Every finding on record at River Garden Hebrew Home for the Aged

Based on kitchen and nourishment room observations, staff interviews, and a review of the facility's policies and procedures, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect more than a few residents who consumed foods from the facility. The facility failed to properly store, label and date food items, remove expired food items, and clean/maintain essential kitchen equipment used to prepare meals in sanitary condition. Food handling risks may include food beyond safe use by dates (including, but not limited to foods that have been opened but were not labeled, etc.)The findings include:On 07/27/2026 at 11:46 AM, an observation of the reach-in cooler adjacent to the kitchen sink revealed one container of tomato juice with a best by date of 02/08/2026. The juice was removed from the reach-in cooler, and the Director of Dining was informed.On 07/29/2026 at 11:37 AM, the kitchen's flat-top grill was observed with food residue and debris collected along the sides of the grill, on the wall behind the grill, and around the wheels of the grill.On 07/29/2026 at 12:56 PM, observations of the facility's T1 Pantry revealed two opened bags of bread with no labels or date marking. During the same tour at 1:00 PM, one box of Raisin Bran cereal with a best by date of 05/28/2026 was observed in the T2 Pantry. At 1:56 PM, observations of the Memory Care Pantry revealed five opened bagged loaves of bread and one opened bag of hotdog buns with no labels or date marking. Observations of two open paper bags containing cookies revealed no labels or date marking. In the same pantry, one bottle of Diet Cola with a best by date of 05/11/2026 was observed. Multiple portioned containers and one large open container of brown sugar were observed with no labels or date marking. During the same tour at 2:16 PM, an observation of the R2 Pantry revealed two opened bagged loaves of bread and two opened bags of cookies with no labels or date marking. Additionally, two bottles of chocolate flavored syrup were observed with best by dates of 2025.During an interview conducted on 07/30/2026 at 12:53 PM, Dining Services Aide M stated dining staff members were responsible for cleaning their assigned pantries, checking for expired items, and ensuring that all food items and drinks were sealed and labeled. If a food or drink item was found expired or opened without proper labeling, that item should be thrown away.During an interview conducted on 07/30/2026 at 2:50 PM, Dietary Aide L stated dining staff members, including dietary aides, were assigned pantries during each of their shifts. They were then responsible for cleaning their assigned pantry, along with disposing of any expired or opened and unlabeled items.During an interview conducted on 07/30/2026 at 3:10 PM, the Director of Dining confirmed that each unit pantry was assigned to a staff member every day. This staff member was then responsible for checking all items for expired or opened and unlabeled food items or drinks. These items were to be discarded. Additionally, the Director of Dining stated the flat-top grill was to be deep cleaned at the end of each day.During an interview conducted on 07/30/2026 at 9:11 AM, the Chief Executive Officer (CEO) stated there was no policy related to food safety and sanitation with regard to cleaning equipment or labeling opened items. The CEO provided the facility's undated Equipment Deep Cleaning List and undated Food Dating Procedure.A review of the facility's undated procedure titled Food Dating Procedure revealed that all prepared, opened, and potentially hazardous food items stored in refrigerators shall be clearly labeled with the date opened. Additionally, food may be stored for a maximum of 3 calendar days, including the day opened or prepared. At the end of day 3, any remaining products should be discarded.A review of the facility's undated procedure titled Equipment Deep Cleaning List revealed that the kitchen grill was scheduled to be cleaned daily.Reference: FDA Food Code 2022. https://www.fda.gov/media/184685/download?attachment; (Accessed on 8/7/2026) Annex 5 - C. Intervention Strategies for Achieving Long-Term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 566. Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.According to USDA, Food Safety, A Need-to-Know Guide for Those at Risk. https://www.fsis.usda.gov/sites/default/files/media_file/2021-04/at-risk-booklet.pdf (Accessed on 8/12/2026). A Best if Used By/Before date indicates when a product will be of best flavor or quality. A Use-By date is the last date recommended for the use of the product while at peak quality. The date has been determined by the manufacturer of the product. Foodborne Illness in the United States: When certain disease-causing bacteria, viruses, or parasites contaminate food, they can cause foodborne illness. Another word for illness-causing bacteria, viruses, or parasites is pathogens. Foodborne illness, often called food poisoning, is an illness that comes from a food you eat. The food supply in the United States is among the safest in the world, but it can still be a source of infection. According to the Centers for Disease Control and Prevention (CDC), foodborne pathogens cause up to 48 million illnesses, 128,000 hospitalizations, and 3,000 deaths in the United States each year. Many of these people are children, older adults, or individuals with weakened immune systems who may not be able to fight infection normally. Since foodborne illness can be serious-or even fatal-it is important for you to know and practice safe food-handling behaviors to help reduce your risk of getting sick from contaminated food. Who Is at Risk? Certain groups of people are more susceptible to foodborne illness than others. They are more likely to get sick from contaminated food, and if they do get sick, the effects are often much more serious. Those at increased risk include: Cancer patients Diabetes patients HIV/AIDS patients Older adults People with autoimmune diseasesReference: USDA (United States Department of Agriculture) Food Safety and Inspection Service https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/shelf-stable-food (Accessed 8/13/2026) A best by label means the food may lose flavor or texture, but serving questionable or older inventory in a commercial care facility violates safety expectations.Reference: Gray & [NAME] https://www.grayandwhitelaw.com/library/nursing-home-food-safety-negligence.cfm (Accessed 8/13/2026) Some of the potential problems that could lead to food-related illnesses for nursing home residents include the following: Expired food. Anyone can get hurt by negligent food handling. However, people over the age of 65 are particularly susceptible to dangerous health complications because of weakened immune systems, chronic diseases, and age. Nursing home residents who suffer from a foodborne illness may incur medical costs, physical pain, and emotional suffering.

