Every finding on record at Still Hopes Episcopal Retirement Community

Based on review of the facility policy, observation and interview, the facility failed to ensure expired medications were removed and not stored with other medications in use for residents, in 1 of 2 medication carts. Furthermore, the facility failed to ensure medications were safely stored. Specifically, medications were left prepoured and unlabeled in the top drawer of the medication cart for 1 of 2 medication carts reviewed for medication storage. Findings include: Review of the facility policy titled Administering Medications with a revision date of April 2019, revealed, Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of the undated facility policy titled Storage of Medications revealed, Policy Statement The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation . 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. During an observation on 06/11/25 at 1:39 PM, of Cart B noted a creamy, thick, white substance in a medication cup in the top drawer of the cart, as well as an opaque creamy substance in a medication cup on the top of Cart B. During an interview with Registered Nurse (RN)1 on 06/11/25 at approximately 3:55 PM revealed these are only topical creams not tablets, they should not matter. I was going to give the medications and one resident was in the bathroom and the other resident was in therapy, so I just stuck them in the cart for later. RN1 stated one is Voltaren cream and one is Vaseline for a dressing change. During an observation of Cart A on 06/11/25 at approximately 3:30 PM, revealed a bottle of Tramadol in the narcotic drawer which expired on 5/2024. During an interview with Licensed Practical Nurse (LPN)1 on 06/11/25 at approximately 3:30 PM, revealed that should not be in the cart. LPN1 stated that should have been given back to resident's spouse. During an interview on 06/11/25 at 4:43 PM, the Assistant Director of Nursing (ADON) stated expired meds should be removed from the medication cart and disposed of, medications should not be poured and left in the med cart.

Based on interview, observations, and record review, the facility failed to ensure infection control procedures were followed for one Resident (R) R13 of six residents reviewed during medication administration. The nurse failed to ensure the blood glucometer used to obtain the resident's glucose level was properly sanitized prior to use and failed to ensure the glucometer was placed on a clean barrier in the resident's room during use. A total of 8 residents were reviewed in the sample. Findings include: The facility's undated Obtaining a Fingerstick Glucose Level Policy read, in pertinent part, Steps in the Procedure; and 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. The (Assure Platinum) Glucometer's undated Instructions for Use read, in pertinent part, The disinfecting procedure is needed to prevent transmission of bloodborne pathogens. Disinfectants recommended for use with the Assure Platinum Glucometer included Super Sani-Cloth Germicidal Disposable Wipes (the disinfectant available in the facility's medication carts for use when sanitizing glucometers and other multi-use equipment). Alcohol prep pads were not indicated as an appropriate product for the disinfection of the Assure Platinum Glucometer. R13's Admission Record, dated 04/17/24 and found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including type 2 diabetes. R13's admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 03/06/24 and found in the EMR under the MDS tab, indicated the resident was moderately cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of nine out of 15. R13's Order Summary Report, dated 04/17/24 and found in the EMR under the Orders tab, indicated orders for the resident's blood sugar to be obtained twice daily. R13's Medication Administration Record (MAR), dated 04/01/24 through 04/17/24 and found in the EMR under the Orders tab, indicated the blood sugar testing was being administered routinely per physician's orders. Registered Nurse (RN1) was observed administering R13's's medication on 04/17/24 at 8:13 AM. RN1 obtained the blood glucometer, used for all residents receiving blood sugar checks, from the medication cart and proceeded to the resident's room to administer his medication and obtain his blood sugar. RN1 placed the glucometer on the resident's overbed table, without a clean barrier between the glucometer and the un-sanitized surface of the overbed table, while administering the resident's oral medication. RN1 then used the glucometer to obtain the resident's blood glucose level prior to returning to the medication cart. RN1 wiped the glucometer for approximately three seconds with an alcohol prep pad prior to placing the glucometer back into the medication cart. A facility approved sanitizer was not observed to be used to properly sanitize the glucometer prior to or after use for R13. During an interview with RN1 on 04/17/24 at 8:38 AM, RN1 stated she always used an alcohol prep pad to sanitize the blood glucometer before and after use and was not aware she was to use a clean barrier when placing the glucometer on an un-sanitized surface in a resident's room. RN1 showed the surveyor a container of Sani-Wipe disinfectant wipes she obtained from the bottom drawer of the medication cart and stated, We can use this (to sanitize the glucometer) or we can use an alcohol pad. I use the alcohol pad. During an interview with the Assistant Director of Nursing (ADON) on 04/17/24 at 09:51 AM, the ADON confirmed R13 was the only resident receiving blood glucose monitoring via the glucometer on the medication cart at the time of the survey and stated her expectation was facility glucometers were to be sanitized with the facility's approved sanitizing solution (Sani-Wipe) and then was expected to be allowed to dry for the two minutes indicated on the product instructions for use prior to and after each resident's blood glucose was obtained to ensure all pathogens on the surface of the machine were eliminated. She stated her expectation was a clean barrier was always to be used when placing a glucometer down on any un-sanitized surface.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure 1 of 3 Residents (R)1 was free from a significant medication error. On 2/17/23 at approximately 11:25 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 2/17/23 at 1:22 PM the Administrator and the Director of Nursing were notified that the allegation of administration of the wrong medication to Resident (R)1 by staff member, Registered Nurse (RN)1 constituted Immediate Jeopardy (IJ) at F760, with an effective date of 2/2/23. The facility presented an acceptable plan of removal for the IJ on 2/17/23 at 3:55 PM. The survey team validated that the immediate jeopardy was removed on 2/17/23 at 3:55 PM following the facility's implementation of the plan of removal of the immediate jeopardy. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F760, constituting substandard quality of care. Findings include: Review of the facility's policy titled,Insulin Administration, last revised September 2014, revealed, To provide guidelines for the safe administration of insulin to residents with diabetes. 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. Review of the Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE]. R1 was admitted with diagnoses including, but not limited to; type 2 diabetes mellitus with hyperglycemia, chronic kidney disease state and long term use of insulin. Review of R1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/18/23 revealed he had a Brief Interview of Mental Status (BIMS) score of 11 out of 15, indicating he was cognitively intact. Review of R1's Physician's order revealed an order which states, Insulin Glargine Subcutaneous Solution Pen-Injector 100 UNIT/ML (Insulin Glargin Inject 25 units subcutaneous in the evening related to Type 2 diabetes and NovoLOG Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: If 0- 77 = CALL MD, 71-149 = 0, 150 - 199 = 2 units, 200- 249 = 4 units, 250- 299 = 6 units, 300 - 349 = 8 units, 350- 399 = 10 units, 400+ CALL MD. Review of R1's Care Plan revealed a risk of complications such as hyperglycemia and hypoglycemia, skin breakdown and imbalance nutrition due to medical DX of Diabetes Mellitus. R1 is on long term insulin. R1's goal is to be free from an s/sx (signs or symptoms) of hyperglycemia and hypoglycemia through the review date and he will not have any complications related to diabetes though the review date . The listed interventions includes R1 will get medications as ordered by doctor. Monitor/document for side effects and effectiveness. Dietary consult for nutritional regimen and ongoing monitoring. Fasting Blood Sugars as ordered by doctor. Monitor/document/report PRN [as needed] any s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing, acetone breath (smells fruity) stupor, coma. Monitor/document/report PRN any s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Offer substitutes for food not eaten. Review of R1's Medication Administration record (MAR) revealed on 2/2/23 at 2100 [9 PM], Registered Nurse (RN)1 administered 25 units of Insulin Glargine. Review of R1's progress notes revealed a note which read, 2/3/23 0115 Notified R1 is unable to respond verbally to staff, observed to be laying in bed flailing his arms and not able to verbally respond to staff, FSBS 43. An additional noted dated 2/3/23 at 0115 revealed R1 was observed to be irritable, sweating, and not able to respond verbally. Vitals taken: BP 145/66, O2 88% on RA, RR 23, and temp 98.7. Oxygen administered via nasal canula at 2L. O2 sat up to 93%. Blood sugar checked and read 43. Glucagon 1mg injection administered to [NAME]. Blood sugar recheck read 52, Glucagan 1 mg administered again in LLQ and recheck read 67. R1 was able to respond verbally and reported he felt better. Additional notes in R1's EMR read, 2/3/23 0541- R1's FSBS 383. Notified MD and orders not to give insulin at this time and re-check at normal time before breakfast. 2/3/23 0730 MD notified that R1's BS 435. VO [verbal order] given via phone to administer 3 units of Novolog since R1 recently had a drop to a BS of 43. 0845 Another called given to MD. R1 has since vomited x1. Vital Signs stable, BS 319 since insulin administration, R1 request to go to hospital since he does not feel well and doesn't know why he feel this way. During an interview on 02/17/23 at 09:24 AM, the Director of Nursing (DON), Assistant DON and Administrator were all present. The DON reported on 2/2/23 a nurse who works the 7:00PM-11:00 PM shift PRN, (RN1) pulled the wrong insulin, and R1 had a hypoglycemia episode around 1:00 AM. During R1's stay with the facility, he had not previously experienced a hypoglycemia event and that is how they were able to figure out he had been administered the wrong insulin. RN1 was not aware she had administered the wrong insulin until the incident was investigated. R1, his spouse and MD were advised of the event. RN1 was given verbal education following the incident, training was scheduled, and the facility's Pharmacist has been asked to come and conduct training on Insulin administration. During an interview with Human Resources (HR) on 2/17/23 at 12:59 PM HR reported, all staff have received annual training and on 1/2023 to include medications/insulin. RN1 was provided additional training related to insulin, which was completed on 2/16/23. During an interview with the Medical Director on 2/17/23 at 1:09 PM, he reported receiving a call in the middle of the night about R1 having a hypoglycemic event. It was reported that R1 was shaky and he had a low blood sugar. He was given crackers and administered Glucagon x 2 and had another episode of hypoglycemia and he was sent to the ER. The MD stated the nurse reported later in the evening about an insulin error, which is currently being investigated. MD stated, R1 had never had a problem with low blood sugars, only high blood sugars, so this was very unusual for him to have a hypoglycemic event. During an interview with RN1 on 2/17/23 at 1:51 PM, she reported, I thought I had given the Glargine insulin but instead I administered regular insulin Aspart. RN1 reported I checked the insulin Aspart three times, but I had a distraction with another medication and was confident the insulin was correct. I thought I used the five rights of medication administration. RN1 reported the regular insulin Aspart was R1's sliding scale insulin and the 2 insulins are stored in 2 different bags. The insulin pens are in one bag on the top of the cart and the bottle of insulin is in another. RN1 stated, I did not realize I had given the wrong insulin and had a medication error until I was called by the facility reporting R1 had a hypoglycemia event at around 1-2:00 AM. She reported completing her med pass at 10:00 PM and her shift was over at 11:00 PM. When R1 had the hypoglycemic episode, she was not in facility. RN1 reported she was provided with reeducation, and this was her first medication error for R1 and herself.

