Every finding on record at Place at Deans Bridge, The

Based on observation, policy review, and staff interviews, the facility failed to ensure that open food items in the dry storage area were securely wrapped, labeled, and dated, and also failed to discard food items by their expiration dates. This deficient practice had the potential to place residents who received an oral diet from the kitchen at risk of foodborne illness. The census was 78.Findings include:Review of facility policy titled Food Safety Handling Policy, included, . Notes labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date or discarded. Foods covered and in air-tight containers.1. Observation on 6/30/2025 at 10:23 am revealed a white plastic container of chicken bouillon concentrate in the walk-in freezer, with a use-by date of 12/11/2024. Further observation in the walk-in freezer revealed a bag of opened and undated breaded chicken tenderloin strips.2. Observation on 6/30/2025 at 10:45 am in the kitchen revealed two floor dry storage bins, unmarked and undated. The Dietary Manager (DM) stated the bins contained sugar and flour.3. Observation on 7/1/2025 at 11:15 am in the walk-in freezer revealed an opened and undated bag of sliced squash, an opened and undated bag of tater tots, and an opened and undated bag of chopped broccoli. In an interview on 6/30/2025 at 10:45 am, the DM verified that the bouillon was expired, and the frozen chopped broccoli was left over from the previous lunch meal, and had not been labeled. He stated that all staff were responsible for discarding expired food items and rotating stock.

Based on observations, staff interviews, and review of the facility's policies titled Handwashing/ Hand Hygiene, Infection Prevention and Control Program, and Laundry Policy, the facility failed to ensure staff follow proper hand hygiene techniques when performing blood glucose testing on one resident (R) (R5). In addition, the facility failed to ensure the infection control process was followed when transporting clean linen to residents' rooms and for clean clothing in the laundry room. These deficient practices had the potential to place the residents at risk of infections due to cross-contamination. Findings include:Review of the facility's policy titled Hand Washing/ Hand Hygiene, revised August 2019, included, .Use an alcohol based hand rub containing at least 62% [percent] alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: after removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/ hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.Review of the facility's policy titled Infection Prevention and Control Program, reviewed November 2022, included . Standard Precautions, Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. All staff shall use personal protective equipment (PPE) according to established facilities policy governing the use of PPE. The Linens section included .Clean linen shall be delivered to resident care units on covered linen carts with covers down.Review of the facility's policy titled Laundry Policy, included . Staff shall consider all previously worn clothing and use linens as potentially contaminated. The facilities laundry area will provide hand washing, PPE. Laundry staff will be in service on handling linens and laundry on a regular basis.1. Review of R5 clinical record revealed diagnoses including, but not limited to, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene.Observation on 7/2/2025 at 11:40 am revealed Licensed Practical Nurse (LPN) JJ performed a finger stick blood glucose test on R5. Observation revealed LPN JJ changed gloves without performing hand hygiene during the procedure.During an interview on 7/2/2025 at 12:04 pm, LPN JJ revealed that she should have performed hand hygiene between glove changes and stated that she was overwhelmed. 2. During an observation of the laundry area on 7/2/2025 at 12:12 pm, with the Maintenance and Housekeeping Manager, observation revealed a laundry attendant transporting clean linen in a covered laundry cart with resident clothing on hangers and hanging from the outside of the cart's handlebars. The clothing was uncovered and was observed brushing against the walls and handrails of the hallway. The Maintenance and Housekeeping Manager confirmed that the resident's clothing was uncovered and that they were brushing the walls and handrails in the hallways. He stated the clothing would have to be rewashed. Further observation of the laundry room revealed a basket containing clean clothing sitting by the folding table. The leg of a pair of pants was observed hanging from the basket and resting on the floor. The Maintenance and Housekeeping Manager stated the pants would have to be rewashed. During an interview on 7/2/2025 at 12:30 pm, the Laundry Attendant revealed that she did not return the soiled resident clothing to the laundry room. She stated that she was unaware that the resident's clothing on the cart needed to be covered, and did not realize the clothing had brushed against the walls in the hallway. The Laundry Attendant confirmed that they had transported the resident's laundry uncovered several times before.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Labeling and Storage, the facility failed to ensure that expired medications were removed from active medication storage in one medication storage room and one of two medication carts. This deficient practices had the potential to place the residents at risk of receiving expired medications and had the potential to allow unauthorized access to controlled medications. Findings include:Review of the facility's policy titled Medication Labeling and Storage, revised February 2023, included, . If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.During an observation on 7/1/2025 at 4:55 pm of the medication storage room, medication cart, and medication refrigerator, with the Assistant Director of Nursing (ADON), the following were observed:In the medication storage room: One bottle of magnesium oxide 400milligram (mg), with an expiration date of 6/2025.One bottle of vitamin D 10mcg with an expiration date of 5/2025. Two bottles of milk of magnesium 16 fluid (F) ounce (oz) with an expiration date of 5/2025.One bottle of Geri Lanta 12oz, with an expiration date of 6/2025. One bottle of iron tablets, 325mg, with an expiration date of 6/2025. Three bottles of docusate sodium liquid 50mg/5 milliliter (ml), with expiration dates of 6/2025. One bottle of aspirin 81mg, with an expiration date of 7/2024.One bottle of folic acid 1000 micrograms (mcg) tablets, with an expiration date of 6/2025, was observed in one of two medication carts. During the observations, the ADON revealed that she had checked the storage room herself only a few days prior to the survey. She stated that she had removed all the expired medications and was very surprised at what was found. She added that a thorough reassessment would be done and all drugs checked and restocked.During an interview on July 2, 2025, at 12:46 p.m., the Director of Nursing (DON) revealed that a pharmacy consultant audits the medication carts and completes medication passes monthly. The DON stated that during the audits, all expired medications were removed and discarded. She stated that the supply clerk was responsible for auditing and stocking the medication supply room. She further stated that the nurses and managers were responsible for discarding expired medications.