Based on observations, interviews, record reviews, and a review of the facility's policies and procedures, the facility failed to implement the person-centered care plans for two (Residents #158 and #13) of three residents reviewed for seizure precautions out of eight residents on seizure precautions involving pool noodles. Failure to follow resident care plans can result in physical and mental decline, including injuries from striking limbs against bed rails during seizure activity.The findings include:1.On 7/28/2026 at 1:20 PM, an observation was made of Resident #158 in her room lying in bed. No padding was observed on the top two half-rails of her bed. On 7/29/2026 at 1:44 PM, an observation was made of Resident #158 in her room lying in bed with her eyes closed. No padding was observed on the top two half-rails of her bed.On 7/29/2026 at 2:45 PM, in an interview with Resident #158, she stated her bed did have Styrofoam pool noodles on both of the top bed rails when she was first admitted to the facility. She said she was not aware of who removed them, or when/why they were removed. During the interview she stated she thought the padding was helpful and prevented bruises on her hands she believed to have obtained from hitting the bed rails in her sleep.A review of Resident #158's medical record revealed an admission date of 6/27/2025 and a diagnosis of seizures and spinal stenosis (narrowing of the spinal column spaces placing pressure on the nerves that travel through it). A review of the resident's most current Comprehensive Minimum Data Set (MDS) assessment, dated 6/18/2026, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. A review of Resident #158's physician's orders revealed an active order, placed on 6/27/2025, for seizure precautions: Styrofoam pool noodle padding on top two half-rails for safety.A review of the most recent Bed Rail Assessment, signed by a registered nurse as completed on 3/17/2026, revealed that top half-rails were indicated for safety, mobility and/or comfort. The assessed indication for the bed rails was to assist the resident with repositioning in bed, assisting with getting in and out of bed, and providing balance when standing.A review of Resident #158's Care Plan revealed a focus area for History of Pressure Area to Left Buttock (initiated on 10/8/2025) with a target date of 9/16/2026. Interventions included: Pad bed rails, wheelchair arms. Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface.2.On 7/30/2026 at 10:40 AM, an observation was made of Resident #13 in her room lying in bed. No padding was observed on the top two half-rails of her bed.A review of Resident #13's medical record revealed an admission date of 1/3/2026 and a diagnosis of epilepsy.A review of the resident's most current Quarterly MDS assessment, dated 7/6/2026, revealed a BIMS score of 15 out of 15 possible points, indicating intact cognition. A review of the resident's physician's orders revealed an active order, placed on 1/3/2026, for seizure precautions: Styrofoam pool noodle padding on top two half-rails for safety.A review of the most recent Bed Rail Assessment, signed by a registered nurse as completed on 6/30/2026, revealed that top half-rails were indicated for safety, mobility and/or comfort. The assessed indication for the bed rails was to assist the resident with repositioning in bed, provide the resident with a feeling of comfort and security, define the parameters of the bed, assist with getting in and out of bed, and provide balance when standing.A review of Resident #13's Care Plan revealed a focus area for Seizure Disorder (initiated on 1/6/2026) with a target date of 9/27/2026. Interventions included: Pool noodles to top-half bedrails to protect against seizures.On 7/30/2026 at 11:07 AM, an interview was conducted with Certified Nursing Assistant (CNA) J who stated some of the residents had Styrofoam pool noodles on their bed rails and they were used as protective padding.On 7/30/2026 at 11:24 AM, an interview was conducted with Licensed Practical Nurse (LPN) K who stated she had been employed by the facility for more than a year. She further stated padding on bed rails, such as Styrofoam pool noodles, was a seizure precaution the facility utilized. She stated she did not remember Resident #158 ever having Styrofoam pool noodles on her bed rails.On 7/30/2026 at 2:35 PM, an interview was conducted with Nurse Manager A who stated Resident #158 did have Styrofoam pool noodles on her bed at some point, but she was unsure of whether or not the seizure precautions were removed from Resident #158's bed. When asked why the Styrofoam pool noodles were removed from the bed rails, despite an active physician's order, Nurse Manager A stated Resident #158 may have removed them herself.On 07/30/2026 at 3:12 PM, an interview was conducted with the Director of Nursing (DON) who stated her expectation was that facility staff follow all physicians' orders as written.A review of the facility's policy titled [facility name] Policies & Procedures, Pharmacy Department, Orders: Physician's PP5200.302 (dated 2/11/2026), revealed:Policy: .admission orders are entered into the electronic medical record by authorized [facility name] staff and providers. All physicians' orders will be reviewed by the Medical Staff as needed and during the providers' visit.

Based on observations, staff interview, and facility policy and procedure review, the facility failed to follow proper sanitation, food distribution and service practices with the potential to affect all of the residents in the facility. The facility failed to ensure dietary staff implemented the policy for for hand hygiene, disposable glove use, and proper sanitation practices in the kitchen during the lunch meal service. Hand hygiene and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: On 04/28/2021 at 12:00 PM, a second observation of the lunch meal service in the kitchen was conducted. At 12:07 PM, Employee F, Dining Staff, was observed doffing her gloves to grab nectar from the refrigerator and did not wash or sanitize her hands prior to donning a new set of gloves. At 12:08 PM, Employee F grabbed a coffee cup and handed it to another employee. She doffed her gloves and did not wash her hands or put on new gloves. Employee F then grabbed a thermometer and sanitizer wipes for the thermometer and tested the food, without gloves. She then donned new gloves without washing or sanitizing her hands. During an interview with the Dining Service Director on 04/28/2021 at 12:10 PM, he was asked about staff hand hygiene for serving food on the second-floor memory care unit. He stated that staff hand washing was to be done in the sink and pointed to the sink next to the tray line. The sink was blocked and covered by the lids that cover the food on the tray line. Review of the facility policy on hand hygiene revealed it read: All direct and indirect caregivers will maintain standards for hand care that will provide an environment that limits exposure to skin integrity issues as well as infection control issues within River Garden. It is up to each health care worker, to become a model of prevention. This includes not wearing artificial nails, keeping nails trimmed and neat, wearing personal protective equipment (PPE), and washing hands when necessary. Care staff affected by this policy includes Nursing, Life Enrichment, Environmental Services, Dietary, Rehabilitative Services and any other department that provides direct care.