Based on observations, interviews, and the review of facility policies, the facility failed to ensure dishware was properly dried prior to stacking and the ice-scoop, properly stored. The facility also failed to ensure proper maintenance of the ice machine, ice-cream covers, and floors. In addition, the facility failed to practice the safe handling of food during the measuring of food temperatures. Findings include: A brief review of the facility's policy dated 3/21/2017 and titled Food Storage revealed Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. A brief review of the facility's policy dated 5/22/2017 and titled Cleaning Instructions: Ice Machine and Equipment revealed Store ice scoop beside or on the machine in a clean non-porous container that allows the water to drain off and not pool around the scoop. A brief review of the facility's policy dated 6/10/2017 and titled Floor Safety revealed 1. Floor will be kept clean and dry A brief review of the facility's policy dated 3/21/2017 and titled Cleaning Dishes/Dish Machine revealed 9. Dishes should be air-dried on the racks. Do not dry with towels. 10. Inspect for cleanliness and dryness, and put dishes away if clean (be sure clean hands or gloves are used) 11. Dishes should not be nested unless they are completely dry. During the initial tour of the main kitchen on 02/22/22 at 10:45 AM, accompanied by the Certified Dietary Manager (CDM), an observation of the dishware area revealed sixteen-six inch deep stainless steel pans stacked, wet (wet nesting). In addition, a cardboard box with a large number of onions, among them were three partially spoiled ones. An observation of the satellite kitchen on 02/22/22 at 11:05 AM, on the rehab unit, revealed the ice-cream covers were soiled and sticky. The floor was also sticky to the point the surveyor's shoes came off while walking on it. The ice machine of this kitchen has dark, black buildup inside the door and the ice scoop was not in an appropriate draining container. During a follow-up visit on 02/23/22 at 11:35 AM, an observation of the lunch meal temperatures revealed the Dietary Aide, after touching several surfaces with her gloved hands, grabbed a piece of cook meatloaf with the same gloved hand and took its temperature and proceeded with her work until she was stopped by the surveyor. The CDM was also present at this time. An interview with the CDM on 02/23/22 at 11:40 AM confirmed the above findings.

