Every finding on record at Spartanburg Hospital for Restorative Care SNF

Based on observations, record review and interviews, the facility failed to ensure that the resident's food was served under sanitary conditions and that their environment was conducive for dining, related to Resident (R)7's lunch tray being placed beside a urinal containing urine during dining, for 1 of 3 residents reviewed during dining. Review of the State Operations Manual Appendix PP - Guidelines to Surveyors for Long Term Care Facilities, Rev. 232; Issued: 07-23-25, Environmental Factors: Appetite is often enhanced by the appealing aroma, flavor, form, and appearance of food. Resident-specific facility practices that may help improve intake include providing a pleasant dining experience (e.g., flexible dining environments, styles and schedules), providing meals that are palatable, attractive and nutritious (e.g., prepare food with seasonings, serve food at proper temperatures, etc.), and making sure that the environment where residents eat (e.g., dining room and/or resident's room) is conducive to dining.Review of R7's Face Sheet revealed that R7 was admitted to the facility on [DATE].Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/01/25 revealed that R7 had a BIMS (Brief Interview for Mental Status) Score of 13. The MDS further revealed that R7's diagnosis included but not limited to other acute osteomyelitis, left tibia and fibula and diabetes mellitus.During a dining observation on 09/21/25 at approximately 12:30 PM a staff member was observed delivering a meal tray to Resident (R)7 in room [ROOM NUMBER] and leaving two urinals on the overbed table, in which one contained urine and the other was empty. The staff member sat the resident's tray on a table to right side of the room, inquired with the resident if he wanted her to remove some cups from the table, put on gloves, removed the cups, removed the gloves, sanitized her hands and placed the resident's tray on the table. R7 sat up on the side of the bed and the staff member uncovered the tray, and exited the room, leaving the urinals in place. At approximately 12:36 PM R7's call light was observed on and a nurse entered the room, and R7 was overheard saying I refuse to eat with this here.During a brief interview on 09/21/25 at 12:42 PM Registered Nurse (RN)1 revealed that the resident did not want the urinal on his table, and she removed it.During an interview on 09/21/25 at 1:50 PM the Director of Nursing (DON) revealed the facility just recently started using nutritional staff to assist with delivering meal trays. The DON states that the nutritional staff is only allowed to place the resident's tray in the room. The DON explains that she has asked the CNAs to check resident's rooms before lunch to ensure that urinals are removed from tables before they are served, however the resident may use the restroom in between the CNAs checking and the trays are served. The DON further revealed that her expectation is that staff would remove urinals before placing the resident's trays and that the nutritional staff would notify someone to have the urinal removed if it's there when they deliver the tray. During an interview on 09/22/25 at approximately 5:15 PM R7 revealed that the urinal being left on the table when his tray was placed didn't make him feel good. R7 stated that I didn't like it. R7 further stated that he understood that the staff can be forgetful, however he felt that the urinal should have been removed.

Based on record review and interviews, the facility failed to ensure that a resident's advance directive of Do Not Resuscitate (DNR) was signed by the resident or had two physical's signature for non decisional capacity. Resident #58 had an advance directive for DNR signed by someone else and there was no documentation of decisional capacity by two physicians. The findings included: The facility admitted Resident #58 on 1/08/2021 with [DIAGNOSES REDACTED]. A review of the paper medical record on 1/11/2021 at approximately 1:11 PM revealed no documentation under the advance directive tab. A review of the electronic medical record on 1/11/2021 at approximately 2:07 PM revealed Resident #58 was coded as a DNR for advance directive. A interview on 1/11/2021 at approximately 2:45 PM with the Director of Nursing (DON) confirmed the resident was coded a DNR in the electronic medical record and that he/she will contact the hospital for copies of DNR request for resident. An interview on 1/12/2021 at approximately at approximately 11:29 AM with the DON and Medical Director confirmed the facility did not get the second physician's signature of decisional capacity until today (1/12/2021) and that the resident was coded DNR before the second signature was obtained.