Based on observations, resident and staff interviews, and review of facility policies titled, Homelike Environment and The Place Facilities Environmental Services Cleaning and Repair, the facility failed to maintain a safe, functional, and sanitary environment in 10 of 50 resident rooms (N 3, N 4, N 5, N 6, N 7, N 10, S 11, S 17, S 18, and S 23). Specifically, resident rooms were observed to contain debris in packaged terminal air conditioner (PTAC) units, eroded/broken dressers/nightstands, dirty air vents in bathrooms, holes/cracks in drywall, and rusted/peeling toilet commode frames. Findings include: Review of the facility policy titled, Homelike Environment, revised February 2021 revealed the following: Policy Statement: Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Review of the facility policy titled, The Place Facilities Environmental Services Cleaning and Repair, revised November 2022 documented its policy as follows: It is the policy of this facility to regularly monitor environmental services to ensure the facility is maintained in a safe and sanitary manner and assessed on a regular basis. Observations of resident rooms beginning on 8/1/2023 at 10:00 a.m. revealed the following: N 3: PTAC unit with debris in the vent. N 3-B: Nightstand with front panel missing from the top drawer; second night stand missing knobs from two drawers. N 4: Bathroom with dirty air vent, loose baseboards, rusted toilet commode frame, large brown stain in the toilet, loose baseboards and holes in the walls surrounding the sink, and television cable wires hanging approximately three to four feet from the floor N 5-A: Nightstand rotting away at the base, PTAC units with black substance on the vent grill. N 5-B: Gashes in the drywall behind the bed, nightstand missing two of four knobs from the top two of three drawers. N 6: Bathroom with a hole in the wall behind the toilet, rusted/peeling toilet commode frame, loose baseboards around the room. N 7: Bathroom: dirty air vent, soap and hand sanitizer dispensers not working, no paper towels in dispenser, toilet with left bolt exposed, and right bolt missing or broken. N 10: Baseboards loose from the wall under the sink, baseboards dirty around the room, windowsill with breaks in the inlet surrounding the window, and bathroom with dirty air vent. S 17: One metal object measuring approximately 1 inch x 4 inches on the floor behind the toilet. Resident (R) (R#64) confirmed he uses the restroom. Observations of resident rooms on 8/2/2023 beginning at 9:15 a.m. revealed the following: S 11: The over bed table located close to bed A was observed to have peeling surface areas on the table edge and scattered brown, crusty areas on the metal frame. S 18: There were two open areas approximately two centimeters in diameter and approximately five feet from the floor on the wall located to the left of the doorway and between the restroom and bed A area. There was peeling paint and missing wall material located on the wall to the left of the doorway and next to bed A. S 23: The paper towel dispenser was observed to have scattered brown areas on the front and both sides of the dispenser. Observations of resident rooms on 8/3/2023 at 3:45 p.m. with the Maintenance Director revealed the conditions of the resident rooms mentioned above were still present and confirmed with the Maintenance Director. He stated the staff were familiar with the process for reporting maintenance concerns and he checked the Maintenance Log frequently throughout the day.

Based on staff interview, record review, and review of the facility policy The Place Facilities Resident Personal Funds-Surety Bond Policy, the facility failed to maintain a surety bond sufficient to cover the current total funds in the resident trust account. The deficient practice had the potential to affect 29 residents with funds managed by the facility. Findings include: Review of the facility policy titled, The Place Facilities Resident Personal Funds-Surety Bond Policy, revised 11/2022, revealed the following: Assurance of Financial Security: 1. The facility will purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. Review of the resident trust account monthly statements dated January 2023 through June 2023 revealed the following beginning monthly balances: January 2023 ($88,529.30), February 2023 ($89, 963.16), March 2023 ($93,150.06), April 2023 ($88,396.63), May 2023 ($83,136.07), and June 2023 ($84,358.70). Review of the Bond Transaction Summary with a Transaction Effective Date of 12/15/2022 and a Term of Bond dated 12/15/2022 through 12/14/2023 documented a bond amount of $70,000. Interview on 8/2/2023 at 2:22 p.m. with the Administrator revealed he was unaware that the surety bond did not cover the monthly beginning/ending balances of the facility's resident trust account. He stated he would increase the amount of the surety bond to $100,000 as soon as possible.

Based on record review and staff interviews, the facility failed to obtain a concurring Physician's signature for a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The sample size was 31 residents. Findings include: 1. Review of medical record for R#19 revealed a POLST with a choice to allow natural death/DNR that was signed by one Physician on 10/13/21 and resident's son, that was not the residents Power of Attorney, on 10/13/21 there was no concurring Physician's signature. Further review of the Medical Record for R#19 also revealed that there was not a Health Care Agent for R#19 on file at facility. Interview with Social Services Director (SSD) On 1/11/22 at 12:19 p.m. revealed that when a resident is admitted to the facility Advanced directives are discussed at that time with the resident and the family member. If the resident is cognitive, they are given the POLST form to complete which is then signed by the resident, physician, and the social services director. If the resident is not cognitive and unable to speak for themselves the residents responsible party is given the POLST document, and they will sign or them. Continued interview revealed that staff member was not aware that at any time there should be a concurring physician signature for residents that are not cognitive and who do not have a health care agent or court appointed guardian. Further interview did confirm that R#19 should have had a second physicians' signature on the POLST document due to residents' cognitive status and lack of legal guardianship. Interview with R#19 family member on 1/11/22 at 12:56 p.m. revealed that he did file for guardianship on October 29, 2021 and will not be finalized until 1/18/2022. Further interview also confirmed that family member did not have guardianship over resident at the time the POLST document was signed on 10/13/2021. Interview with Direct of Nursing (DON) revealed that the POLST form for residents with a cognitive deficit should have two physician signatures if they do not have health care agent on file. Further interview also confirmed that R#19 should have had a concurring physician signature on the POLST document. 2. Review of the clinical record for R #66 revealed a POLST signed by the daughter of R#66 on 11/30/21 but there was no evidence that the daughter was the residents Health Care Agent. Review of the POLST revealed that it only had one Physician's signature with no concurring Physician signature. Review of document titled Guidance for completing POLST form revealed under additional guidance for health care professionals Section III. When a POLST form is signed by an authorized person (other than the health care agent) and attending Physician; I. If section A indicates allow natural death -Do Not Attempt Resuscitation, this order may be implemented when the patient is a candidate for non-resuscitation as defined by Georgia Code 31-39-2 (4). A concurring physician signature is required per Georgia code 31-39-4 (c)

Based on observations and interviews the facility failed to ensure that privacy curtains for three of sixteen rooms on the South Hall were clean and provided complete privacy for one resident (R) R#66. The facility also failed to repair a hole in the wall in room five on the South Hall. Findings include: Observation of resident's privacy curtain on south hall for R#66 on 1/09/22 at 3:47 p.m. revealed brown stains noted by the hem of the curtain and does not provide full privacy. Observation on 1/10/22 at 8:37 a.m. revealed there was a whole in the wall behind the door south hall room S5. Observation resident privacy curtain room South 12a on 1/10/22 at 8:43 a.m. revealed dark brown stains noted on the outside and inside of the curtain near the outer aspects of the curtain. Observation on 1/10/22 at 9:27 a.m. revealed privacy curtain has dark brown stain at the base of the curtain by the hem on both sides of the curtain room South 11. An interview with License Practical Nurse (LPN) FF revealed that there is a maintenance book at the nursing station for staff use. If there are any maintenance issues, they are put in the book which is checked daily by the Maintenance Director. Further interview also revealed that she did not notice that the privacy curtain for R#66 did not provide full privacy. Environmental rounds conducted with Administrator and Maintenance/Housekeeping supervisor on 1/12/22 at 8:16 a.m. confirmed all environmental observations that were observed during facility initial tour. An interview with Maintenance Director on 1/12/22 at 8:26 a.m. revealed that when there is an issue that needs to be addressed, the staff will fill out a form in the maintenance book that is at each nursing station. The Maintenance Director further revealed that if there are any emergency repairs that need to be attended to the staff will let him know verbally and he would address those issues immediately. The maintenance book is checked every morning for any needed repairs. Further interview also revealed that he was not aware of the repairs nor the condition of the privacy curtains that were revealed during environmental rounds. Continued interview also revealed that deep cleanings are conducted which entails disinfecting the entire room including the bed and bed rails, changing the privacy curtains, and fogging the room with disinfectant as well. An interview with Housekeeper EE on 1/12/22 at 1:09 p.m. revealed that the deep cleaning process consist of cleaning the entire room and disinfecting it with Clorox. Housekeeper EE further revealed that the deep cleaning also includes the bed rails, floors, any stains that are on the walls and the privacy curtains are inspected as well. If the privacy curtains are stained it is reported to the laundry department and they would remove the curtain and replace them with a clean curtain. Further interview also revealed that deep cleans for the residents' rooms are completed as needed. An interview with the Administrator on 1/12/22 at 1:15 p.m. revealed that the observations that were revealed during environmental rounds were not known to him.