Based on observation, interview, and review of facility policy and procedure the facility failed to ensure 1 of 1 staff Licensed Practical Nurse (LPN)2 performed proper hand hygiene for 2 of 2 Residents (R)7 and 14) during medication administration. Specifically, the failure to perform hand hygiene has the potential to cause infections within the residents during medication administration. Findings include: Review of undated facility policy titled Instillation of Eye Drops revealed, Steps in the procedure .2. Wash and dry your hands thoroughly. 3. Put on gloves .13. Remove gloves and discard into designated container. Wash and dry your hands thoroughly . During an observation of eye drop medication administration of R7 on 02/23/22 at 8:38 AM revealed LPN2 donned a pair of clean gloves post administration of by mouth pills (PO) without sanitizing her hands for administration of the eye drops. During an observation of intravenous medication administration of R14 on 02/23/22 at 9:47 AM LPN 2 performed hand hygiene and donned clean gloves. The intravenous (IV) bag of medication was hung on the IV pole, the tubing line was primed (medication flowed through the line), and gloves removed post priming the IV tubing with no hand hygiene performed and clean gloves donned. During an interview on 02/23/22 at 09:50 AM with LPN2 stated, Yes I didn't perform hand hygiene when I should have.

Based on observation and interview, the facility failed to ensure that expired medications were removed from the Medication Dispensing System to prevent administration to residents in 1 of 1 Medication Dispensing System. The findings included: On 05/30/19 at 09:22 AM, review of the medication dispensing cabinet revealed multiple doses of multiple expired medications as listed: [MEDICATION NAME] Trihydrate 250 milligrams - 6 tablets, expired 03/14/19 [MEDICATION NAME] 250 milligrams - 5 tablets, expired 05/14/19 [MEDICATION NAME] 500 milligrams - 4 tablets, expired 05/22/19 Aripiprazole 5 milligrams - 6 tablets, expired 05/21/19 [MEDICATION NAME] XL 150 milligrams - 4 tablets, expired 05/25/19 [MEDICATION NAME] 200 milligrams - 1 tablet, expired 05/21/19 [MEDICATION NAME] 5 milligrams - 5 tablets, expired 05/25/19 [MEDICATION NAME] 5 milligrams - 1 tablet, expired 05/16/19 [MEDICATION NAME] 75 milligrams - 11 tablets, expired 05/14/19 [MEDICATION NAME] 0.6 milligrams - 8 tablets, expired 05/16/19 [MEDICATION NAME] 10 milligrams - 5 tablets, expired 05/21/19 Carvedilol 3.125 milligrams - 11 tablets, expired 05/14/19 Cranberry Capsules 405 milligrams - 6 tablets, expired 05/25/19 [MEDICATION NAME] 300 milligrams - 1 tablet, expired 05/10/19 [MEDICATION NAME] 500 milligrams - 2 tablets, expired 05/14/19 [MEDICATION NAME] 4 milligrams - 7 tablets, expired 05/14/19 [MEDICATION NAME] Sodium 125 milligrams - 1 tablet, expired 05/09/19 Folic Acid 1 milligram - 5 tablets, expired 05/03/19 [MEDICATION NAME] 10 milligrams - 3 tablets expired 05/09/19, 1 tablet expired 05/24/19 [MEDICATION NAME] ER 30 milligrams - 4 tablets expired 05/22/19 [MEDICATION NAME] 5 milligrams - 6 tablets expired 05/14/19 [MEDICATION NAME] Chloride 5 milligrams - 6 tablets expired 05/28/19, 1 tablet expired 05/01/19 [MEDICATION NAME] 0.25 milligrams - 5 tablets expired 05/24/19 [MEDICATION NAME] 600 milligrams - 1 tablet expired 05/22/19 [MEDICATION NAME] 50 milligrams - 4 tablets expired 05/28/19 [MEDICATION NAME] Sodium Extended 100 milligrams - 3 tablets expired 05/16/19 [MEDICATION NAME] 25 milligrams - 5 tablets expired 05/16/19 [MEDICATION NAME] 10 milligrams - 2 tablets expired 05/22/19 [MEDICATION NAME] 1 gram - 2 tablets expired 05/15/19 [MEDICATION NAME] Sodium 25 micrograms - 4 tablets expired 05/14/19 [MEDICATION NAME] 2.5 milligrams - 3 tablets expired 05/14/19 [MEDICATION NAME] Sodium 100 micrograms - 5 tablets expired 05/24/19, 1 tablet expired 05/14/19 [MEDICATION NAME] 100 milligrams - 7 tablets expired 05/24/19, 3 tablets expired 05/14/19 [MEDICATION NAME] Sodium 1 milligram - 3 tablets expired 05/10/19 [MEDICATION NAME] Sodium 3 milligrams - 5 tablets expired 05/14/19 [MEDICATION NAME] Sodium 5 milligrams - 3 tablets expired 05//22/19 Moxifloxacin 400 milligrams 5 tablets expired 05/04/19 [MEDICATION NAME] 7.5 milligrams - 6 tablets expired 05/09/19 [MEDICATION NAME] 500 milligrams - 4 tablets expired 05/16/19 Sterile Water for Injection, 10 milliliter - 3 vials expired 01 (MONTH) 2019 Vitamin K1 Injection 10 milligrams per milliliter - 5 -1 milliliter [MEDICATION NAME] expired 1 (MONTH) 2019 During an interview at the time of the review, the Director of Nursing (DON) stated the pharmacist comes weekly and also stated the pharmacist conducts a review of the (Autonomous Pharmacy Name) for expired medications. The DON stated the facility only had 1 set of keys for the (Autonomous Pharmacy Name) and that the nursing staff do not check the machine for expired medications. During an interview on 05/30/19 at 12:58 PM, the Director of Nursing (DON) stated the facility had an issue approximately 1 year ago with medications not being obtained timely. The DON further stated the staff was re-educated regarding using the back-up pharmacy. Two Pharmacy Consultants, Consultant #1 and Consultant #2, were also present and stated the pharmacist and a pharmacy technician came to the facility 2 times a week for restocking and checking expiration dates. Consultant #1 stated that the pharmacist, Consultant #2, thought the technician was checking the expiration dates but the technician did not.

