were viewed and no expired or mislabeled medications were observed. Documentation indicated that facility nurses were being inserviced on correctly determining expiration dates for insulin and correctly labeling of insulin with the appropriate expiration date. Interviews with facility licensed nursing staff confirmed they were trained on the correct dating of insulin and were able to demonstrate that skill. The Administrator was informed of this on 04/30/15 at approximately 6:00 PM. The Immediate Jeopardy at F-333, F-428, F-431, and F-520 was removed but the citations remained at a lowered scope and severity of "E."

Based on record review and interviews, the facility failed to identify quality deficiencies related to insulin vials labeled with incorrect expiration/discard dates. Though the facility had a performance improvement plan in place related to expired medication, the facility failed to identify the mislabeling of insulin and implement a plan of action to correct the deficient practice. Failure of the Quality Assurance (QA) Committee to identify this specific issue during weekly audits and implement action plans to correct the deficient practice contributed to insulin being administered after the expiration/discard date and resulted in the potential for clinically significant adverse consequences to residents receiving ongoing treatment for [REDACTED]. The findings included: Cross Refer CFR 483.60(e) Storage of Drugs and Biologicals, F-431 related to failure of the facility to ensure that 7 opened/punctures vials of insulin were labeled appropriately and expired medications were not available for administration. Failure to label insulin using current standards of practice resulted in medication being administered after the expiration/discard dates to Residents #18, #51, #85, and #103 and resulted in the potential for clinically significant adverse consequences to residents receiving ongoing treatment for [REDACTED].#5, #95, and #197) identified with mislabeled medication had the potential to be administered Insulin after the actual expiration/discard date. Cross Refer CFR 483.25(m)(2) Free of any Significant Medication Errors F-333 related to failure of the facility to ensure that 4 residents were free of significant medication errors. Residents #18, #51, #85, and #103 received multiple insulin doses after discard/expired dates when staff failed to label vials of insulin with appropriately calculated discard dates. Cross Refer CFR 483.60(c)(1) Drug Regimen Review, F-428 related to the pharmacist's failure to identify and report irregularities in medication labeling for insulin vials in current use. Failure to identify and report 7 mislabeled vials of insulin to the facility for correction contributed to medication being administered after the expiration date to Residents #18, #51, #85, and #103 and resulted in the potential for clinically significant adverse consequences to residents receiving ongoing treatment for [REDACTED].#5, #95, and #197) identified with mislabeled medication had the potential to be administered Insulin after the actual expiration/discard date. Review of information provided by the facility on 4-30-15 revealed that two Process Improvement Plans related to expired medications were already in place. A QA (Quality Assurance) review with a start date of 12-20-13 for Pharmaceutical Services stated "3rd shift nurse to check med cart daily to ensure no expired meds are in cart. Supervisors to check med carts weekly to ensure no expired meds located in cart. Supervisor monitoring forms to be turned in to CQI weekly." A second QA with a start date of 9-15-14 for "F-431-Expired Meds" referenced the additional audit of medication rooms for expired drugs. During an interview on 04/30/15 at approximately 8:48 AM, the facility Assistant Director of Nursing (ADON)/Quality Assurance Coordinator (QAC) confirmed the facility had not identified the mislabeling of expiration/discard dates on insulin vials for Residents #18, #51, #85 and #103. The Assistant Director of Nursing/Quality Assurance Coordinator stated the facility had started a quality assurance review on expired medication in the medication carts on 12/20/13 that had been ongoing. The Assistant Director of Nursing/Quality Assurance Coordinator stated the staff was looking at the label regarding the expiration date and not making sure the label affixed by the staff when the vials were opened had the expiration/discard date calculated correctly. The ADON/QAC stated that the licensed nurses did not notice the open and discard dates on the insulin. The Allegation of Compliance was submitted, reviewed, and approved on 4-30-15 at 10:30 AM: The Director of Nursing removed seven vials of incorrectly dated insulin from the Unit II med cart on 04/29/15 at approximately 5:30 PM. The replacement vials were labeled and dated appropriately. The Director of Nursing reviewed the four resident's records who could have been negatively affected and completed medication error reports on 04/30/15. The Physician and families were notified. The two nurses responsible for incorrectly dating vials were inserviced individually with return demonstration performed correctly on 04/29/15. An immediate "Quality Assurance Performance Plan" was initiated to prevent recurrence of the problem. Beginning on 04/29/15 and finishing on 04/30/15, all insulin vials on Units I, II, and III were checked by the Unit Supervisor to assure appropriate dates were placed on insulin vials and signed for review and accuracy by two nurses. On 04/29/15 at 6:45 PM, training was initiated by the Staff Education Nurse for all facility licensed nursing staff regarding the appropriate method for dating insulin vials. All current licensed nursing staff employed by the facility will be inserviced by the Staff Education Nurse or designee on correct dating of insulin vials prior to working in the facility. Any newly hired nurses or agency nurses will be inserviced regarding correct dating of insulin vials prior to administering any medications in the facility. A letter was faxed to notify the staffing agencies on 4-30-15 of this requirement. Allegation of Compliance (AOC) date is 04/30/15. Observations, record reviews, and interviews revealed the AOC submitted by the facility on 04/30/15 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. Medication carts were viewed and no expired or mislabeled medications were observed. Documentation indicated that facility nurses were being inserviced on correctly determining expiration dates for insulin and correctly labeling of insulin with the appropriate expiration date. Interviews with facility licensed nursing staff confirmed they were trained on the correct dating of insulin and were able to demonstrate that skill. The Administrator was informed of this on 04/30/15 at approximately 6:00 PM. The Immediate Jeopardy at F-333, F-428, F-431, and F-520 was removed but the citations remained at a lowered scope and severity of "E."