Based on observations, interviews, record reviews and policy and procedure review for oxygen administration, the facility failed to ensure that two (Residents #56 and #32) of ten residents on oxygen therapy, received the correct number of liters of oxygen ordered by the physician, in a total sample of 39 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: 1. On 4/27/21 at 10:36 AM, Resident #56 was observed lying in bed with oxygen via nasal cannula. An observation of her oxygen tank revealed the flow meter was above the maximum 5 liters (L) level for the concentrator (photographic evidence obtained). An interview was conducted with Resident #56 on 4/27/21 at 10:38 AM concerning how much oxygen she was supposed to receive. She stated, My oxygen rate should be at 6 liters/minute (L/min). A review of Resident #56's medical record noted an admitted [DATE] and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders revealed, Oxygen at 6 L/min via nasal cannula to keep saturation at 92%. An interview was conducted with Employee A, Licensed Practical Nurse (LPN) on 4/28/21 at 2:30 PM concerning the oxygen order for Resident #56. She confirmed that Resident #56 had orders for 6 L/min of oxygen to maintain saturation at 92%. When asked what the oxygen concentrator was reading, she stated 6 L. When asked how she could be sure the resident was receiving 6 L/min when the concentrator's maximum flow was 5 L, she stated that when the dial was all the way at the top of the meter, then the flow was 6 L. When asked if there was a mark indicating 6 L, Employee A confirmed that there were no markings indicating the oxygen level was at 6 L. An interview was conducted with Employee B, Registered Nurse (RN)/Unit Manager on 4/28/21 at 02:39 PM concerning the oxygen order for Resident #56. She confirmed that Resident #56 had orders for 6 L/min of oxygen to maintain saturation at 92%. When asked how she ensured that the concentrator with a 5 L maximum provided the oxygen flow at 6 L as ordered, she said, When the staff dial the meter all the way up, then we assume the concentration is at 6 L. An interview was conducted with Director of Nursing (DON) on 4/29/21 at 10:45 AM concerning the oxygen order for Resident #56. She confirmed that the 5 Liter concentrator used by Resident #56 had a maximum flow of 5.5 L/min. However, the flow meter had the capability of going above the maximum level of 5.5 L, hence the resident could be receiving more oxygen. When asked how much oxygen was contained while the dial flow meter was above the 5.5 L, she stated that it could not be determined. She also added that when the dial flow meter was past the maximum level, oxygen was dispensed at a high pressure. A review of the Invacare Perfecto2 Oxygen concentrator user manual read, Do not set the flow above the RED ring. An oxygen flow greater than 5 L/min will decrease the oxygen concentration. 2. On 4/28/21 at 3:26 PM, Resident #32 was observed sitting in a recliner in her room with oxygen via nasal cannula. Her oxygen flow was set at 3 L/min. An interview was conducted with Resident #32 on 4/28/21 at 3:28 PM concerning how much oxygen she was supposed to receive. She stated, The oxygen has always been at 3 liters. An interview was conducted with Employee C, Registered Nurse (RN) on 4/28/21 at 3:45 PM. She confirmed that Resident #32's oxygen was on 3 liters and adjusted the flow to 2 liters. A review of Resident #32's medical record noted an admitted [DATE] and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders revealed, Oxygen humidified via nasal cannula at 2 L/min routine to keep saturation greater than 92%. A review of nursing progress notes for Resident #32, dated 4/27/21 at 1:31 AM, revealed continuous oxygen at 3 L/min via nasal cannula in progress. On 4/22/21 at 3:36 AM, the nursing note revealed, able to verbalize needs without difficulty, continuous oxygen at 3L/min via nasal cannula in progress, no respiratory discomfort observed. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/29/21 at 10:53 AM. She confirmed that Resident #32's was receiving the wrong oxygen flow rate and she should have been receiving 2 L/min. A review of the facility policy and procedure entitled Oxygen Administration read: To maintain basic life support to all residents when needed, oxygen available to all residents and is administered by a physician's order. Trained CNAs under the supervision of the charge nurse may switch the oxygen from portable tank to concentrator and vice- versa, adjust regulator according to the physician's order and fill humidifier bottle with distilled water. Trained CNAs will report immediately to the charge nurse any identified issues.

Based on observations and interviews, the facility failed to store refrigerated medications within appropriate temperatures for one (Rehab Two Unit) out of five medication refrigerators in the facility. Failing to properly store medication can change its molecular form, potentially resulting in decomposition of the medication. This can change the medication's potency and/or result in new or different effects. The findings include: On 4/11/2019 at 2:36 PM, and observation was made of the medication room on the Rehab Two Unit. Upon review of the refrigerator temperature log, the refrigerator temperature had been recorded at below the normal range (Normal Range 36 to 46 degrees) on the following dates: 1/3/19 - 34 degrees 1/14/19 - 34 degrees 1/23/19 - 30 degrees 1/24/19 - 32 degrees 1/30/19 - 32 degrees 2/9/19 - 34 degrees 2/10/19 - 34 degrees 2/21/19 - 34 degrees 2/22/19 - 32 degrees 2/28/19 - 32 degrees 3/5/19 - 34 degrees 3/23/19 - 34 degrees 3/29/19 - 32 degrees 3/30/19 - 34 degrees 3/31/19 - No temperature documented 4/4/19 - 30 degrees 4/5/19 - 32 degrees 4/6/19 - 32 degrees 4/7/19 - 32 degrees 4/8/19 - 32 degrees 4/9/19 - 32 degrees 4/10/19 - 30 degrees On 4/11/2019 at 2:38 PM, an interview was conducted with Employee N, Registered Nurse (RN), and she stated that she was not sure what the refrigerator temperature was supposed to be, because the night shift staff dealt with that. On 4/11/2019 at 3:15 PM, an interview was conducted with Employee O, RN, regarding what the facility's practice was if the refrigerator temperatures were below the normal temperature range, and she stated that they were supposed to notify Plant Operations and they could fix the temperature remotely. She pointed to the refrigerator, and stated that the antenna looking device on the side of the refrigerator was a remote device for temperature control. She was then showed the logs from the Rehab Two Unit, and she stated that it was unacceptable for the temperature to run below the normal range for five (5) days, and no one do anything or notify Plant Operations. On 4/11/2019 at 3:19 PM, an interview was conducted with Unit Manager for the Rehab Two Unit regarding the refrigerator temperatures running below the normal range, and she stated that environmental services should have been contacted, so they could come to the floor and fix it. She further stated that the nursing staff were supposed to notify environmental services immediately when the temperature was too low. She was asked what would be done about the insulin and other medication stored in the refrigerator, and she stated that she would notify the pharmacy. A review was conducted of the facility's policy and procedure on the front of the temperature log binder on the locked unit (photographic evidence obtained), and it revealed the following: Nursing Services Manual of Policy and Procedures Part PP5200.188 Temperature Recording of Medication Refrigerator Policy: The 77-1 Charge Nurse will be responsible for checking and recording the temperature of the medication refrigerator in the medication room nightly. Purpose: To insure the medications are stored at the appropriate temperatures. Procedure: 1. Record the temperature of the medication refrigerator on the log next to the corresponding date. 2. Notify Nursing Supervisor when temperature controls are below 34 degrees F (Fahrenheit) or above 46 degrees F (2-8 degrees C(Celsius)). 