Based on observation, staff interview, and record review the facility failed to develop a Comprehensive Care Plan related to the use of a [MEDICAL CONDITION]/hypnotic (Ambien) medication for one resident (R) (R#65). The sample size was 18. Findings include: Record review revealed that R#65 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of R#65 physician's orders [REDACTED]. Review of the Admission Care Plan dated 5/31/2018 revealed that the resident receives a hypnotic as needed. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident received a hypnotic all seven days of the assessment period. However, review of the Comprehensive Interdisciplinary Care Plan dated 6/6/18 revealed that there was not a care plan to address the residents use [MEDICATION NAME] interventions to monitor for possible complications.

Based on staff interview, and record review the facility failed to provide a rational for the continued use of a PRN (as needed) [MEDICAL CONDITION]/hypnotic (Ambien) past 14 days for one resident (R) (R#65). In addition, the facility failed to respond to a recommendation made by the Consultant Pharmacist to consider adding a rational and duration of the PRN order for the Ambien. The sample size was 18 residents. Findings include: Review of the facility policy Administering Medications (not dated) line 25. If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team (IDT) with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, a standing dose of medication is clinically indicated. Review of R#65 medical record revealed that the resident had a [DIAGNOSES REDACTED]. Review of her Physician's Orders revealed an order for [REDACTED]. Review of her Admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident had received a hypnotic all seven days of the assessment period. Review of her baseline care plan dated 5/31/2018 revealed she received a hypnotic as needed for sleep. Review of her Comprehensive Interdisciplinary Care Plans, dated 6/6/18, revealed there was no care plan developed for the use of a hypnotic for sleep. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the document titled Consultant Pharmacist Communication to Physician dated 7/5/18 revealed the pharmacist recommended that the PRN order for [MEDICAL CONDITION] drugs are to be limited to 14 days. The physician's response on 7/9/2018 was to add a rational of chronic anxiety, [MEDICATION NAME] chronic [MEDICAL CONDITION] with a duration of six months. The resident continued with a PRN hypnotic order for 41 days. Interview on 07/11/2018 at 3:07 p.m. with the Director of Nursing (DON) confirmed that the document titled Consultant Pharmacist Communication to Physician dated 7/5/2018 was in the resident's medical record but a corresponding clarification order was not written to reflect the Physicians Order. Interview on 07/11/2018 at 3:48 p.m. with the Pharmacy Consultant revealed his expectations are that when he makes a recommendation, the Physician will either agree or disagree with his recommendation. A telephone interview on 07/11/2018 at 5:30 p.m. with the Owner and Pharmacist for the dispensing pharmacy revealed he verified that the resident was admitted on the [MEDICATION NAME] mg one tablet at HS PRN for sleep. He revealed according to the dispensing pharmacy policy titled Medication Orders Stop Orders that all PRN non-antipsychotic [MEDICAL CONDITION] will be automatically stopped at 14 days.

Based on observation, review of the policy titled Serving Meals and staff interviews, the facility failed to ensure a homelike environment during dining. Specifically, the facility failed to remove the meal trays after delivering meals to 35 residents in the Main Dining room, in an effort to de-emphasize an institutional setting. The facility census was 73 residents. Findings include: Observation in the Main Dining room on 8/7/17 beginning at 11:55 a.m. revealed 32 residents seated at tables for lunch. At 12:05 p.m. the facility staff began serving the residents their meals on meal trays. The staff did not remove the meal trays when the meals were delivered to all 32 residents until the residents completed their meal. Further, the staff was not observed asking any of the 32 residents if they wanted the meal tray to remain in place. Observation in the Main Dining room on 8/8/17 at 12:00 p.m. revealed 31 residents seated at tables for lunch. All 31 residents were served their meals on a serving tray. The serving trays were not removed when the meals were delivered to all 31 residents and the staff was not observed asking any of the 31 residents if they wanted the meal tray to remain in place. The meals trays remained in place until they were picked up after the residents completed their meals. Observation in the Main Dining room on 8/10/17 at 12:11 p.m. revealed 35 residents seated at tables for lunch. All 35 residents had been served their meals on meal trays that were not removed. Interview on 8/10/17 at 12:15 p.m. with resident Y in the main dining room revealed he eats most all of his meals in the Main Dining room. The resident stated that the staff brings the meals on a serving tray and the tray is not removed. Resident Y stated the trays are not picked up until they are finished eating. Interview on 8/10/17 at 12:18 p.m. with the Activities Staff DD revealed she assist in the dining room almost every day. She stated that they serve the residents' meals on the meal trays and they do not remove the trays. Activities Staff DD further stated she did not know why they don't remove the trays, it has always been that way. Interview on 8/10/17 at 12:24 p.m. with Certified Nursing Assistant/Restorative Aide (CNA AA) revealed she has worked in the facility since January 2017. CNA AA revealed that they do not remove the meals trays after serving the residents' their meals and it has been that way since she started working in the facility. CNA AA further stated that it had never been explained to her to remove the trays but that having the trays in place makes it easier to pick everything up at once rather than in separate pieces. Interview on 8/10/17 at 12:26 p.m. with the Dietary Manager (DM) revealed they have never removed the food items from the trays because it helps keep everything in place for the residents. The DM further stated that they have never gone to fine dining in which all the items on the tray would be removed. Interview on 8/2/17 at 12:32 p.m. with the Administrator revealed that for the past [AGE] years, they had never removed the meal trays when serving meals to the residents. The Administrator stated that it helps keep everything in place. She stated the meal cards remain on the tray and whichever staff member picks up a tray, they observe how much a resident ate and write it on the meal ticket. The meal tickets are then collected for the North and South Halls and the CNAs document the intakes of the residents in a book. Further interview with the Administrator, on the same day, at 1:39 p.m. revealed she reviewed the facility's policy for dining and it does not indicate to remove the food items from the meal trays. She stated a tray would be removed if something spilled on the tray and replaced with a clean tray. She stated they had never implemented fine dining in this facility which meant they would use table clothes, center pieces and remove all of the food items, plates, glasses, condiments and utensil from the tray. She stated fine dining would be more of a five star dining experience and they have never done that in this facility. The Administrator stated that they have not asked the residents in the past if they would like their food and items removed from the trays. The Administrator further stated that they have a policy for the dining room but the policy does not address the removal of meal trays. Review of the policy titled Serving Meals revised April 2001 addresses Preparation, Equipment, Supplies, and Resident Rights. There is no documentation in the policy that addressed a homelike environment or ways to de-emphasize an institutional environment during dining. There is no documentation in the policy that addressed removal of meal trays once a meal had been served.