Based on record review and interview, the facility failed to ensure that policies and procedures were followed to ensure that medications were administered as ordered for Resident #15, 1 of 6 residents sampled for unnecessary medication review. The findings included: Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's Physicians Orders revealed an order dated 07/20/18 for [MEDICATION NAME] 5 mg (milligrams) every 24 hours as needed at bedtime for [MEDICAL CONDITION]. On 05/29/19 at 10:30 AM, review of Resident #15's Daily Skilled Nurse's Note dated 07/20/18 through 07/28/19 revealed a note dated 07/20/18 at 16:40 indicating the nurse attempted to administer an antibiotic, Keflex, to Resident #15 and the resident reported s/he had already received an antibiotic. The note revealed the (Autonomous Pharmacy Name) report indicated the LPN (Licensed Practical Nurse) had [MEDICATION NAME] the resident. Further review of the nursing notes revealed a note dated and timed 07/24/18 at 08:09 [MEDICATION NAME] when arrived via (her/his) spouse. Review of the Controlled Substance Declining Inventory Record revealed one tablet [MEDICATION NAME] milligrams was received but did not indicate where the medication was received from. The documentation indicated the LPN administered 1 tablet on 07/22/18 at 22:16 PM. Review of a Medication Administration Incident Report dated 07/24/18 revealed the previous shift nurse had received a bottle of medication from a family member with one tablet [MEDICATION NAME] the nurse indicated s/he administered the whole 10 milligram tablet. Review of the facility's policy entitled Medications Brought to the Facility by the Resident/Family revealed If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician and Consultant Pharmacist, shall check to ensure that: a. State laws and regulations allow such use; b. The medications have been ordered by the resident's Attending Physician, and documented on the physician's orders [REDACTED]. The contents of each container have been verified by a licensed pharmacist. During an interview on 05/30/19 at 12:58 PM, the Director of Nursing (DON) confirmed the nurse [MEDICATION NAME] Keflex was ordered. The DON also confirmed the resident received 10 milligrams [MEDICATION NAME] of 5 milligrams as ordered. The Director of Nursing stated the facility had an issue approximately 1 year ago with medications not being obtained timely. Staff was re-educated regarding using the back-up pharmacy. The DON stated s/he did not know why the nurse did not utilize the back-up pharmacy and stated that s/he should have obtained the medication from the back-up pharmacy if it wasn't available in the (Autonomous Pharmacy Name). Two Pharmacy Consultants were also present during the interview and Pharmacy Consultant #1 stated that the Pharmacist (Pharmacy Consultant #2) and a pharmacy technician come to the facility 2 times a week for restocking and checking expiration dates. Consultant #1 further stated that the pharmacy had a cut-off time for sending requests for medications of 05:30 PM Monday through Friday and 3:00 PM on Saturday for receiving medications the same day which would then be delivered between 09:00 - 10:00 PM. In addition, the facility uses (Name of Pharmacy) for back-up if the medication was not available in the (Autonomous Pharmacy Name) medication dispensing system.

Based on record review and interview, the facility failed to administer medications as ordered for Resident #15, 1 of 6 residents for unnecessary medication review. Resident #15 received a dose of an incorrect antibiotic and received twice the dose of an ordered hypnotic, [MEDICATION NAME]. The findings included: Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's Physicians Orders revealed an order dated 07/20/18 for [MEDICATION NAME] 5 mg (milligrams) every 24 hours as needed at bedtime for [MEDICAL CONDITION]. On 05/29/19 at 10:30 AM, review of Resident #15's Daily Skilled Nurse's Note dated 07/24/18 at 08:09 [MEDICATION NAME] when arrived via (her/his) spouse. Review of the Controlled Substance Declining Inventory Record revealed one tablet [MEDICATION NAME] milligrams was received 07/22/18 but did not indicate where the medication was received from. The documentation indicated the LPN administered 1 tablet on 07/22/18 at 22:16 PM. Review of a Medication Administration Incident Report dated 07/24/18 revealed the previous shift nurse had received a bottle of medication from a family member and handed the LPN one tablet [MEDICATION NAME] the nurse indicated s/he administered the whole 10 milligram tablet. Review of Resident #15's Hospital History and Physical dated 07/08/18 revealed Resident #15 had been on [MEDICATION NAME] 10 mg at bedtime. The admitting physician indicated that the [MEDICATION NAME] was to be held as it was on the DeBeers List (A list by the American Geriatrics Society (AGS) for Potentially Inappropriate Medication Use in Older Adults) and not recommended in the elderly at that dose. Review of the discharge documentation revealed orders for [MEDICATION NAME] 5 mg at bedtime as needed on the 07/08/18 discharge summary from the hospital. During an interview on 05/30/19 at 12:58 PM, the Director of Nursing (DON) confirmed the resident received 10 milligrams [MEDICATION NAME] of 5 milligrams as ordered. The Director of Nursing stated the facility had an issue approximately 1 year ago with medications not being obtained timely. The DON stated the staff was re-educated regarding using the back-up pharmacy. The DON stated s/he did not know why the nurse did not utilize the back-up pharmacy and stated that s/he should have obtained the medication from the back-up pharmacy if it wasn't available in the (Autonomous Pharmacy Name). Two Pharmacy Consultants were also present during the interview and Pharmacy Consultant #1 stated that the pharmacy had a cut-off time for sending requests for medications of 05:30 PM Monday through Friday and 3:00 PM on Saturday for receiving medications the same day which would then be delivered between 09:00 - 10:00 PM. In addition, Pharmacy Consultant #1 stated the facility was to use (Pharmacy Name) for back-up if the medication was not available in the (Autonomous Pharmacy Name) medication dispensing system.