3. Nursing Supervisor will complete a maintenance requisition form notifying Plant Operations of temperature variations. 4. The Nursing Supervisor will determine if medications need to be removed to another refrigerator should the temperature fall below 36 degrees F or above 46 degrees F (2-8 degrees C). History: Rev. 3/10/04 CT, Revised (format only) 7/27/05 et

Based on observation, facility policy review, record review, and staff, resident and family interviews, the facility failed to provide pain management services consistent with professional standards of practice for one resident (#157) observed during provision of wound care out of five residents with in-house acquired wounds. Resident #157 was not reassessed for pain during wound care when verbal and non-verbal indicators of pain were expressed. Facility staff continued with wound care in spite of expressions of pain. Resident was not consistently medicated for pain prior to treatment as ordered, and no attempt was made to re-evaluate the resident's pain, and confer with the physician to determine whether another pain medication might be more effective. Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The findings include: A record review for Resident #157 revealed physician's treatment orders as follows: 1. On 4/8/2019: Wound to right malleolus (ankle): Cleanse wound to right malleolus with normal saline, pat dry, and apply [MEDICATION NAME] Blue Classic, then Xtrasorb, secure with Kerlix and tape. Change dressing on Monday, Wednesday, and Friday on 7/3 shift. 2. On 3/12/2019: Wound to left calcaneus (heel): Apply [DEVICE] (Vac) continuously at 125 MM/HG (millimeter of mercury) pressure, restart bridging with all wounds, use black foam when replacing dressing. Change dressing Monday, Wednesday, and Friday. 3. On 12/26/2018: [MEDICATION NAME]-[MEDICATION NAME] tablet 325 mg-5 mg (milligrams), one tablet by mouth daily 30-60 minutes prior to dressing change. The resident had a significant change Minimum Data Set (MDS) assessment on 3/18/2019. It revealed the resident had three Stage 4 pressure ulcers. The resident had a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 points, indicating severe cognitive impairment. The resident's care plan revealed Alteration in Comfort: Pain related to pressure wounds, bilateral lower stents, and bilateral knee contractures with [DIAGNOSES REDACTED]. This care plan was last reviewed on 3/12/2019. The goal was to alleviate pain whenever present through interdisciplinary team interventions daily and with collaboration. Approaches were to assess for verbal and non-verbal cues for pain. Medicate for pain as needed. Administer pain medication before wound dressing change as ordered. Re-evaluate efficacy of treatment. Note and report onset of acute or unrelieved pain. Apply bilateral heel boots at all times. An observation of the treatment to all wounds was conducted on 4/10/2019 at 10:30 AM. Employee A (nurse assigned to Resident #157), Employee B (the Assistant Director of Nursing), Employee C (the Unit Manager), and the Wound Care Doctor (WCD) were present. Employees A and C were positioning the resident in bed, and when they touched the resident's feet, the resident yelled oh!. The WCD stated she had been taking care of this resident since her admission to this facility. She stated the resident had [MEDICAL CONDITION] (MRSA) in her foot and previously received rounds of intravenous antibiotics. On 4/10/2019 at 10:32 AM, Employee A was removing the old dressing from the resident's left foot. The old dressing was sticking to the resident's wound. The resident squinted her eyes and stiffened her body as Employee A pulled off the old dressing. Employee B stated the wound vac (vacuum) was still running and she would turn it off. After the old dressing was removed, Employee B measured the wound. On 4/10/2019 at 10:38 AM, Employees A, B and C were asked how they addressed this resident's pain. Employee A stated that she pre-medicated the resident with [MEDICATION NAME] (pain medication) about an hour before the procedure, and there was a physician's orders [REDACTED]. None of the staff present (Employees A, B and C), or the WCD reassessed the status of the resident's pain at this time. On 4/10/2019 at 10:44 AM, Employee A, after cleansing the wound, applied a clear adhesive dressing around the left calcaneus (heel), and applied the black sponge directly to the wound bed. The resident exclaimed, Eww!. The resident also displayed non-verbal evidence of pain by grimacing and tensing her body. Employee C was holding the black foam sponge on the resident's wound while Employee A was preparing the final dressing to go over the wound. On 4/10/2019 at 10:51 AM, the resident continued grimacing for approximately 10-15 seconds while the final dressing was put in place over the wound. Resident #157 was observed pushing Employee C's arm away. On 4/10/2019 at 10:54 AM, Employee A began cutting a small hole in the clear dressing over the black sponge so the wound vac could be applied to the wound. The Resident stated Oh! again when staff was manipulating the resident's wound. Employee C lifted the resident's left leg to put on her boot, the resident did verbally say Owie!. She also grimaced. On 4/10/2019 at 10:55 AM, Employee C was giving instructions to the resident to turn on her left side while Employee A was setting up for the next wound treatment to the right foot. At first, the resident was not following instructions, and Employee C kept pushing the resident's right leg to the side. The resident grimaced again. After Employee C removed the old dressing, the WCD measured the wound. Then Employee A began cleansing the right foot with cleanser. She was asked whether the resident was in pain. Employee A stated that whenever the resident's wound was touched with anything, she was in pain. She only had [MEDICATION NAME] ordered once before the procedure. This was her normal response during wound treatments. On 4/10/2019 at 11:05 AM, Employee C placed the [MEDICATION NAME] on the three open wound areas on the resident's right foot/heel. On the heel, she placed the non-shiny side down and the other two areas on the right outer ankle, she placed the shiny side down. Employee A was holding the resident's leg up so Employee B could hold the dressings in place and wrap them in Kerlix. The entire time, the resident was observed grimacing. The resident was interviewed on 