Based on review of facility files, record review and interview, the facility failed to ensure Resident #59 was free of Neglect, that resulted in harm for 1 of 3 sampled residents reviewed for Neglect. Resident #59's bed alarm was not turned on as ordered and per the care plan at the time of a fall with major injury. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. Record review of the facility's 5-Day Report and complete investigation on 3/6/19 at 3:11 PM, revealed on 1/25/19 at or around 8:00-8:15 PM, Licensed Practical Nurse (LPN) #1 administered medication to and assisted Resident #59 with toileting. After using the urinal, the resident asked to sit on the side of the bed for a while. LPN #1 then placed the call light in reach and went to assist other residents. LPN #1 checked on Resident #59 in between residents. At 8:45 PM, Certified Nursing Assistant (CNA) #1 checked on the resident and the resident was lying down in bed. At 8:52 PM, after leaving another resident's room, LPN #1 heard Resident #59 moaning and found the resident on the floor with a large amount of bleeding from the nose and mouth. Review of a written statement by LPN #1, from the facility's investigation, on 3/6/19 at 3:11 PM, revealed at or around 8:15 PM, LPN #1 went into Resident #59's room and assisted the resident to use the urinal. The statement indicated Resident #59 had a bed alarm in use at the time. LPN #1 turned off the alarm so the resident could get up to use the urinal. The statement indicated the resident requested to sit for a while because he was tired of lying in the bed. A call light went off in another resident's room and LPN #1 went to assist that resident. After assisting that resident, LPN #1 checked on Resident #59 who was still sitting on the bed. LPN #1 then went to give another resident medication. When LPN #1 left that resident's room he/she heard Resident #59 moaning. Upon reentering Resident #59's room, the resident was found on the floor bleeding from the nose and mouth. A rapid response was coded, and the resident was sent to the emergency department. LPN #1's statement did not indicate the resident's bed alarm was turned back on after assisting with the urinal or after checking on the resident. The facility's investigation determined the alarm was not on at the time the resident fell from the bed. Record review of Resident #59's computerized tomography (CT) scan results on 3/6/2019 at 3:47 PM, revealed the resident suffered multiple facial bone fractures as a result of the fall. Record review of Resident #59's hospital discharge summary on 03/06/19 at 3:47 PM, revealed the resident was hospitalized from 1/25-2/1/19 as a result of the fall. The resident suffered 4 facial fractures requiring surgical repair. In addition, the resident received 3 facial lacerations from the fall. Record review of Resident #59's physician's orders [REDACTED]. Record review of Resident #59's care plan on 3/7/19 at 9:39 AM, revealed a problem area for safety. Interventions for the resident's safety included the use of a bed alarm while in bed. Record review of Resident #59's Fall Assessments on 3/6/19 at 3:39 PM, revealed the resident was assessed as a high fall risk on admission and prior to the 1/25/19 fall. Record review of Resident #59's nurse practitioner (NP) progress note, dated 1/21/19, on 3/7/19 at 9:01 AM, revealed the resident continued to have confusion that was worse in the evening. The NP also noted the resident had a bed and chair alarm in use due to multiple attempts to get up unassisted. During an interview with Physician #1 on 3/7/19 at 8:52 AM, Physician #1 stated alarms are not a guarantee that falls can be prevented, but it was possible Resident #59's fall could have been prevented if the alarm had been turned on. During an interview with CNA #1 on 03/07/19 at 9:50 AM, CNA #1 stated Resident #59 was sleeping when s/he started her/his rounds on the night shift (7PM-7AM) on 1/25/19. CNA #1 stated s/he verified that the resident's bed alarm was turned on and continued her/his rounds. When CNA #1 came back to see if the resident needed any assistance, LPN #1 was in the room giving Resident #59 medication and assisting with the urinal. CNA #1 stated s/he was unaware and was not told the bed alarm was not turned back on after LPN #1 left the resident. CNA #1 confirmed s/he looked into the resident's room, prior to the fall, at 8:45 PM to check on him/her. CNA #1 stated the resident was laying down in the bed and appeared asleep. During an interview with the Director of Nursing (DON) on 3/7/19 at 10:11 AM, the DON confirmed Resident #59's bed alarm was not on at the time of the fall as ordered and per the care plan. The DON stated LPN #1 chose to monitor the resident visually between residents instead of turning the alarm on prior to leaving the resident's room. The DON stated during the fall investigation s/he asked LPN #1 why the alarm was not turned back on. Per the DON, LPN #1 stated s/he wanted to give the resident some time without the alarm, so s/he could sit up without worrying about the alarm going off, to promote his/her dignity. LPN #1 was unavailable for interview. The DON stated LPN #1 only worked weekends and frequently traveled on off days. Attempts to reach LPN #1 by phone were not successful.