Based on record review and interview, the facility failed to provide evidence of written notice of transfer for Residents #4, 5 and 14 to the Residents Responsible Party for 3 of 3 resident's reviewed for hospitalization . The findings included: Resident #4 was admitted with [DIAGNOSES REDACTED]. During review of the medical record on 6/06/18 revealed that Resident #4 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the medical record shows no documentation that a written notice of transfer was given to the Resident #4 or to his/her Emergency Contact. The Skilled Assessment Progress Note on 5/6/18 at 18:31 states, .Notified on call physician of her (Resident #4) symptoms and received an order to send her/him to the LMC ER. Husband also notified and stated he would meet her/him at the ER. Around 9:45 PM her/his husband called and notified that she/he was being admitted . During an interview on 6/7/18 at 9:19 AM with the DON and the ADON (Assistant Director of Nursing) said that the Facility sends with the resident to the hospital a copy of the SBAR Communication Form and Progress Note. Both the DON and the ADON validated that no written documentation that a written notice of transfer was given to Resident #4 or to his/her Emergency Contact at the time of Resident #4's transfer to the hospital nor was a written notice of transfer mailed to the resident or his/her Emergency Contact. Resident #14 was admitted with [DIAGNOSES REDACTED]. During review of Resident #14's medical record on 6/6/18 revealed that Resident #14 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the medical record shows no documentation that a written notice of transfer was given to Resident #14's (RP) Responsible Party. The Health Status Note on 5/1/18 at 11:30 states: .MD made aware and spoke to daughter both feel resident should be evaluated at the hospital. During an interview on 6/7/18 at 9:19 AM with the DON and the ADON (Assistant Director of Nursing) said that the Facility sends with the resident to the hospital a copy of the SBAR Communication Form and Progress Note. Both The DON and the ADON validated that no written documentation that a written notice of transfer was given to Resident #4 or to his/her Emergency Contact at the time of Resident #4's transfer to the hospital nor was a written notice of transfer mailed to the resident or his/her Emergency Contact. Review of the form titled, Transfer or Discharge, Emergency, states: .4. Should it become necessary to make and emergency transfer or discharge to a hospital or other related institution , our facility will implement the following Procedures: a. Notify the resident's Attending Physician, b. Notify the receiving facility that the transfer is being made., c. Prepare the resident for transfer;, d. Prepare a transfer form to send with the resident;, e. Notify the representative (sponsor) or other family member;, f. Assist in obtaining transportation; and, g. Others as appropriate or as necessary. The facility admitted Resident #5 on 4-24-18 with [DIAGNOSES REDACTED]. Review of Progress Notes on 06/07/18 at 02:13 PM revealed that the resident was alert and oriented x 4 and repeatedly refused administration of sliding scale insulin based on finger stick blood sugars. S/he had chronic [MEDICAL CONDITION] of bilateral lower extremities of which her/his physician and oncologist were aware. The resident was seen by the oncologist on 5-22-18 and, after being seen by the attending physician/extender at the facility on 5-23-18 for [MEDICAL CONDITION], ankle pain, and weight gain, was sent to the emergency room . The resident returned to the facility with a [DIAGNOSES REDACTED]. On 5-27-18 at 8:30 AM, the Certified Nursing Assistant notified the nurse of the resident's heart rate of 162 and blood pressure of 81/59. The ambulance was called and the resident was transported to the emergency room . There was no evidence in the record that the resident and resident representative had been given written notices of transfer on either the 5-23-18 or the 5-27-18 facility-initiated transfer. During an interview on 06/07/18 at 03:06 PM, when asked if the resident and resident's representative had been notified in writing of the reasons for the transfers, the Director of Nursing stated Resident #5 had been sent to the hospital each time with a packet of transfer documents that included the reason for transfer. After review of these documents, it was noted that they did not specify that a copy had been given to the resident or the resident's representative.

Based on record review and interview, the facility failed to provide evidence of written notice of Bed- Hold for Residents #4, 5, 14, for 3 of 3 residents reviewed for hospitalization . The Bed-Hold policy did not include required information related to the Right-to- Return for 3 of 3 residents reviewed for hospitalization . The findings included: Resident #4 was admitted with [DIAGNOSES REDACTED]. During review of the medical record on 6/06/18 revealed that Resident #4 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the medical record shows no documentation that a written notice of a Bed Hold was given to the Resident #4 or to his/her Emergency Contact. During an interview on 6/7/18 at 9:19 AM with the both DON and the ADON validated that no written documentation that a written notice of Bed Hold was given to Resident #4 or to his/her Emergency Contact at the time of Resident #4's transfer to the hospital nor was a written notice of Bed Hold mailed to the resident or his/her Emergency Contact. Resident #14 was admitted with [DIAGNOSES REDACTED]. During review of Resident #14's medical record on 6/6/18 revealed that Resident #14 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of the medical record shows no documentation that a written notice of bed hold was given to Resident #14's (RP) Responsible Party. During an interview on 6/7/18 at 3:06 PM with both The DON and the ADON validated that the no written documentation that a written notice of a Bed Hold was given to Resident #14 or to his/her Responsible Party at the time of Resident #14's transfer to the hospital nor was a written notice of bed hold mailed to the Resident's RP. The DON and the DON show the Admission Agreement for Still Hopes which is given to residents on admission which states: 6. Bed Hold: If we hold or reserve a vacant bed for you at your request and the charges for the bed are not paid by insurance or any third-party payor, you are responsible for paying our daily charges for the bed each day we hold or reserve the bed for you. Our bed/hold/reservation requirements are set forth in Attachment C to this Agreement. The form titled, Still Hope Nursing Facility Admission Agreement, Attachment C, Facility Bed Hold Policy, states:, Policy Statement: Our facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed-hold policy. Policy Interpretation and Implementation: I understand in the care of hospitalization , if I fail to notify the Social Service Director and/or the Business Manager of my intentions, the bed will be filled with another resident twenty-four hours after I have been discharged to the hospital. I understand in the event of hospitalization , Still Hopes Retirement Community will hold the bed open for readmission provided the responsible party chooses to do so. In the event the Business Manger and or Social Worker are not notified of your decision on the bed hold, the bed will be released for occupancy twenty-four hours after discharge . During an interview on 06/07/2018 the DON verified that the Bed-Hold Policy did not include the right to be readmitted to the 1st available bed. The DON said that he/she was not aware of this. The facility admitted Resident #5 on 4-24-18 with [DIAGNOSES REDACTED]. Review of Progress Notes on 06/07/18 at 02:13 PM revealed that the resident was alert and oriented x 4 and repeatedly refused administration of sliding scale insulin based on finger stick blood sugars. S/he had chronic [MEDICAL CONDITION] of bilateral lower extremities of which her/his physician and oncologist were aware. The resident was seen by the oncologist on 5-22-18 and, after being seen by the attending physician/extender at the facility on 5-23-18 for [MEDICAL CONDITION], ankle pain, and weight gain, was sent to the emergency room . The resident returned to the facility with a [DIAGNOSES REDACTED]. On 5-27-18 at 8:30 AM, the Certified Nursing Assistant notified the nurse of the resident's heart rate of 162 and blood pressure of 81/59. The ambulance was called and the resident was transported to the emergency room . There was no evidence in the record that the resident and resident representative had been given written notices of bedhold on either the 5-23-18 or the 5-27-18 facility-initiated transfer. During an interview on 06/07/18 at 03:06 PM, when asked if the resident and resident's representative had been notified in writing of the facility's bedhold policies, the Director of Nursing (DON) stated Resident #5 had been sent to the hospital each time with a packet of transfer documents that included the bedhold policy. After review of these documents, it was noted that they did not specify that a copy had been given to the resident or the resident's representative. During a review of the facility's bedhold policy with the DON, s/he verified it did not include the resident's right to be readmitted and stated s/he was unaware of this requirement