Based on observation, staff interview and facility policy review. The facility failed to ensure that staff follow proper infection control guidelines when passing ice to residents on one (South) of two hallways. The facility census was 73. Findings include: Review of facility's Infection Control Prevention Manual for Long Term Care for Ice chests and Ice Machines (revised 2009) revealed: Policy: The following policy should be followed to reduce the likelihood of contamination of ice chest (ice-storage compartments) and ice machines. II. Ice scoops used should be smooth and impervious and should be kept on an uncovered stainless steel, impervious plastic or fiberglass tray on tope of the chest or in a mounted holder when not in use. Observation on 08/07/2017 11:45 am. Certified Nursing Assistant (CNA) BB passing ice on the south hall. Observed each time she filled a resident's cup with ice she would place ice scoop back into the ice chest on top of the ice to be given. Also noted CNA BB going from one room to the next with no indication of her rubbing her hands together to indicate that she had washed her hands or used sanitizer. Interview 08/07/2017 12:12 pm. with CNA BB when she returned ice chest to nurses' station revealed, when the ice chest was opened, the ice scoop lying on top of ice that was remaining in ice chest. Further interview with CNA BB stated that I'm supposed to place the ice scoop within the bag in the drawer underneath the ice chest. CNA BB further stated when she passes ice to just a few rooms that she just puts the scoop back into the ice chest between rooms then reported that she should have replaced scoop into bag between each resident. Interview 08/10/2017 4:57 p.m. with the Infection control nurse revealed that the staff are expected to wash their hands after each residents' cup is filled with ice and ice scoop is to be replaced within the plastic bag underneath ice chest between each use not inside ice chest. Interview 08/10/2017 5:09 pm. Director of Nursing (DON) Surveyor ask what her expectations are of her staff when passing ice. She stated that she expects them to wash their hands after filling each resident's cup with ice and use good infection control practice by placing the ice scoop within a plastic bag in the drawer underneath the ice chest between each use. She was unaware that CNA BB was not following this practice.

Based on observation and staff interview that facility failed to ensure food items were securely wrapped, labeled and dated in the walk-in freezer, one (1) of two (2) dry storage areas, and for two (2) of two (2) refrigerators; the facility also failed to demonstrate the correct technique for using the three (3) compartment sink to prevent food borne illness. This deficient practice had the potential for effecting fifty-eight (58) residents receiving an oral diet. Findings include: Observation on 09/27/15 at 10:45 a.m. of the two (2) door reach in refrigerator revealed a gallon container of sweet pickle relish and a gallon container of salsa both opened with no date of when they were opened for usage. Observation on 09/27/15 at 10:50 a.m. of one (1) of the two (2) dry storage areas revealed a clear plastic bin that contained food items that had been opened and wrapped for storage. Continued observation revealed that there was an opened packet of yellow cake mix and an opened wrapped package of marshmallows that had no date of when they were opened. Observation on 09/27/15 at 10:55 a.m. of the walk-in freezer revealed a blue colored plastic bag containing a food item was open and tied in a knot on the top, this bag had no label to identify the item or date when it was opened. Continued observation of the freezer revealed a clear plastic zip lock bag that contained pork chops with no date of when opened. There was also a clear plastic bag containing diced chicken that was open and the top was rolled down which did not secure the food item in the bag. The diced chicken did not have a date of when it was opened. The freezer also contained a clear zip lock bag of diced green peppers that had no date of when it was opened. Further observation of the walk-in refrigerator revealed a white colored plastic bag that contained six (6) pieces of fried chicken that was open, was not securely wrapped and had no date of when it was opened. Observation on 09/27/15 at 11:05 a.m. of the walk-in refrigerator revealed an open three (3) pound bag of shredded cheddar cheese, an open three (3) pound bag of grated parmesan cheese, an open bag of shredded carrots, and an open bag of shredded lettuce all of which were not securely wrapped and did not have a date of when they were opened. Interview on 09/27/15 at 11:30 a.m. with the Dietary Manager (DM) revealed that she acknowledge that the sweet pickle relish and the salsa in the two (2) door reach in refrigerator had been opened by staff and did not have a date placed on the containers before placing back for storage. She acknowledged that the yellow cake mix and the marshmallows in the dry storage area had been opened and were placed back without a date of when it was opened. The DM acknowledged that the blue plastic bag containing a food item, pork chops, diced green peppers, were open with no date placed on the bags. Continued interview with the DM revealed that she acknowledged that the diced chicken and the six (6) pieces of fried chicken were in plastic bags that were not securely wrapped and had no dates of when they were opened. Further interview, the DM revealed that she acknowledged that the shredded cheddar cheese, grated parmesan cheese, shredded lettuce, and shredded carrots in the walk-in refrigerator were all opened and not securely wrapped and had no dates of when they were opened on them. The DM does expects dietary staff to securely wrap food items as well as label and date all food items after opening and before placing them for storage. Observation on 09/29/15 at 10:05 a.m. of AA dietary cook revealed that she did not use the three (3) compartment sink correctly in order to sanitize the food processor bowl, lid, and blade to prevent food borne illness. AA was observed pureeing chicken and needed to use the food processor bowl, lid, and blade to puree broccoli and cauliflower. The dietary cook rinsed the food processor bowl, lid, and blade under running water then placed the equipment back on the base of the food processor for use, she did not wash or sanitize the items. AA was questioned regarding her technique and she then took the food processor bowl, lid, and blade and washed the items in soapy water, rinsed under running water, placed the equipment pieces in the sanitizing solution for thirty (30) seconds and then placed on a shelf to dry. Interview on 09/29/15 at 10:10 a.m. with AA dietary cook revealed that she acknowledged that she at first only rinsed the bowl, lid and blade under running water and revealed that the reason why as she was going to use them again to puree the broccoli and cauliflower. AA revealed that she normally washes the bowl, lid, and blade between food items, but could not explain why that was not demonstrated. Continued interview with the dietary cook revealed that she acknowledged that she had the kitchen equipment in the sanitizing solution for thirty (30) seconds. She revealed that items need to be submerged for two (2) to three (3) minutes in the sanitizing solution and confirmed that she did not have the items in the solution long enough. AA could not explain why she did not demonstrate the correct amount of time items need to be in the sanitizer Further interview with the dietary cook revealed that she was told by the Department of Health that kitchen equipment only needed to dipped into the sanitizing solution then air dried. When asked if she knew what the manufactures recommendations were for the use of the sanitizing solution that the facility currently uses and the time kitchen equipment needed to submerge in the solution, AA was not aware of the correct time. Interview on 09/29/15 at 10:15 a.m. with the DM revealed that she acknowledged that the manufactures recommendations for using the sanitizing solution was that items are to be submerged for sixty (60) seconds then air dry. She expects dietary staff to follow the correct procedure for using the three (3) compartment sink. The DM revealed that she had not conducted an in-service on the three (3) compartment sink for some time. Review of the gallon container of Q-Sanitizer revealed that it indicated to submerge items in the sanitizing solution for sixty (60) seconds or longer and air dry. Review of the in-service conducted on 05/28/15 revealed that dietary staff were educated on sanitation, safety, and infection control. An in-service was also conducted on 09/08/15 and revealed that dietary staff were educated on food storage and sanitation. The information that the dietary staff received revealed that all food items were to be covered, labeled, and dated. The in-service also covered the use of chemicals for cleaning and the use of the sanitizing solution for the three (3) compartment sink is to immerse object in the quaternary ammonium solution for one minute.