Based on review of facility files, record review and interview, the facility failed to follow the care plan related to bed alarms for Resident #59, 1 of 5 sampled residents reviewed for Accidents. Resident #59's bed alarm was not in use, per the care plan, when the resident had a fall resulting in multiple facial fractures. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. Record review of the facility's 5-Day Report (investigation) on 3/6/19 at 3:11 PM, revealed on 1/25/19 at or around 8:00-8:15 PM, Licensed Practical Nurse (LPN) #1 administered medication to and assisted Resident #59 with toileting. After using the urinal, the resident asked to sit on the side of the bed for a while. LPN #1 then placed the call light in reach and went to assist other residents, checking on Resident #59 in between residents. After leaving another resident's room, LPN #1 heard Resident #59 moaning and found the resident on the floor with a large amount of bleeding from the nose and mouth. Review of a written statement by LPN #1, from the facility's investigation, revealed at around 8:15 PM, LPN #1 went into Resident #59's room and assisted the resident to use the urinal. The statement indicated Resident #59 had a bed alarm in use at the time. LPN #1 turned off the alarm so the resident could get up to use the urinal. The statement indicated the resident requested to sit for a while because s/he was tired of lying in the bed. A call light went off in another resident's room and LPN #1 went to assist that resident. LPN #1's statement did not indicate the resident's bed alarm was turned back on. The facility's investigation determined the alarm was not on at the time the resident fell from the bed. Record review of Resident #59's computerized tomography (CT) scan results on 3/6/2019 at 3:47 PM, revealed the resident suffered multiple facial bone fractures as a result of the fall. Record review of Resident #59's care plan on 3/7/19 at 9:39 AM, revealed a problem area for safety. Interventions for the resident's safety included the use of a bed alarm while in bed. During an interview with Physician #1 on 3/7/19 at 8:52 AM, Physician #1 stated alarms are not a guarantee that falls can be prevented, but it was possible Resident #59's fall could have been prevented if the alarm had been turned on. During an interview with the Director of Nursing (DON) on 3/7/19 at 10:11 AM, the DON confirmed Resident #59's bed alarm was not on at the time of the fall and the care plan was not followed. The DON stated LPN #1 chose to monitor the resident visually between residents instead of turning the alarm on prior to leaving the resident's room. LPN #1 was unavailable for interview. The DON stated LPN #1 only worked weekends and frequently traveled on off days. Attempts to reach LPN #1 by phone were not successful.