Based on record reviews and interviews, the facility failed to ensure that 2 of 5 sampled residents reviewed for nutrition had medications available for administration. Resident #15 did not have [MEDICATION NAME] (anticoagulant) and Resident #221 did not have [MEDICATION NAME] (steroid) Solution, [MEDICATION NAME] (anticonvulsant), or Eliquis (anticoagulant) available for administration. The findings included: The facility admitted Resident #15 on 5-16-18 with [DIAGNOSES REDACTED]. Record review on 6/06/18 at 1:50 PM revealed an admission physician's orders [REDACTED]. Inject 0.5 ml subcutaneously one time a day for 5 weeks. Review of the Medication Administration Record [REDACTED]. The reason code entered was 9 (Other-See Progress Notes). Progress Notes for 6-1-18 reviewed on 6/06/18 at 2:48 PM stated that the [MEDICATION NAME] was unavailable. Pharmacy called and spoke to (representative) to confirm that medication will come in today. MD made aware of missed dose. During an interview on 6/07/18 at 12:21 PM, the Unit Manager (UM) stated that the medication was not on-site in the Omnicell Pharmacy Dispensing System and that the nurse should have reordered the medication from the pharmacy before the supply was exhausted. The UM also stated that the nurse could have used the back-up pharmacy if the medication would be unavailable in a timely manner. When asked about the order date, the UM supplied a printout indicating the medication was not reordered until 6-1-18. The facility admitted Resident #221 on 6-1-18 with [DIAGNOSES REDACTED]. Record review on 06/05/18 04:21 PM revealed admission (6-1-18) physician's orders [REDACTED]. Apply to gums topically onetime a day for gum discomfort, [MEDICATION NAME] tablet 500 mg. Give one tablet by mouth two times a day ., and Eliquis tablet 2.5 mg. Give 1 tablet by mouth two times a day for [MEDICAL CONDITION] ([MEDICAL CONDITION] [MEDICATION NAME]. Review of the MAR indicated [REDACTED]. The Eliquis and [MEDICATION NAME], both ordered twice daily, were not started until 6-2-18. The reason codes referred to the Progress Notes. Progress Notes for 6-1-18 at 11:07 PM reviewed on 6/06/18 at 9:38 AM stated that the medications were not on hand. Progress Notes for 6-2-18 and 6-3-18 indicated the medication was on order. During an interview on 6/07/18 at 12:03 PM, the UM reviewed the record to check the resident's admission arrival time and found it to be 12:49 PM. S/he stated they should have gotten the medications from the pharmacy that evening if ordered before 5 PM. If not, we have backup at (pharmacy) 24/7. The UM checked the Omnicell list and stated that the dispensing system had both the Eliquis 2.5 mg and [MEDICATION NAME] 250 mg and 500 mg. The UM further stated,We would expect the nurses to check all resources and give the medication as ordered. The pharmacy policy titled Medication Shortages/Unavailable Medications states I. Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy .2.2 If the next available delivery causes delay or a missed dose ., Facility nurse should obtain the medication from the Emergency Medication Supply . 2.3 If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery . 3. If a medication shortage is discovered after normal Pharmacy hours: . 3.2. If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1. Emergency delivery; or, 3.2.2 Use of an emergency (back-up) Third party Pharmacy.

Based on record reviews and interviews, the facility failed to follow policies to ensure that significant medication errors were not incurred for 2 of 5 sampled residents reviewed for nutrition. Resident #15 did receive [MEDICATION NAME] (anticoagulant) and Resident #221 did not receive [MEDICATION NAME] (steroid) Solution, [MEDICATION NAME] (anticonvulsant), or Eliquis (anticoagulant) because they were available for administration. The findings included: The facility admitted Resident #15 on 5-16-18 with [DIAGNOSES REDACTED]. Record review on 6/06/18 at 1:50 PM revealed an admission physician's orders [REDACTED]. Inject 0.5 ml subcutaneously one time a day for 5 weeks. Review of the Medication Administration Record [REDACTED]. The reason code entered was 9 (Other-See Progress Notes). Progress Notes for 6-1-18 reviewed on 6/06/18 at 2:48 PM stated that the [MEDICATION NAME] was unavailable. Pharmacy called and spoke to (representative) to confirm that medication will come in today. MD made aware of missed dose. During an interview on 6/07/18 at 12:21 PM, the Unit Manager (UM) stated that the medication was not on-site in the Omnicell Pharmacy Dispensing System and that the nurse should have reordered the medication from the pharmacy before the supply was exhausted. The UM also stated that the nurse could have used the back-up pharmacy if the medication would be unavailable in a timely manner. When asked about the order date, the UM supplied a printout indicating the medication was not reordered until 6-1-18. The facility admitted Resident #221 on 6-1-18 with [DIAGNOSES REDACTED]. Record review on 06/05/18 04:21 PM revealed admission (6-1-18) physician's orders [REDACTED]. Apply to gums topically onetime a day for gum discomfort, [MEDICATION NAME] tablet 500 mg. Give one tablet by mouth two times a day ., and Eliquis tablet 2.5 mg. Give 1 tablet by mouth two times a day for [MEDICAL CONDITION] ([MEDICAL CONDITION] [MEDICATION NAME]. Review of the MAR indicated [REDACTED]. The Eliquis and [MEDICATION NAME], both ordered twice daily, were not started until 6-2-18. The reason codes referred to the Progress Notes. Progress Notes for 6-1-18 at 11:07 PM reviewed on 6/06/18 at 9:38 AM stated that the medications were not on hand. Progress Notes for 6-2-18 and 6-3-18 indicated the medication was on order. During an interview on 6/07/18 at 12:03 PM, the UM reviewed the record to check the resident's admission arrival time and found it to be 12:49 PM. S/he stated they should have gotten the medications from the pharmacy that evening if ordered before 5 PM. If not, we have backup at (pharmacy) 24/7. The UM checked the Omnicell list and stated that the dispensing system had both the Eliquis 2.5 mg and [MEDICATION NAME] 250 mg and 500 mg. The UM further stated,We would expect the nurses to check all resources and give the medication as ordered. The pharmacy policy titled Medication Shortages/Unavailable Medications states I. Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy .2.2 If the next available delivery causes delay or a missed dose ., Facility nurse should obtain the medication from the Emergency Medication Supply . 2.3 If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery . 3. If a medication shortage is discovered after normal Pharmacy hours: . 3.2. If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1. Emergency delivery; or, 3.2.2 Use of an emergency (back-up) Third party Pharmacy.