Based on observations and staff interview, the facility failed to ensure that one (1) power strip was mounted to the wall for one (1) resident (#94) and failed to ensure that medical equipment was plugged into the wall outlet and not the power strip, to provide the resident with a hazard free environment. The total sample size was thirty (30). Findings include: Observations on 09/27/15 at 1:45 p.m., 09/28/15 at 10:00 a.m., and on 09/28/15 at 2:30 p.m. revealed that resident #94 had a power strip on the floor under the his bed. Continued observation of the power strip revealed that there was medical care equipment, such as an oxygen concentrator and a tube feeding pump plugged into the power strip. Interview on 09/29/15 at 2:35 p. m. with Maintenance Director revealed that he acknowledge that the power strip was on the floor under the resident's bed. He expects all power strips to be mounted to the wall. He revealed that he conducts weekly rounds in each resident ' s room to look for issues such as power strips. Continued interview with the Maintenance Director revealed that he was not aware that resident care equipment could not be plugged into a general power strip that the equipment could only be powered by a medical grade power strip.

Based on record review and staff interview, the facility failed to notify the physician of finger stick blood sugar (FSBS) levels greater than 350 five (5) times in October and November 2014 for one (1) resident (#98). The sample size was twenty-nine (29) residents. Findings include: Review of the clinical record for resident #98 revealed a [DIAGNOSES REDACTED]. Review of the FSBS measurements for resident #98 on the October and November Medication Administration Records (MAR) revealed that the BS exceeded 350 on the following dates and times: 1. 10/17/14 at 11:30 a.m. FSBS=373 2. 10/28/14 at 11:30 a.m. FSBS=471 3. 11/03/14 at 11:30 a.m. FSBS=385 4. 11/11/14 at 4:30 p.m. FSBS=365 5. 11/28/14 at 11:30 a.m. FSBS=366 Upon further review it was noted that the correct amount of insulin was given per the sliding scale order, but there was no evidence of documentation that the physician was notified as ordered. Interview with the Director of Nursing (DON) on 12/11/14 at 11:25 a.m., she verified that there was no documentation in the Nurse's Notes that the physician was notified of the blood sugars over 350 on the above dates. Interview with the DON on 12/11/14 at 12:20 p.m., revealed that they had not been able to locate a confirmation fax to the physician's office notifying him of the elevated blood sugars. Review of the facility's protocol for residents on sliding scale insulin noted for a BS of 350 and above, to give ten (10) units of Regular Insulin, call the physician, and fax the office. Review of the facility's Diabetes-Clinical Protocol revealed that the physician will follow up on any acute episodes associated with a significant change in blood sugars or deterioration of previous glucose control.

Based on record review and staff interview, the facility failed to ensure that lab results were obtained in a timely manner for one (1) resident (#101) from a sample of twenty-nine (29) residents. Findings include: Review of the clinical record for resident #101 revealed that he was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of the August Medication Administration Record [REDACTED]. Continued review of the physician's orders [REDACTED]. Review of the resident's labs revealed that blood for a PT/INR, Comprehensive Metabolic Panel (CMP), Lipid panel, C-peptide, and HgbA1C was collected on 08/20/14 at 1:25 a.m., received by the lab on 08/20/14 at 1:42 p.m., but results were not reported to the facility until 08/25/14. Further review of the results revealed that the PT was 44.3 (normal range 11.0-15.0), and the INR was 4.92 ([MEDICATION NAME] for venous [MEDICAL CONDITION] 2.00-3.00), and the glucose level contained in the CMP was 52 (normal 65-100). Further review of the lab results revealed that there was a handwritten notation that the physician was notified on 08/26/14 at 5:00 p.m., and that the resident had been admitted to the hospital on 08/24/14. Review of resident #101's Medication Administration Record [REDACTED]. Review of the Nurse's Notes dated 08/24/14 revealed the resident had suicidal ideation's and was transferred to the hospital for suicidal ideation's, and was re-admitted to the facility on [DATE]. Interview with the Director of Nursing (DON) on 12/10/14 at 12:10 p.m., revealed that the facility's routine for residents on [MEDICATION NAME] was to draw a PT/INR on Monday mornings, and that she was responsible for notifying the physician when the results came back, which was usually on Tuesday or Wednesday. The DON further revealed that the lab drew the blood around midnight on the day it was ordered, and that occasionally lab results would take two (2) or three (3) extra days to come back. The DON verified that resident #101's lab work drawn on 08/20/14 did not come back until 08/25/14, and that the PT/INR results were above the therapeutic range. Continued interview revealed that the resident was sent to the hospital on [DATE], and when she got the lab results back on 08/25/14 she notified the hospital nurse. The DON further revealed that her expectation for getting routine lab results back was twenty-four (24) to forty-eight (48) hours. In addition, the DON verified that the results of a Complete Blood Count (CBC) and PT/INR drawn on 09/08/14 for resident #101 was not reported to the facility until 09/12/14. Interview with the Administrator on 12/11/14 at 2:10 p.m., revealed that after speaking to their laboratory provider, she was told that the lab would have called them if the results were critical, and that the INR was not considered critical until it was 5.00 (the INR result on 08/20/14 was 4.92).