Based on review of facility files, record review and interview, the facility failed to follow physician's orders for a bed alarm for Resident #59, 1 of 5 sampled residents reviewed for Accidents. Resident #59's bed alarm was not in use as ordered when the resident had a fall resulting in multiple facial fractures. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. Record review of the facility's 5 Day Report (investigation) on 3/6/19 at 3:11 PM, revealed on 1/25/19 at or around 8:00-8:15 PM, Licensed Practical Nurse (LPN) #1 administered medication to and assisted Resident #59 with toileting. After using the urinal, the resident asked to sit on the side of the bed for a while. LPN #1 then placed the call light in reach and went to assist other residents. LPN #1 checked on Resident #59 in between residents. At 8:45 PM, Certified Nursing Assistant (CNA) #1 checked on the resident and the resident was lying down in bed. At 8:52 PM, after leaving another resident's room, LPN #1 heard Resident #59 moaning and found the resident on the floor with a large amount of bleeding from the nose and mouth. Review of a written statement by LPN #1, from the facility's investigation, revealed at around 8:15 PM, LPN #1 went into Resident #59's room and assisted the resident to use the urinal. The statement indicated Resident #59 had a bed alarm in use at the time. LPN #1 turned off the alarm so the resident could get up to use the urinal. The statement indicated the resident requested to sit for a while because he was tired of lying in the bed. A call light went off in another resident's room and LPN #1 went to assist that resident. After assisting that resident, LPN #1 checked on Resident #59 who was still sitting on the bed. LPN #1 then went to give another resident medication. When LPN #1 left that resident's room he/she heard Resident #59 moaning. Upon reentering Resident #59's room, the resident was found on the floor bleeding from the nose and mouth. A rapid response was coded and the resident was sent to the emergency department. LPN #1's statement did not indicate the resident's bed alarm was turned back on after assisting with the urinal or after checking on the resident. The facility's investigation determined the alarm was not on at the time the resident fell from the bed. Record review of Resident #59's computerized tomography (CT) scan results on 3/6/2019 at 3:47 PM, revealed the resident suffered multiple facial bone fractures as a result of the fall. Record review of Resident #59's hospital discharge summary on 03/06/19 at 3:47 PM, revealed the resident was hospitalized from 1/25-2/1/19 as a result of the fall. The resident suffered 4 facial fractures requiring surgical repair. In addition, the resident received 3 facial lacerations from the fall. Record review of Resident #59's physician's orders on 03/06/19 at 3:33 PM, revealed a bed alarm was ordered for the resident on 1/16/19. Record review of Resident #59's Fall Assessments on 3/6/19 at 3:39 PM, revealed the resident was assessed as a high fall risk on admission and prior to the 1/25/19 fall. Record review of Resident #59's nurse practitioner (NP) progress note, dated 1/21/19, on 3/7/19 at 9:01 AM, revealed the resident continued to have confusion that was worse in the evening. The NP also noted the resident had a bed and chair alarm in use due to multiple attempts to get up unassisted. During an interview with Physician #1 on 3/7/19 at 8:52 AM, Physician #1 stated alarms are not a guarantee that falls can be prevented, but it was possible Resident #59's fall could have been prevented if the alarm had been turned on. During an interview with CNA #1 on 03/07/19 at 9:50 AM, CNA #1 stated Resident #59 was sleeping when s/he started her/his rounds on the night shift (7 PM-7AM) on 1/25/19. CNA #1 stated s/he verified that the resident's bed alarm was turned on and continued her/his rounds. When CNA #1 came back to see if the resident needed any assistance, LPN #1 was in the room giving Resident #59 medication and assisting with the urinal. CNA #1 stated s/he was unaware and was not told the bed alarm was not turned back on after LPN #1 left the resident. CNA #1 confirmed s/he looked into the resident's room, prior to the fall, at 8:45 PM to check on him/her. CNA #1 stated the resident was laying down in the bed and appeared asleep. During an interview with the Director of Nursing (DON) on 3/7/19 at 10:11 AM, the DON confirmed Resident #59's bed alarm was not on at the time of the fall as ordered. The DON stated LPN #1 chose to monitor the resident visually between residents instead of turning the alarm on prior to leaving the resident's room. The DON stated during the fall investigation s/he asked LPN #1 why the alarm was not turned back on. Per the DON, LPN #1 stated s/he wanted to give the resident some time without the alarm, so s/he could sit up without worrying about the alarm going off, to promote his/her dignity. Upon readmission to the facility on [DATE], Resident #59 was placed on 1:1 supervision for the remainder of his/her stay at the facility. This was confirmed per record review and interview with staff. In addition, record review of the facility's discharge summary and nurse's notes revealed the resident's physical and mental status/cognition improved significantly prior to discharge from the facility to assisted living facility. LPN #1 was unavailable for interview. The DON stated LPN #1 only worked weekends and frequently traveled on off days. Attempts to reach LPN #1 by phone were not successful.