4/15/2019 at 11:10 AM. She stated if her wounds were not touched, they were not painful, but if they were touched at all, they were very painful. On 4/15/2019 at 11:13 AM, after Employee C finished wrapping the resident's right foot with Kerlix, she was asked if the [MEDICATION NAME] should have the shiny side up or down on the wound. She stated she believed that the shiny side should be up. Employee C unwrapped the dressing on the right foot and looked at the placement of the three [MEDICATION NAME] treatments. She then flipped the two [MEDICATION NAME] treatments on the resident's right ankle and began wrapping the foot again with the Kerlix. After a few seconds, Employee C stated she was going to replace those two pieces, and went to the use the [MEDICATION NAME] that was on the table. She cut out two new pieces and placed them on the wounds. During this unwrapping, changing of the treatment to the correct placement and re-wrapping, the resident also displayed verbal cues of pain, OW! as well non-verbal cues evidenced by grimacing. On 4/10/2019 at 11:35 AM, Employee A was asked to review the clinical record for Resident #157's pain assessments during the wound treatments and provision of pain management. A review of the (MONTH) 2019 Medication/Treatment Record with Employee A revealed that Resident #157 was scheduled to have dressing changes on (MONTH) 1st, 3rd, 5th, 8th, and 10th. Further review revealed the [MEDICATION NAME] ([MEDICATION NAME]) was given on the 1st at 9:15 AM, on the 3rd at 9:06 AM, on the 5th at 8:50 AM and on the 10th at 9:46 AM. There was no documentation to verify that it was given on the 8th. Employee A stated that the resident went out to the wound clinic that day. She was asked if the resident was usually pre-medicated before she went to the clinic, and Employee A stated no. She was unsure about whether the resident should have been medicated. On 4/1/2019, there were no nursing progress notes describing the dressing change. On 4/3/2019 at 9:58 AM, Employee A's progress notes revealed rounds were made with the Advanced Registered Nurse Practitioner. On the right heel, the wound bed had granulation, slough, serosanguinous exudate, and the condition of the peri-wound was maceration, induration and [DIAGNOSES REDACTED]. The wound vac was applied at 125 mm (millimeters) of pressure. This note was signed by Employee C on 4/4/2019 at 8:03 AM. On 4/5/2019, there was only one nursing note at 8:50 AM documenting that [MEDICATION NAME] was given 30-60 minutes prior to the dressing change. On 4/8/2019 at 1:00 PM, Employee A documented the resident was out of the facility for a wound care appointment and the nurse did not change her dressings. The resident returned at 4:00 PM with her sister-in-law. Noted recommendation orders from physician: Resume wound vac to left heel. On the right heel and right ankle, cleanse with normal saline, pat dry, apply [MEDICATION NAME] Blue classic and then Xtrasorb. Secure with Kerlix dressing and tape. Change every Monday, Wednesday, and Friday. Heel suspension boots to bilateral heels at all times for off-loading. On 4/8/2019 at 5:00 PM, the new order for wound care was implemented to both the left heel and the right heel/ankle. There was no documentation to verify that the resident was assessed for pain or was pre-medicated before these treatments occurred. On 4/10/2019 at 10:35 AM, Employee A documented greater than mild pain in the lower left extremity. She also documented the right ankle revealed pain present with greater than mild pain, tolerated procedure, pre-medicated prior to dressing change. Documentation of the right heel revealed mild pain. Employee A looked back at her notes, and stated that she did not document everything she should have in the progress notes, including verbal and non-verbal signs of pain in her assessments. She only completed a more comprehensive note on 4/10/2019 after surveyor discussion. Employee A stated that today the resident did appear to be in pain during the procedure, and maybe she could ask the doctor to prescribe something stronger in the future. On 4/10/2019 at 11:54 AM, Employee C confirmed that there were no nursing notes on 4/5/2019 regarding dressing change(s) at all. She confirmed that the resident went out to the wound care clinic on (MONTH) 8, 2019. She stated that the wound care clinic probably did the treatments when she was there. However, after review of the progress note dated 4/8/2019 at 5:00 PM, the facility nurse here implemented the new wound care treatment after the resident returned from the wound care clinic. She confirmed that no [MEDICATION NAME] was documented as having been given on 4/8/2019 per the physician's orders [REDACTED]. On 4/10/2019 at 12:10 PM, Employee B stated that each time a dressing/treatment was performed on a resident, the nurse should document in the progress note, and the facility had a template of what should be included in that note. The template was to ensure all pertinent information was documented. Nurses were to document location, size, depth, drainage, odor, wound bed, condition, pain, any premedication, and resident/patient education. The facility's Pain Management policy (PP#5200.170) was reviewed. Effective pain management is essential to fulfilling the commitment to quality care. Pain relief requires individualized assessment and treatment of [REDACTED]. We will work to comprehensively assess and manage pain, to avoid undue suffering, and help residents achieve satisfactory pain relief in accordance with their unique goals. That if you are not able to communicate adequately, that your signs of pain or possible pain will be communicated to the physician. For residents who are not able to communicate their pain adequately, the nurse will observe for signs and symptoms of pain: nonverbal sounds, vocal complaints, facial expressions, and protective body movements or postures. All treatments will be documented on the pain monitoring flow sheet. Pain assessment and management is an on-going process. The Interdisciplinary team assesses the residents' changing needs on a regular basis and changes are made as necessary. On 4/10/2018 at 2:39 PM, Employee B confirmed there was either no documentation or inconsistent documentation over the past two weeks to confirm that the nurse was correctly documenting the treatment of [REDACTED]. Employee B stated that based on her observation today, the resident tolerated the treatment very well. She did not think the resident was in much pain. They did other interventions of holding her hand and distracting her. Employee B was reminded of the resident's frequent non-verbal grimacing and body posturing as well as exclamations of OH!, Owie! and EW! during the procedure. The resident's sister- in-law) was interviewed on 4/11/2019 at 5:13 PM. She stated that her sister had these wounds for about 2 years. One was acquired out of the facility and one was acquired at the facility. They would improve and then worsen. The wound care clinic was excellent and she went to every visit with her sister and watched all of the procedures. She further stated that they did medicate her at the clinic with local [MEDICATION NAME]. She was unsure of the resident's pain during the procedures at this facility.