Based on record review and staff interview the facility failed to develop, review and revise a comprehensive care plan based on the resident assessments for three (3) residents (#1, #31, and #42) from a survey sample of thirty-one (31) residents related to feeding tubes and positioning. Findings include: Medical record reviews were conducted on the nine (9) residents identified by the facility with PEG/[DEVICE]s and two (2) residents, Resident #31 and Resident #1, were identified as having no care plan developed for the assessment and care to be provided for the [DEVICE] site. 1. Review of Resident #31's Comprehensive Minimum Data Set ((MDS) dated [DATE] documented under Section K/Nutritional approaches that a feeding tube was used for this resident. Further record review revealed a care plan for this resident had been updated on 6/16/11. Additional review of the care plan revealed interventions listed to address checking the [DEVICE] for placement, residual, and flushes; however, did not include any interventions related to the cleaning, dressing, assessing, and documentation of treatment of [REDACTED]. Review of documentation in the Nurses Notes revealed the [DEVICE] was dressed on 9/14/11 and 9/15/11. Further review of the Nurses Notes for the last six months revealed no documentation/evidence of cleaning, dressing, and monitoring/assessing of the appearance of the [DEVICE] and/or [DEVICE] site. Review of the physician's orders [REDACTED]. Review of Resident #1's Quarterly (MDS) assessment dated [DATE] documented under Section K/Nutritional approaches that a feeding tube was used for this resident. Further record review revealed a care plan for this had been last updated on 8/11/11. Additional review of the care plan revealed that although the [DEVICE] was listed as a concern on the care plan, there were no interventions to address the cleaning, dressing, assessing or documentation of treatment of [REDACTED]. Review of the current physician's orders [REDACTED]. Review of documentation in the Nurses Notes related to the [DEVICE], did not reveal any evidence of the cleaning, dressing and monitoring/assessing of the appearance of the [DEVICE] and/or [DEVICE] site. A skin assessment completed for September 2011 noted a [DEVICE], but did not provide any documentation related to the appearance of the [DEVICE] site. During an interview conducted on 9/15/11 at 12:30 p.m. with the DON and ADON in reference to the above examples and the lack of monitoring/assessing, cleaning, dressing and care of the [DEVICE] and/or site, they concurred with these findings. 2. During observations of Resident #42 on 9/14/11 at 11:00 a.m. and on 9/15/11 at 10:30 a.m., the resident was observed up in the wheelchair with a lap tray on, leaning to the right side with her shoulder and head on the metal part of the right upper back part of the wheelchair. The Minimum Data Set comprehensive assessment dated [DATE] assessed the resident as dependent for positioning and documented functional limitations for range of motion of the upper and lower extremities. Review of the of the Plan of Care for Resident #42 revealed documentation of a problem related to the resident being at risk for episodes of pain and listed as an approach was to assist with positioning;however, there was not a Care Plan for positioning to include use of the adaptive devices nor was this mentioned on the Pain Care Plan. Interview with the Care Plan Coordinator on 9/15/11 at 3:26 p.m., revealed there was no care plan for positioning. 3. Review of the clinical record for resident #42 revealed that the annual Minimum Data Set ((MDS) dated [DATE] assessed the resident as having broken or loosely fitting full or partial dentures (chipped.) The Care Area Assessment Summary revealed that dental care was to be care planned. Review of the resident's care plan revealed that although the resident was care planned for the provision of routine oral care and as needed, the facility failed to develop a comprehensive care plan that met the needs of the resident regarding the broken teeth.

Based on observation, record review and staff interview, the facility failed to ensure chemical cleaning agents were properly stored and electrical equipment was properly secured in the beauty shop and toilets and grab bars were properly secured in the shower room on one (1) of two (2) units. The facility also failed to ensure side rails were used safety to prevent entrapment for one (1) resident (#38) on a sample of thirty-one (31)residents. Findings include: 1. During an observation on 9/12/11 at 2:27 p.m. resident #38 was observed to have the head of bed elevated and the resident was in the bed leaning to the right side. The bed had full side rails in place which were raised. There was a space of at least 12 inches observed between the bottom of the side rail and the top of the mattress. The bed also had a air mattress in place which was easily depressed when pressure was applied. The elbow of the resident was noted to be protruding under the side rail. Review of guidelines provided by the Assistant director of Nurses (ADON) for the use of side rails indicated the space between the rail and the top of the mattress should not be greater that 5 inches. Observation on the resident's bed with Licensed Practical Nurse (LPN) "BB" on 9/15/11 at 11:15 a.m. confirmed when the head of the bed is elevated and the rails are raised, a gap greater than 5 inches existed between the bottom of the rail and the top of the mattress. 2. During the initial tour on 9/12/11 at 10:45 a.m., the beauty salon, located near the dining room, was found unlocked and unattended. Two unlabeled spray bottles were found in a unlocked closet. The liquid in the spray bottles was identified by the administrator as glass cleaner and air freshener. Review of the Material Safety Data Sheets (MSDS) revealed the glass cleaner could cause respiratory tract, eye and skin irritation and could cause central nervous system depression. Continued review revealed that the air freshener could cause eye and skin irritation. Additional observation in the beauty salon at this time revealed a curling iron found in the "on" position sitting on top of an electrical power strip. Interview with the Administrator on 9/12/11 at 10:47 a.m. revealed that a family member had been giving hair care to a resident a few minutes prior to the initial tour. He stated that the salon had been unlocked for the family member. Interview with the Assistant Director of Nursing on 9/15/11 at 10:00 a.m. revealed that forty-five (45) residents in the facility were assessed as independently mobile with cognitive impairment. 3. Observations during environmental tour on 9/14/11 at 2:00 p.m. of the South Hall common shower area revealed the grab bar next to the toilet and the base of the toilet were loose. The toilet base could be moved 2 inches from side to side. The Administrator was notified at that time of the observation.

Based on observations, record review, resident and staff interviews, it was determined that the facility failed to provide a restricted fluid intake of 1200cc as directed by the care plan for one (1)resident ("Z") from a survey sample of thirty-one (31) residents. Findings include: Review of the care plan revealed that the resident was to have fluids restricted to 1200cc per day. An interview with the Dietary Manager on 9/14/2011 at 1:50 p.m. revealed that the resident received 6 ounces (180cc) of fluid three (3) times a day with each meal with a total intake with meals on 540cc. Interview with Licensed Practical Nurse (LPN) "ZZ " at 2:05 p.m. and LPN "YY" at 3:50 p.m., revealed intake of fluids that were recorded on the Medication Administration Record (MAR) were the amount of fluid administered with the medication pass only. Additional review of the Total Intake and Output Record revealed when fluids were added to the amounts recorded in the MAR the resident received in excess of the 1200 cc allowed.