Based on observation, interview, and review of facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 2 of 2 kitchens reviewed and has the potential to effect 21 of 21 residents with ordered diets as evidenced by failing to do the following: Disposing of expired food items, labeling and dating opened food, wearing facial hair restraints, cleaning pans/scoops/oven and temp foods without cross contamination. The findings included: On 4/3/17 at approximately 2:16 PM, an initial tour of the main kitchen with the Assistant Director of Culinary and the Registered Dietician (RD) revealed: Kitchen area: 1.) (5) Half 2 inch Shot Gun pans and (2) Hotel 2 inch pans were stacked wet 2.) Scoops were lying in the flour, grits, bread crumb, and sugar bins with ingredients on the handles 3.) (3) kitchen staff without facial hair restraints 4.) (2) Ovens with a build-up of grease in and on the face with food spatter on the face and sides Walk-in refrigerator: 5.) (2) packages of 12 inch, 41 ounce flour tortillas with expiration dates of 1/26/17 6.) (1) package of 12 inch, spinach tortillas with a use by date of 3/28/17 7.) (5) packages of 12 inch, spinach tortillas with no expiration date 8.) (6) packages of 12 inch, tortillas with no expiration date 9.) 12 pound box of Won Ton no expiration date 10.) (1) Box of Butter Ball 8.55 ounce butter pats opened uncovered exposing pats with no expiration date Walk-in freezer: 11.) Cookie tray of 12 with 6 cookies remaining that was uncovered and undated 12.) Bag of unbaked bread rolls opened and undated 13.) Bag of 4 pizzas opened and undated 14.) Lemon Italian Cream cake opened with 6 of 12 pieces remaining and a use by date of 4/2/17 15.) 59 ounce Carrot cake opened with 1/3 remaining and a use by date of 3/21/17 Dry Storage: 16.) 32 ounce bag of Blue Diamond Almonds opened, unsealed, and undated 17.) 32 ounce bag of Pistachios opened, unsealed and undated 18.) Sunflower seed were scattered on 2 levels of the rack not bagged Following the initial tour observations of the main kitchen the Assistant Director of Culinary and the Registered Dietician (RD) verified the above 18 findings. On 4/4/17 at 4:48 PM, during an observation of the dinner line temping with the Food Service Manager and Server #1, revealed the Server used the same temperature probe between food items fried pork chop, cauliflower, rice, and sweet potato, sanitizing the probe with the same alcohol pad. Following the observation of the dinner line temping, Server #1 and the Food Service Manager verified the same sanitizing pad was used between food items and indicated a new pad should have been used between food items to avoid cross food contamination. On 4/5/17 at 9:35 AM, an observation of the main kitchen with the Assistant Director of Culinary and the RD revealed (2) kitchen staff were not wearing a facial hair restraint. The Assistant Director of Culinary and RD indicated that all facial hair including mustaches need to have a facial hair restraint. Review of the facility policy entitled, Labeling and Dating of Foods states under procedure (1) Opened dry goods shall be clearly marked to indicate the date by which the food shall be consumed or discarded for a maximum of 10 days. Also, procedure (4) states, Unopened ingredients must be discarded on or before the Manufactures Expiration Date. If received and no Manufactures' Expiration Date can be found a received Date must be written on the side of the container.

Based on observation, record review, interview, and review of the facility policy and the [MEDICATION NAME] and [MEDICATION NAME] N package insert, the facility failed to meet professional standards of quality for 2 of 2 residents reviewed for insulin administration. Resident #99 and #101 insulin injection sites were not rotated. The findings included: The facility admitted Resident #99 with a [DIAGNOSES REDACTED]. On 4/4/17 at 8:34 AM, an observation during med pass revealed Resident #99's was administered [MEDICATION NAME] N (NPH), 10 units in the right lower quadrant (RLQ) of the abdomen . Following the procedure Registered Nurse (RN) #1 recorded the injection location as Abdomen - RLQ in the Medication Administration Record [REDACTED]the abdomen right lower quadrant, and indicated s/he did not rotate the injection location. On 4/4/17 at 11:30 AM, a review of Resident #99's (MAR) dated 3/1/17 to 4/4/17 revealed the resident received 11 of 67 subcutaneous injections of [MEDICATION NAME] N insulin in the same location as the previous injection without rotating the site. Review of the facility policy entitled Insulin Administration, revealed under Steps in the Procedure, (16) Select an injection site. (b.) Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). Review of the [MEDICATION NAME] N manufacture recommendations revealed under Instructions for Use, Giving your [MEDICATION NAME] N injection bullet (2), Change (rotate) your injection site for each injection. The facility admitted Resident #101 with a [DIAGNOSES REDACTED]. On 4/4/17 at 8:17 AM, an observation during med pass revealed, Resident #101's was administered [MEDICATION NAME] 10 units in the right rear upper arm and [MEDICATION NAME] 2 units in the right rear upper arm. On 4/4/17 at 11:40 AM, a review of the Resident #101's (MAR) dated 3/8/17 to 4/4/17 revealed the resident received 4 of 26 [MEDICATION NAME] and 8 of 61 Insulin [MEDICATION NAME] Solution ([MEDICATION NAME]) subcutaneous injections of insulin in the same location as the previous injection without rotating the site. On 4/5/17 at 11:30 AM, the Director of Nursing (DON) verified Resident #101's MAR indicated [REDACTED]. The DON then indicated that insulin sites should be rotated. Review of the facility policy entitled, Insulin Administration, revealed under Steps in the Procedure, (16) Select an injection site. (b.) Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm)

Based on observations and interview, the facility failed to ensure that residents rights were respected related to dignity. Staff was observed entering residents' rooms without knocking. Random observations on 1 of 1 unit. The findings included: During random observation on initial tour on 4/03/17 at approximately 3:17 PM two Certified Nursing Aides (CNAs) were observed entering room [ROOM NUMBER] without knocking. There was a resident in the room on a low bed. The CNAs then proceeded to enter another resident room without knocking. During random observation on 4/04/17 at approximately 9:02 AM Certified Nurse Aide (CNA) #1 was observed entering room [ROOM NUMBER] without knocking. The resident was observed on the telephone with his/her back to the door. The CNA proceeded to get soiled items from the room and began to engage in a conversation with the resident. The resident who was on the telephone at the time turned around and stated to the CNA that he/she was not aware they were in the room. An interview on 4/04/17 at approximately 9:04 AM with CNA #1 confirmed he/she had entered the resident's room without knocking. The CNA further stated he/she was aware he/she should have knocked on resident's door.