Based on observations, interviews and record reviews the facility failed to maintain an infection prevention and control program by not following guidelines for cleaning and disinfecting blood glucose monitoring devices and providing adequate barriers for three of three residents observed for blood glucose monitoring (Residents #314, #150, & #313) and for one resident's device per interview (#68) out of a total sample of 37 diabetic residents. The facility also did not ensure hand hygiene was performed during a wound treatment for [REDACTED]. The findings include: 1. On 4/10/19 at 11:33 AM, observation of blood glucose monitoring checks began with Employee G, Registered Nurse (RN) and Resident #314. Employee G had a separate cart with all of the blood glucose supplies on it. He took a tissue and placed it on Resident #314's bedside table as a barrier. Employee G entered the room and placed the glucometer (blood monitoring device), lancet, alcohol wipe, and bottle of test strips on the tissue. He then placed the bottle of bleach wipes on the bedside table with no barrier. He washed his hands and donned gloves. He then pricked the middle finger on the resident's left hand. He opened the test strip bottle, removed a strip and inserted it into the glucometer. He obtained a drop of blood and her blood sugar was 244 mg/dL (milligrams/deciliter). Employee G kept the same gloves on, and removed a bleach wipe from the container with the blue top. He then wiped the glucometer for two (2) seconds, one swipe down the front and one down the back. He did not clean the glucometer on the sides. He then placed the items in the tissue and returned to the cart. He placed the lancet in the sharps container, and then placed the glucometer on the cart, without a barrier. (Photographic evidence was obtained) He washed his hands and placed the towel over all of the items. He returned to the medication cart to look for the resident's insulin coverage amount. He determined that she needed four (4) units of [MEDICATION NAME] (insulin), so he returned to Resident #314's room and administered her coverage. He then returned to the clean utility room and obtained the blood glucometer cart. Employee G went to Resident #150's room to obtain her blood sugar. He picked up the second glucometer on the cart, obtained a lancet, two alcohol wipes, and the container of bleach wipes. He entered the resident's room and placed the supplies on her bedside table. He then placed the blood strip container and the bleach wipe container on the bedside table without a barrier. (Photographic evidence was obtained) Employee G donned gloves and cleansed the 4th finger on Resident #150's left hand. The blood sugar level was 165 mg/dL. He removed a bleach wipe and cleansed the glucometer with one wipe down the front and a second wipe down the back. He did not clean the sides. He then placed the glucometer on the dirty barrier that was on the table. He picked up the barrier with the glucometer on it and returned to the cart in the hallway. Employee G then went to Resident #313's room, knocked on the door and asked about checking her blood sugar. She stated it was okay. He turned around and obtained the glucometer that had just been used on Resident #150, a lancet, two alcohol wipes, and the bleach wipe container. He entered the room and placed the bleach wipes on the resident's bedside table on top of her magazine. (Photographic evidence was obtained) Employee G then wiped Resident #313's right pointer finger and obtained a blood sugar level of 158 mg/dL. He removed the strip from the glucometer and placed it on the barrier with the alcohol wipes. He removed a bleach wipe from the container and covered the glucometer with it half way. He then took the glucometer from the room and placed it on the cart. He changed gloves, removed another bleach wipe, wiped the front and back of the glucometer, and placed it back on the cart. On 4/10/19 at 12:52 PM an interview was conducted with the Director of Nursing (DON) regarding glucometer cleaning and she was asked for the policy and procedure. She found the policy and printed it out. Upon review of the policy, she was asked about the procedure for cleaning a glucometer including if wiping it once in the front and in the back was acceptable. The DON indicated that was not how it should be done and staff need to clean all of the surfaces to ensure complete cleaning. On 4/10/19 at 2:31 PM an interview was conducted with Employee G, RN, in the room with the Accu-check/glucometer cart regarding cleaning of the glucometers. He stated they use the bleach wipes to wipe the front and the back each glucometer, and then wait two minutes for it to dry. They have two machines to use while one machine dries. He was asked if he is supposed to wipe the insertion site for the test strip and he stated, No, just the front and back, because that is how they want us to do it. We can't wipe it there and get it wet, and we can't get it very wet on the back, due to the speaker right here. (pointing to the speaker on the back) He was asked about taking the container of bleach wipes in and out of each resident's room, and he stated that is how they do it. He was asked about setting them down without providing a barrier, and he indicated that they only need to provide a barrier for the glucometer, and not the bleach wipe container. He was asked about the towel that is placed over all of the supplies on cart, and when it gets changed. He stated, I believe it gets changed every night, on night shift. On 4/10/19 at 4:30 PM, Employee D, a Licensed Practical Nurse (LPN), was interviewed regarding cleansing/disinfection of the glucometers. She just finished the glucometer blood test for Resident #68. She stated after she used it, she cleaned it with alcohol wipes and placed it the black case and put it in the medication cart. She has not had a chance to disinfect it yet with the bleach wipes. Employee D stated there was no room for the bleach wipe containers to fit in her medication cart, so she just wipes them with alcohol first and then will take them to the medication room and use the wipes. They are not allowed to bring the bleach wipes and leave them on the cart because the residents in the Memory Care Unit might ingest them. On 4/10/19 at 5:47 PM an interview was conducted with the DON and she confirmed that the glucometers were cleaned inappropriately including the duration times for cleaning and drying of the devices. She stated that training was scheduled for all nurses prior to performing any further blood glucose monitoring. Review of the EvenCare G2 manufacturer's instructions for cleaning the glucometer devices included the following: Wash hands with soap and water and dry thoroughly. Inspect for blood, debris, dust, lint anywhere on the meter. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. NOTE: Do not get water inside the meter or immerse the meter in water or any other liquids. Do not use glass or other household cleaners on the meter. Avoid using ammonia to clean the meter. Avoid wetting the test strip port of the meter. To disinfect the meter, clean the meter with one of the validated disinfecting wipes listed below. Other EPA registered wipes may be us for disinfecting the EvenCare G2 system, however these other wipes have not been validated and could affect the performance of the meter. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's direction's for use. Wipe meter dry or allow to air dry. Wash hands with soap and water and dry thoroughly. Micro-Kill Bleach Wipes Instructions for Use: Directions: 30 second contact time is required to kill all bacteria [MEDICAL CONDITION] on the label, except a one minute contact time is required to kill [MEDICAL CONDITION] and [MEDICATION NAME] mentagrophytes, and three minute contact time is required to kill [MEDICAL CONDITION] spores. Re-apply as necessary to ensure that the surface remains wet for the entire contact time. Allow surface to air dry and discard used wipe. Review of the facility's policy for glucometer cleaning included the following: The meter should be cleaned and disinfected after each patient/resident use. Clean and disinfect the glucometer with 1:10 Clorox bleach wipes. Allow exterior to be wet for at least 1 minute on a piece of barrier after wiping the meter to adequately clean and disinfect the glucometer, then air dry. Wear gloves during the procedure. 2. On 4/10/2019 10:30 AM, wound treatments performed by Employee A, LPN, and Employee C, RN/Unit Manager, were observed for Resident #157. Employee A was performing the wound treatment to the resident's left heel and Employee C was assisting by holding the resident's leg/foot. Both nurses had donned gloves. They set up a barrier on the over-the-bed table and were removing supplies from the drawer and placing them on the barrier. Employee A cleansed the wound on 4/10/2019 at 10:42 AM. After removing the dirty dressing and cleansing the wound, both employees removed their gloves. Employee A washed her hands and put on new gloves. Employee C put on new gloves, but did not perform hand hygiene or wash hands. Employee C returned to holding the resident's leg up so Employee A could continue to apply the new dressing. On 4/10/2019 at 10:51 AM, Employee C was not only holding the resident's leg, but also began holding the clean black sponge of the new dressing. Then Employee A put the clear dressing over the sponge. Then Employee C went over to the resident's right leg and began to remove the old dressing from the right foot. Employee A used the same pair of gloves to complete the entire dressing change on the resident's right foot (from dirty to clean) without performing hand hygiene. On 4/10/2019 at 11:15 AM, Employee C was told that she was not observed to wash hands or perform hand hygiene when removing her gloves and putting on new ones, and also between going from dirty to clean during the dressing change. Employee C stated she was unsure if she washed her hands or not. The facility's Infection Control and Prevention Program Handwashing/Hand Hygiene Program (PP#5200.232) revealed hand hygiene is the primary means to prevent the spread of infections. It revealed that an alcohol-based hand rub or soap and water should be used when removing gloves and before moving from a contaminated body site to a clean body site during resident care.

Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to implement the care plan for one (Resident #115) of two sampled residents reviewed for pressure ulcer care. Thirty-four residents in total were sampled. The findings include: Wound care was observed for Resident#115 on 01/31/2018 at 11:14 AM. Employee A, Registered Nurse (RN), provided wound care. She was assisted by a charge nurse. Resident #115 was observed lying in bed, covered with a blanket. The resident was alert, and responded 'yes' and 'no' to questions regarding his comfort level during the wound care procedure. When the nurses proceeded, they uncovered the resident and turned him onto his left side to expose the area of his back where the wounds were located. Two surveyors observed that the resident's legs and feet were not floated on pillows/cushions, nor were pressure relieving boots used prior to the initiation of or during provision of wound care. When asked whether the resident had other wounds, the wound care nurse explained that the resident had very fragile skin, and several skin tears on the lower extremities that were being treated and monitored. She pulled down the protective socks covering the resident's calves to reveal the wounds. She stated the resident had a healed area on the left heel that she was monitoring as well. She proceeded to take off the resident's left sock to reveal the area. A blackened necrotic area the size of a quarter was observed on the resident's left heel. It appeared to be crusted over and the skin was not open. When she removed the sock, the resident grimaced and cried out in pain, Ooh, ooh, ooh, until she put the sock back on, put the foot down, and covered the resident with a blanket. She stated the physician wanted it left open to the air to heal. Neither of the nurses placed pillows or cushions under the resident's feet to float his heels after the procedure was finished. A review of the nursing notes dated 01/25/2018, revealed a note that read, Left heel continues to have hard dark skin that measured 2.4 x 1.4 cm. No open areas. A review of the Minimum Data Set (MDS) assessments dated 12/24/2017 and 01/08/2018, revealed that Resident #115 had one Stage One or greater wound, scar over bony prominence. The resident was at risk of developing pressure ulcers. The date last pressure ulcer was identified was 12/11/2017. It was identified as a Stage Two. No pressure ulcers on last assessment. No Unstageable-Deep tissue: Suspected deep tissue injury in evolution. [DIAGNOSES REDACTED]. A review of the care plan dated 01/18/2018, revealed an identified problem area of 'Alteration in skin integrity with risk for additional skin breakdown: Has open area to lumbar spine area. Reabsorbed blister to left heel. Risk for further alteration in skin integrity status [REDACTED].' The goal read, 'Area of breakdown will exhibit signs of healing through interdisciplinary team interventions within the next 90 days. Will not develop further skin alteration through staff interventions daily this next 90 days.' Interventions included, 'Treatment to areas as ordered. Off-load pressure. Assist with repositioning frequently and as needed while on low air loss surface mattress. Elevate bilateral lower extremities. Pressure ulcer relief boots to be worn in bed. Weekly skin checks and daily. Prevention skin care.' A review of the physician's orders [REDACTED]. While in bed - Diagnosis: [REDACTED]. First, second and third shifts, every day. A second observation of Resident #115 was made on 01/31/18 at 3:03 PM. Resident #115 was lying in bed with the covers on. A private sitter was in the room with the resident. She was asked to whether the resident's heels were floated. The private sitter stated that they were not floated, and she pointed at two cushions on a cabinet across from the foot of the bed. Two u-shaped cushions were observed stacked on top of each other, and lying on top of the cabinet. She stated that they used the cushions to float the resident's feet. They had assisted the resident back to bed, and had not put the cushions under his feet yet. The nurse, Employee B, came into the room. She was asked to show the surveyor the resident's feet. She pulled the covers back to reveal that the feet were not resting on any flotation device, but were in direct contact with the mattress. The resident had no pressure reducing boots on. She stated the resident was