Based on observations, record review and staff interviews the facility failed to provide the necessary care and services for one (1) residents (#42) regarding positioning needs and one (1) resident ("Z") with Physician order [REDACTED]. Findings include: 1. During observations of Resident #42 on 9/14/11 at 11:00 a.m. and on 9/15/11 at 10:30 a.m., the resident was observed up in the wheelchair with a lap tray leaning to the right side with her shoulder and head on the metal part of the right upper back part of the wheelchair. The Minimum Data Set comprehensive assessment dated [DATE] assessed the resident as dependent for positioning and documented functional limitations for range of motion of the upper and lower extremities. An Occupational Therapy Progress Report for the period of 8/24/11 through 8/30/11 for a treatment [DIAGNOSES REDACTED]. This document also indicated that adaptive equipment included right lateral support and a pommel cushion. Page two (2) of the Updated Plan of Treatment was signed by the Occupational Therapist on 9/06/11,at which time she was discharged from therapy, and documented caregiver education provided relative to proper implementation of the functional maintenance program and proper use of the wheel chair adaptive equipment. During interview with the Restorative Certified Nursing Assistant on 9/15/11 at 10:38 a.m., when asked about a right side bolster/adaptive equipment for her posture, she had no knowledge of the right side bolster/positioning device. During interview with the Occupational Therapist on 9/15/11 at 10:50 a.m., in the resident's room while she was up in the chair she concurred with the surveyor that the resident was in need of proper/better positioning in her wheelchair and also agreed that the Occupational Therapy assessment of 9/06/11 documented she should have an adaptive side bolster in her wheelchair. 2. Observations on 9/14/2011 at 9:30 a.m., 10:30 a.m., 11:15 a.m. and 2:02 p.m. revealed that resident "Z" had a pitcher of ice at the bedside. Review of the September 2011 Physicians Order revealed that the resident was to have a restricted fluid intake of 1200 cc a day. Interview with nurse " ZZ " at 3:00 p.m. on 9/14/2011 revealed the resident was not to have an ice pitcher at the bedside. An interview with the Dietary Manager on 9/14/2011 at 1:50 p.m. revealed that the resident received 6 ounces (180cc) of fluid three (3) times a day with each meal with a total intake with meals on 540cc. Interview with Licensed Practical Nurse (LPN) "ZZ " at 2:05 p.m. and LPN "YY" at 3:50 p.m., revealed intake of fluids that were recorded on the Medication Administration Record (MAR) were the amount of fluid administered with the medication pass only. Additional review of the Total Intake and Output Record revealed when fluids were added to the amounts recorded in the MAR the resident received in excess of the 1200 cc allowed. A sample on the daily intakes were as follows (not all inclusive). 9/13/11: 1400 cc 9/12/11: 1700 cc 9/11/11: 1340 cc 9/09/11:1780 cc 9/08/11:1460 cc 9/07/11:1980 cc 9/06/11:1460 cc

Based on record review and staff interview the facility failed to ensure that residents who are fed by gastrostomy tube receives the appropriate treatment and care to prevent the potential for complications in tube feedings for two (2) residents (#1 and #31) from a survey sample of thirty-one (31) residents. Findings include: Medical record reviews were conducted on the nine (9) residents identified by the facility with PEG/[DEVICE]s and two (2) residents, Resident #31 and Resident #1, were identified as having no evidence the facility had provided treatment and care to the [DEVICE] site. 1. Review of Resident #31's Comprehensive Minimum Data Set ((MDS) dated [DATE] documented under Section K/Nutritional approaches that a feeding tube was used for this resident. . Review of documentation in the Nurses Notes revealed the [DEVICE] was dressed on 9/14/11 and 9/15/11 by facility staff due to leakage of the [DEVICE]. Further review of the Nurses Notes for the last six months revealed no documentation/evidence of staff providing care, treatment, and monitoring of the [DEVICE] and/or [DEVICE] site. Review of the physician's orders [REDACTED]. 2. Review of Resident #1's Quarterly (MDS) assessment dated [DATE] documented under Section K/Nutritional approaches that a feeding tube was used for this resident. Review of the physician's orders [REDACTED]. Review of documentation in the Nurses Notes related to the [DEVICE] as far back as May 2011 , did not reveal any evidence of the facility staff routinely cleaning, dressing and/or monitoring/assessing the appearance of the [DEVICE] and/or [DEVICE] site. A skin assessment completed for September 2011 noted a [DEVICE], but did not provide any documentation related to the appearance of the [DEVICE] site. During an interview conducted on 9/15/2011 at 12:30 p.m. with the DON and ADON revealed there was no documentation regarding monitoring/assessing or treatment for [REDACTED].

Based on record review and facility document review, the facility failed to ensure that one (1) resident (#1), on the survey sample of eight (8) residents, was transferred in accordance with the resident's written plan of care. This resulted in Resident #3 experiencing a right-leg fracture, thus representing actual harm to the resident. Findings include: Record review for Resident #3 revealed a Care Plan entry of 02/12/2009 which specified the use of two (2) staff for transfers at all times. A Nurse's Note of 03/28/2009 at 10:00 a.m. documented that the resident was observed with swelling and pain of the right knee, and documented that the physician was called and gave an order to transfer the resident to the hospital. A subsequent Nurse's Note of 03/28/2009 at 2:30 p.m. documented that the resident had returned to the facility from the hospital with a [DIAGNOSES REDACTED]. In a 03/31/2009 written statement by Certified Nursing Assistant (CNA) "BB", this documented that on 03/28/2009, she had transferred Resident #3 with the Hoyer lift without any assistance, and that during the transfer, the resident had hit his/her leg against the bed. The CNA further documented that when she laid the resident down, she noted swelling to the resident's right leg. Cross refer to F323, example 1, for more information regarding Resident #3.