Based on observations and interviews, the facility failed to maintain a clean homelike environment. The carpeted area on 1 of 1 unit noted with trash, debris and stains on the days of the survey. The findings included: During random observation on initial tour on 4/03/17 at approximately 3:20 PM a large black area was noted on the carpet near a door across from room 259. During an individual interview, when a resident was asked, does the facility keep the building clean? The resident stated no. The resident further stated the floors are dirty, the furniture was not moved during cleaning, the overbed tables are not wiped down and that the therapy equipment was not wiped down after each resident use. A random observation on 4/04/17 at approximately 2:42 PM revealed the carpeted area noted with multiple small pieces of debris throughout the unit. The large black area was still noted on the carpet near a door across from room 259. There were black spots noted on the carpet to the entrance of nurse's station from room 247 side. An interview and observation on 4/05/17 at approximately 9:20 AM with the Housekeeping Supervisor at reviewing the carpeted area of the facility confirmed the multiple small pieces of debris throughout the unit. The Housekeeping Supervisor stated the black area on the carpet near the door across from room 259 came from the kitchen area. The Housekeeping Supervisor reviewed the black spots near room 247 and stated one of them was chewing gum. The Housekeeping Supervisor further stated the area was supposed to be cleaned daily but had no documentation such as a cleaning schedule to indicate the cleaning was done daily. The Housekeeping Supervisor stated his/her department was responsible for making sure the therapy equipment was cleaned and that the equipment was cleaned at the end of the day.

Based on record review and interview, the facility failed to update the care plan for 1 of 3 residents reviewed for nutrition. Resident #50 experienced a severe weight loss over the course of one month, but no updates were made to the care plan to address the significant weight change. The findings included: Resident #50 was admitted to the facility 1/24/17 with [DIAGNOSES REDACTED]. Review of resident weights on 4/3/17 at approximately 4 PM revealed that Resident #50 weighed 130 lbs on 1/24/17. Resident #50 weighed 115 lbs on 2/20/17. Review of Resident #50's care plan on 4/4/17 at approximately 2:30 PM revealed that no updates or revisions were made to the care plan to address significant weight change. Review of physician orders [REDACTED]. The resident had a regular diet with chopped meat texture and regular consistency. Review of Dietary Progress Note dated 1/31/17 on 4/4/17 at approximately 2:39 PM revealed that the resident had a body mass index of 18.2 and that his/her usual body weight was 120 - 125 lbs. Interview with the Registered Dietitian on 4/5/17 at approximately 9:18 AM revealed that Resident #50 was not on a supplement during his/her stay. S/he revealed that the resident had [MEDICAL CONDITION] when admitted and was on [MEDICATION NAME]. S/he confirmed there was no additional documentation that would confirm s/he was evaluated by the dietitian after his weight loss. Review of Weight Assessment and Intervention policy on 4/5/17 at approximately 10:31 AM revealed that severe weight loss is defined as greater than 5% loss of weight within a month. As of survey exit, no documentation was provided that indicated the care plan was updated after Resident #50 experienced severe weight loss.

Based on record review and interview, the facility failed to maintain nutritional status in 1 of 3 residents. Resident #50 experienced a severe weight loss over the course of one month, but no interventions were put in place to address the significant weight change. The findings included: Resident #50 was admitted to the facility 1/24/17 with [DIAGNOSES REDACTED]. Review of resident weights on 4/3/17 at approximately 4 PM revealed that Resident #50 weighed 130 lbs on 1/24/17. Resident #50 weighed 115 lbs on 2/20/17. Review of physician orders [REDACTED]. The resident had a regular diet with chopped meat texture and regular consistency. Review of 1/31/17 dietary progress note on 4/4/17 at approximately 2:38 PM revealed that the resident's body mass index was 18.2 prior to the significant weight change. Interview with the Registered Dietitian on 4/5/17 at approximately 9:18 AM revealed that Resident #50 was not on a supplement during his/her stay. S/he revealed that the resident had [MEDICAL CONDITION] when admitted and was on [MEDICATION NAME]. S/he confirmed there was no additional documentation that would confirm s/he was seen by the dietitian after his/her weight loss. Review of Weight Assessment and Intervention policy on 4/5/17 at approximately 10:31 AM reveals that severe weight loss is defined as greater than 5% loss of weight within a month. As of survey exit, no documentation was provided that indicated the interventions were put in place to address Resident #50's severe weight loss.

Based on observation, record review, interview, review of the facility policy and manufacture recommendations, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 25 opportunities for error, resulting in a medication error rate of 8%. The findings included: Error #1 On 4/4/17 at approximately 8:17 AM, during observation of Resident #101's medication administration on the A-Cart hall, Registered Nurse (RN) # 1 administered 10 units of insulin from a [MEDICATION NAME] FlexTouch Pen without checking insulin flow before administration. Following the observation RN #1 verified s/he did not check for insulin flow before administration and stated, I don't have to do an air shot with a [MEDICATION NAME] Pen. Review of the facility policy entitled, Insulin Administration states under, Preparation (5) The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of the [MEDICATION NAME] manufactures recommendations revealed under, Checking the insulin flow procedure (G) warning icon Always check the flow before you inject. If you do not check the flow, you may get too little insulin or no insulin at all. This may lead to too high blood sugar level. Error #2 On 4/4/17 at approximately 8:52 AM, during observation of Resident #99's medication administration on the A-Cart hall, Registered Nurse (RN) #1 administered 2 inhalations (puffs) of [MEDICATION NAME] Aerosol 160-4.5 micrograms within 10 seconds of each other to the resident, and did not shake the inhaler prior to administration. Following the administration, RN #1 reviewed the [MEDICATION NAME] inhaler packaging and pharmacy stamped instructions that stated, Medication has a boxed warning. Wait 1 minute between puffs. Shake well before using. Rinse mouth after each use. RN #1 then verified s/he did not shake the inhaler and did not wait 1 minute between inhalations.

Based on observations, record review, interview, review facility policy and manufacture recommendations, the facility failed to administer medication in accordance with the physician's orders for 1 of 2 resident's reviewed for insulin administration. Resident #101 did not receive the correct amount of insulin. The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. On 4/4/17 at approximately 8:17 AM, during observation of Resident #101's medication administration on the A-Cart hall, Registered Nurse (RN) # 1 administered 10 units of insulin from a [MEDICATION NAME] FlexTouch Pen without checking insulin flow before administration. Following the observation RN #1 verified s/he did not check for insulin flow before administration. Review of the facility policy entitled, Insulin Administration states under, Preparation (5) The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of the [MEDICATION NAME] manufactures recommendations reveals under, Checking the insulin flow procedure (G) warning icon Always check the flow before you inject. If you do not check the flow, you may get too little insulin or no insulin at all. This may lead to too high blood sugar level.