supposed to have his feet elevated, because of an area on one of his heels that needed pressure relief. She applied a medicated skin preparation to the heel every day. She stated the resident refused to have heel protector boots on. The private sitter then stated that the feet were elevated that morning, and sometimes he shifts in the bed and they come off the cushions. During an interview with Employee B on 01/31/18 at 3:25 PM, she stated that the private sitter should have put the cushions under the resident's feet when they moved the resident back into bed. When asked if the private sitter worked for the facility and if it was her responsibility to provide direct care to the resident, Employee B replied, No, she does not work for the facility, and the Certified Nursing Assistant (CNA) assigned to the resident should have floated the heels. She stated that the resident did express pain when she applied the skin prep to his left heel. It is important to keep the heels floated to keep the area on the left heel from getting worse, and so that no new areas open up. The resident's skin is fragile and is declining. During a second interview with Employee A on 01/31/18 at 4:00 PM, she stated that she had gone into Resident #115's room prior to provision of wound care earlier that day, and she removed the pillows and cushions from under his feet to prepare for the wound care procedure, because they would need to turn the resident onto his side. She stated that she did not know she should have left them in place until the surveyors came into the room. She stated the private sitter was very good about making sure the cushions were in place. She agreed that the facility was ultimately responsible for the placement of the cushions under the resident's feet while in bed, and the facility staff that transferred the resident should have made sure his heels were floated after they put the resident back in bed. During an interview with the Director of Nursing on 01/31/2018 at 4:45 PM, she stated that she had been informed by Employee A that the survey team did not observe the resident's heels off-loaded prior to or after the wound care procedure on first shift. She was made aware of the observation again on second shift when the resident's heels were not floated. She stated the CNA was responsible for care of the resident, and should have put the cushions under his feet when they put him back in bed. She was aware that Resident #115 had a physician's orders [REDACTED]. She confirmed that the private sitter hired by Resident #115's family was not a CNA and could not provide nursing care. A review of the facility's policy and procedure entitled 'Standards of Nursing Care-Standing Orders Policy PP#5200.153' revealed, [MEDICAL CONDITION] Management: Elevate the foot of the bed; Utilize pillows to elevate upper or lower extremities. Review of the policy and procedure entitled Information For Families And Sitters revealed, In either case, nurse or sitter, the private duty individual, as well as the family, need to understand that the facility staff have ultimate responsibility for the resident residing in the facility. In the section 'Your Role As A Sitter' it read, You must not do any nursing procedures or give any care that you have not been trained, certified, or licensed to do.

Based on observations and staff interviews made on 10/12/13 at 11 am, and on 10/14/15 at 9:30 am, the facility failed to store, prepare, and serve food under sanitary conditions. The findings include: On 10/14/2015 9:36 am, the following observations were made in the dry storage room and the kitchen floors: 1. Chipped floor tiles in the dry storage room, and the dishwashing areas of the kitchen. 2. Four cases of outdated thickened juices were observed on the dry storage room shelf. The dietary manager read the date as expired from January 2015. During an interview on 10/14/2015 at 9:38 a.m, the dietary manager apologized for the expired juices, and his assistant who accompanied us on the tour of the kitchen noted that information on his yellow writing pad. He stated that he would take care of the expired juices immediately. 3. A dented can of tuna was also removed from the shelf. 4. Observations on 10/14/2015 at 9:45 am revealed the high traffic areas between the kitchen and the main dining room were heavily impacted with black looking debris. The debris appeared as an oval shape around the door-way. The Dietary Manager acknowledged the findings of the observation. The tile flooring in the main dining room where the steam table was parked was soiled with dirty impacted foot marks. The surrounding tiled floor was observed with dust all around the periphery. The Dietary Manager stated, during this observation, that this area should have been swept and mopped but it will be cleaned right away. 5. On 10/14/2015 at 12:55 pm, the T3 Rehab refrigerator shelves were soiled with food debris. The dietary manager stated that he would inform the housekeeping director to clean them. The T3 refrigerator temperature was observed at 60F. The dietary manager stated at 12:56 pm on 10/14/2015 that the staff had been going in and out of the refrigerator during the tray line service; hence, the high temperature. He also promised to recheck the temperature because the kitchen staff had recently stocked the refrigerator with supplements and snacks. On 10/15/2015 at 10:30 am, the refrigerator in T1 was observed at 42F, and the T3 refrigerator was observed at 48 F degrees. On 10/15/2015 at 10:35 am, the dietary manager stated that the refrigerator's air was not circulating properly and probably needed to be replaced.

Based on observation, clinical record review and interviews, the facility failed to provide pharmaceutical services and procedures that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. The findings include: On 3/9/11 at 2:30 pm, the medication cart containing medications for residents on the Shelter Care 1 unit was inspected for drug expiration dates. A box of Hydroxyzine 25 mg tablets for Resident #43 was observed on the medication cart with an attached label on the box that stated "discard after 4/22/11." However, thirteen (13) packets of the medication were in the box and each packet had "beyond use 11/1/10" printed on the label. At that time, the nurse assigned to the medication cart confirmed the labeling of each medication packet. An interview with the Director of Pharmacy was conducted on 3/9/11 at 2:35 pm to explain the meaning of "beyond use 11/1/10" and to explain the process for checking medication expiration dates. The Director of Pharmacy stated that all scheduled medications on the cart on Shelter Care 1 unit were exchanged once per month by the pharmacy tech. During the exchange of medications, the pharmacy tech was supposed to check all "as needed" and narcotic medications for expiration dates. A review of the clinical record for Resident #43 revealed that she had received one dose of the medication on 1/25/11 at 5:35 pm. The interview with the Director of Pharmacy confirmed that the resident may have received medication that was expired. A review of the facility's policy entitled "Expiration Dates: Monitoring" stated, "Expiration dates of drugs and devices shall be checked during the monthly medication area inspections and all drugs and devices scheduled to expire during the next month shall be removed from stock." .