Based on record review, observation, and interview, the facility failed to use proper procedure during wound care observation for one of two residents reviewed for pressure ulcer(Resident #255). During wound care a staff member was observed to cleanse the pressure ulcer area with normal saline with no physician's order for normal saline use. After cleansing the wound, the staff member did not change gloves, wash or sanitize hands for the continuation of the treatment one of two pressure ulcer wounds reviewed. The findings included: The facility admitted Resident #255 with [DIAGNOSES REDACTED]. During observation of pressure ulcer treatment on 4/4/18 at 12:30 PM, Registered Nurse(RN)#1 cleansed the area, applied skin prep and applied an Allevyn dressing to the area without changing gloves and/or washing/sanitizing hands. Review of the physician orders along with RN #1 after the pressure ulcer treatment observation on 4/4/18 revealed there was no physician's order to use normal saline to cleanse the wound. During an interview with the Director of Nursing on 4/4/18 at 4:03 PM, s/he stated the expectation of the nurse after cleaning a wound would be to remove gloves, sanitize or wash hands, don gloves and continue with the treatment. During an interview with RN#1 on 4/4/18 at 5:40 PM, s/he stated normally an order is put into the system before the treatment. S/he stated using normal saline is standard practice and it was an oversight the order was not in the computer system. S/he stated there was no drainage from the wound and the outer gauze s/he was using was clean and had there been heavy drainage gloves would have been changed and s/he would wash his/her hands. S/he continued by stating the information we use does not say anything about changing gloves during a treatment. Review of the facility policy on 4/4/18 titled Dressings Changes did not address removal of gloves and washing hands after cleansing the wound. Review of the information provided by the facility titled Fundamental Nursing Skills and Concepts-Eleventh Edition did not address removal of gloves and washing hands after cleaning the wound.

On the days of the survey, based on observations, limited record reviews, interviews, and review of the policy provided by the facility entitled "Nova Glucometer" dated 02/13, the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure multiple resident use glucometer's were cleaned with the appropriate disinfectant between resident use. Concerns were identified for 2 of 3 sampled residents who received Fingerstick Stick blood sugars (FSBS), Residents #9 and #10. The facility failed to conduct an antibiotic review timely for Resident #6, one of four sampled residents reviewed for Urinary Tract Infections (UTIs). The findings included: Observation of a fingerstick blood sugar on 7/15/13 at 4:38 PM revealed CNA (Certified Nursing Assistant) #1 taking a multiple resident use glucometer into the room of Resident #9. CNA #1 did not clean the glucometer prior to performing the fingerstick blood sugar. After the fingerstick blood sugar had been taken, CNA #1 used a Purell Hand Sanitizer Wipe (62% ethyl alcohol) to wipe the surface of the glucometer before putting it back into the charger at the nurses station. When asked, CNA #1 stated that prior to this blood sugar check, Resident #9 had his/her blood sugar checked at breakfast that morning. Observation of a fingerstick blood sugar on 7/15/13 at approximately 4:45 PM revealed CNA #2 taking a different glucometer out of a 2nd charger at the nurses station. CNA #2 cleaned the glucometer with a sani-cloth wipe (Germicidal Cleaner) taken from a "pop up" container located on a shelf at the nurses station. CNA #2 then went into Resident #3's room and performed a fingerstick blood sugar. At 4:52 PM, CNA #2 went into Resident #10's room to perform another fingerstick blood sugar without cleaning the glucometer in between the two residents. CNA #2 knocked, and informed Resident #10 that s/he needed to perform a fingerstick blood sugar. CNA #2 prepared the glucometer and was ready to stick the resident's finger when the surveyor asked CNA #2 to step out in the hall. The surveyor told CNA #2 that s/he had noted the glucometer had not been cleaned in between the two residents. CNA #2 stated that s/he didn't clean the glucometer every time, that they were supposed to clean the glucometer