Based on record review, staff interview, and facility document review, the facility failed to ensure that two (2) residents (#s 1 and 3), on the survey sample of eight (8) residents, received adequate supervision during transfer and/or the provision of care. This resulted in Resident #3 experiencing a right-leg fracture, thus representing actual harm to the resident. Findings include: 1. Record review for Resident #3 revealed a 02/10/2009 Minimum Data Set (MDS) assessment which indicated that the resident was totally dependent on staff for transfers. A Care Plan entry of 02/12/2009 specified the use of two (2) staff for transfers at all times. A Nurse's Note of 03/28/2009 at 10:00 a.m. documented that the resident was observed with swelling and pain of the right knee, and documented extreme heat on the knee. This Note documented that the physician was called and gave an order to transfer the resident to the hospital emergency room for evaluation. A Nurse's Note of 03/28/2009 at 10:25 a.m. documented that the transport service had arrived and transported the resident to the hospital. A subsequent Nurse's Note of 03/28/2009 at 2:30 p.m. documented that the resident had returned to the facility from the hospital with a splint on the right leg and a [DIAGNOSES REDACTED]. Review of the facility's investigation into this resident's injury revealed a 03/31/2009 written statement by Certified Nursing Assistant (CNA) "BB". In this statement, CNA "BB" documented that on 03/28/2009, she had transferred Resident #3 with the Hoyer lift without any assistance, and that during the transfer, the resident had hit his/her leg against the bed when the CNA was attempting to turn the resident around and place him/her in the Geri-Chair. The CNA further documented that when she laid the resident down, she noted swelling to the resident's right leg. 2. Record review for Resident #1 revealed a 01/09/2009 MDS assessment which indicated that the resident was totally dependent on staff for all activities of daily living. A Resident Incident Report dated 01/29/2009 documented that a nurse had been summoned to the shower room by CNA "CC" to find Resident #1 lying on his/her right side on the concrete floor of the shower room. This Report documented that the resident was assessed at that time, with no injuries noted. A 01/29/2009 Incident/Accident Follow-up Investigation Report to the incident referenced above documented that Resident #1 had been placed on the shower bed when a screw came out and the resident fell on the floor of the shower room. In a 01/29/2009 written statement, CNA "DD" documented that as she was drying Resident #1 after a shower, the resident, who was lying on a shower bed, slipped to the left. The CNA further documented that the pin holding the bed rail then popped loose, and the resident fell . During an interview conducted on 04/06/2009 at 10:30 a.m., the Administrator stated that facility policy specified for two (2) staff members to be present during the provision of care for Resident #1, but acknowledged that only one (1) CNA was attending to Resident #1 at the time of the resident's 01/29/2009 fall.

Based on record review and staff interview the facility failed to notified the resident's attending physician of blood glucose levels which would require medical intervention. This affected two (2) residents (#10 and #11) from a sample of eighteen (18) residents. The findings include: 1. Record review for resident #10 revealed sliding scale blood glucose monitoring was to be conducted four (4) times daily. The resident's insulin administration was based on this blood glucose monitoring. A review of the resident's Medication Administration Records (MAR) on 2/08/09, 2/09/09, 2/26/09 and 3/05/09 recorded the resident's blood glucose results were below 60. Review of the clinical record revealed the physician had not been notified. An interview with the facility's Director of Nursing (DON) on 3/17/09 at 9:00 a.m. confirmed that the resident's physician was not notified about the low blood sugar results. 2. Record review for resident #11 revealed sliding scale blood glucose monitoring was to be conducted two (2) times per day. The resident's insulin dosage was based on this blood glucose monitoring. A review of the resident's MAR indicated [REDACTED]. An interview with charge nurse LPN "AA" on 3/18/09 at 1:15 p.m. confirmed that physician was not notified about the high blood sugar results. The facility's Diabetic Care Protocol policy directed that the resident's physician be notified if the blood sugar results were less than 60 or more than 400.

Based on medical record review and staff interview, the facility failed to ensure that one (1) resident (#1), in a survey sample of ten (10) residents, was free of a significant medication error, regarding the failure to administer the prescribed dose of [MEDICATION NAME] intended to address the resident's extrapyramidal symptoms resulting from antipsychotic drug therapy. This represented actual harm, as the resident's extrapyramidal symptoms subsequently worsened. Findings include: Record review revealed a Nurse's Note of 09/05/2008 which documented that the resident had been admitted to the facility. A 09/06/2008 physician's orders [REDACTED]. The October and November 2008 Medication Records documented that the resident received doses of [MEDICATION NAME] every six (6) hours as ordered through 11/13/2008. An 11/13/2008 Nurse's Note at 12:25 p.m. documented that a physician's orders [REDACTED]. A Nurse's Note of 11/19/2008 at 11:10 a.m. documented that due to the resident's behavior, the physician had ordered to restart [MEDICATION NAME] 1 milligram every six hours, and to continue the [MEDICATION NAME] therapy. The November Medication Record documented that [MEDICATION NAME] therapy was discontinued on 11/13/2008 and restarted on 11/19/2008 as ordered, and that [MEDICATION NAME] therapy was initiated and administered as ordered from 11/13/2008 through 11/30/2008. The December 2008 Medication Record documented that the [MEDICATION NAME] and [MEDICATION NAME] therapy were administered as ordered from 12/01/2008 through 12/18/2008. Then, a 12/18/2008, 1:10 p.m. Nurse's Note documented that new physician's orders [REDACTED]. The December 2008 Medication Record documented that the [MEDICATION NAME] was changed to be administered on an as-needed basis, and the dose of [MEDICATION NAME] was increased to 75 milligrams twice daily, on 12/18/2008 as ordered, and documented that the resident received these drugs as ordered through 12/31/2008. A Nurse's Note of 12/30/2008 at 11:20 a.m. documented that the resident was beginning to have a tic with the shoulders and that the shoulders were moving in an up-and-down motion. This Note documented that the physician was notified. A 12/30/2008 Physician's Interim/Telephone Order specified for the resident to receive a one (1) milligram dose of [MEDICATION NAME] each night at bedtime. The January 2009 Medication Record documented that the resident received both a 1 milligram dose of [MEDICATION NAME] at bedtime, and 75 milligram doses of [MEDICATION NAME] twice daily, as ordered from 01/01/2009 through 01/07/2009. A Nurse's Note of 01/04/2009 documented that a jerking motion was noted to the resident's upper extremities, and a Nurse's Note of 01/07/2009 at 9:00 a.m. documented that the resident continued to have a tick or twitch with the shoulders. A physician's orders [REDACTED]. A Nurse's Note of 01/08/2008 at 1:00 p.m. documented that staff had spoken with the physician's assistant about the resident's twitching, and the physician's assistant had stated that the twitching was a side effect of the drug. Thus, a 01/08/2009 Physician's Interim/Telephone Order increased the frequency of administration of [MEDICATION NAME] to one (1) milligram twice daily, thus increasing the total daily dose of [MEDICATION NAME] to two (2) milligrams. However, the January 2009 Medication Record documented that the resident continued to receive one (1) milligram of [MEDICATION NAME] only at bedtime from 01/08/2008 through 01/28/2009, yielding a total daily dose of only one (1) milligram of [MEDICATION NAME], instead of two (2) milligrams as ordered. A Nurse's Note of 01/12/2009 at 9:00 p.m. documented that the jerking motion was still noted to the resident's upper extremities. A Nurse's Note of 01/22/2009 documented that the resident seemed to be getting worse with symptoms, that the neck was continuing to roll, and that the speech was getting harder to understand. A Nurse's Note of 01/23/2009 at 6:00 a.m. documented that the resident continued to have an upper extremity jerking motion. A Nurse's Note of 01/26/2009 at 1:40 p.m. documented that the resident's speech was not clear, and that the resident continued to move the mouth fast as if he/she was chewing, but nothing was noted in his/her mouth. During an interview conducted on 02/05/2009 at 10:15 a.m., the Administrator and the Director of Nursing acknowledged an error in the administration of the resident's [MEDICATION NAME].