with the Sani-wipe only before starting the blood sugars. CNA #2 was asked what product s/he usually used to clean the glucometers and stated that they were cleaned with the Sani-wipes. The surveyor asked CNA #2 what s/he had meant by only cleaning the glucometers before starting the blood sugars. The surveyor asked if this meant that the glucometer was cleaned prior to starting blood sugars for all the residents with blood sugars due before dinner or all the residents with blood sugars due before breakfast, and that the glucometer would be cleaned once before starting the procedures, and the CNA stated "yes". CNA #2 added that they usually did not clean the glucometers between every blood sugar from room to room. When the surveyor asked, "Are you supposed to?", CNA #2 stated, "I may need to get another one and clean it again". After a pause, CNA #2 stated, "I'll get another Sani-wipe". At approximately 5:00 PM, CNA #2 cleaned the glucometer with a Sani-wipe and performed the fingerstick blood sugar on Resident #10. During an interview on 7/15/13 at 5:15 PM, CNA #1 was asked about when the glucometer should be cleaned. CNA #1 stated that the glucometer should be cleaned before leaving the resident's room and prior to hanging the glucometer back onto the charger. When asked how s/he knew the glucometer had been cleaned prior to using it, CNA #1 stated, "Usually people know" (to clean the glucometer after using it). When asked what was used to clean the glucometers, CNA #1 stated that they used Sani-wipes. The surveyor asked CNA #1 to show her/him the wipes that were to be used. CNA #1 went to the glucometer carrying case and pulled out a Purell Sanitizing Hand wipe and stated that those were the wipes used to clean the glucometers. CNA #1 verified that s/he had used a Purell wipe to clean the glucometer after checking Resident #9's blood sugar. The surveyor showed CNA #1 the back of the wipe and CNA #1 verified the wipe contained 62% ethyl alcohol. CNA #1 was asked and stated that it didn't matter which glucometer was used, that staff just pick one from the charger (at random) to use to check the blood sugars. During an interview on 7/15/13 at 5:25 PM, CNAs #1 and #2 stated they had received training at the beginning of the year on how to use the new brand of glucometers and how to clean them. However, they did not recall training on the type of wipes to be used. During an interview on 7/15/13 at 5:30 PM, the Administrator and Minimum Data Set (MDS) Assessment Nurse were present. They were both informed of a concern that the glucometers had not been cleaned appropriately. The surveyor asked the Administrator and MDS nurse about when glucometers should be cleaned and what should be used to clean them. The Administrator attempted to contact a Clinical Coordinator by phone to get information on the cleaning of the glucometers. The MDS nurse stated that s/he thought the glucometers should be cleaned each time after each use. S/he stated that staff were to use soap to wash the glucometers, then stated that maybe they should ask RN #1 if alcohol was supposed to be used. When asked, the MDS Coordinator stated that s/he did not perform blood sugar checks or clean glucometers, nor was s/he responsible for providing any staff education on glucometers. On 7/15/13 at 5:35 PM, the Administrator was notified of Immediate Jeopardy related to the inappropriate cleaning of the glucometers. During an interview on 7/16/13 at 9:45 AM, the Chief Nursing Officer for the facility provided additional information that included the statements of the 2 CNA staff members observed improperly cleaning the glucometers along with a statement from the Activities Coordinator. According to the Chief Nursing Officer, the Activities Coordinator, who is not a nurse, overheard the CNAs talking about the process (of cleaning the glucometers) and gave CNA #1 the Purell hand sanitizer wipes and said, "here", indicating the CNA was to use those wipes. According to the Activities Coordinator's statement, s/he had been trying to find something (to clean the glucometers) that would work that was individually wrapped so they could be taken into the resident rooms. During an interview on 7/16/13 at 9:52 AM, the Point of Care Coordinator stated that staff had been educated on the use of the glucometers and that this included information that the meters should be cleaned with the Sani-cloth wipes between each resident use. The POC Coordinator stated that staff are not given access to the use of the meter until training that includes a check off and a post test is completed. Review on 7/16/13 of the Instructions for Use Manual for the Stat Strip Nova Biomedical Glucose Hospital Meter revealed under Cleaning the Meter, that either dilute bleach (10% solution of household bleach Sodium Hypochlorite), 70% [MEDICATION NAME] rubbing alcohol, or a commercial surface decontamination preparation approved for use by the facility could be used to clean the meter. Review on 7/16/13 of the policy provided by the facility entitled, "Nova Glucometer Skilled Unit- SHRC Only" revealed under Cleaning of the Meter, "....Use Sani-cloth to clean the exterior of the meter. All blood and other body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the Sani-cloth. Open, unfold first sani-cloth to remove heavy soil. Use second sani-cloth to thoroughly wet surface. Allow to remain wet 2 minutes, let air dry...". According to information received from the facility, there were only 3 residents (Residents #3, #9, and #10) with orders for FSBS on the skilled unit. Record review on 7/16/13 at approximately 11:30 AM revealed the facility admitted Resident #9 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record for July 2013 revealed the resident received FSBS before meals and at bedtime starting 7/6/13 at 4:30 PM through 7/12/13. On 7/13/13 the order was changed to FSBS twice daily. The resident received these twice daily checks at 7:30 AM and 4:30 PM from 7/13/13 through 7/15/13. Record review on 7/16/13 at approximately 12:00 Noon revealed the facility admitted Resident #10 with [DIAGNOSES REDACTED]. Review of the July 2013 Medication Record revealed Resident #10 received FSBS twice daily (7:30 AM and 4:30 PM) starting 7/9/13 at 4:30 PM. On 7/11/13 the order had been changed to FSBS before meals and at bedtime which the resident received 7/12/13 through 7/15/13. CFR 483.65 Infection Control, F-441 was identified at a scope and severity level of "J". The facility Administration failed to assure that appropriate policies and procedures were followed related to the cleaning and disinfection of multiple resident use glucometers. The systemic failure of the facility to effectively provide appropriate disinfection of the glucometers placed the residents at risk for serious harm. On 7/16/13, based on review of education provided to facility staff on 7/15/13-7/16/13, interviews, and review of policies and procedures, it was determined that the Allegation of Compliance submitted by the facility on 7/16/13 had been implemented by the facility and was in practice as of 7/16/13 removing the immediacy of the deficient practice. The citation at F-441 remained at a lower scope and severity of "D". The Immediate Jeopardy was removed upon exit from the facility. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 7/16/13 at 12:15 PM revealed a Physicians Order Form dated 7/9/13 at 9:40 AM which stated, "(Positive) UTI ecoli, Pt (Patient) on Cipro, resistant to Cipro, [MEDICATION NAME], + [MEDICATION NAME]". The entry had been signed by a nurse. Below the entry was a response from the Nurse Practitioner dated 7/9/13 at 10:00 PM, "Thank you! D/C (Discontinue) Cipro, [MEDICATION NAME] 300 mg (milligrams) po (By mouth) BID (twice daily) X 10 days then D/C, [MEDICATION NAME] 100 mg po BID x 10 days". Further review of the record revealed the resident had initially been placed [MEDICATION NAME] mg twice daily for 5 days on 7/4/13 after a Urinalysis had been reported as positive. The Urinalysis dated 7/4/13 revealed a large amount of blood and Leukocyte Esterase, Innumerable White blood cells per high powered field, Many Urine Bacteria, and Occasional Urine Mucous. Review of the urine culture report with a final status (last updated 7/6/13 at 5:23 PM) revealed Escherichia coli >100,000 CFU/ml that was resistant to [MEDICATION NAME]. RN #2 verified the above findings and did not know why the culture report had not been addressed sooner. During an interview on 7/16/13 at 12:40 PM, the Nurse Practitioner reviewed the reports and stated that the nurses put the lab results in a folder for the doctors to review. The Nurse Practitioner thought that since the culture report came in over the weekend, it had possibly been missed.