Every finding on record at W D Bill Manning Tennessee State Veterans Home

Based on policy review, medical record review, observation, and interview, the facility failed to maintain and ensure the prevention and spread of infection when 1 of 7 (Licensed Practical Nurse (LPN A) nurses failed to wear Personal Protective Equipment (PPE) during medication administration for 1 of 9 (Resident #15) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, Infection Control Manual .Enhanced Barrier Precautions (EBP), revealed dated 4/25/2024, revealed .Enhanced Barrier Precautions[EBP] refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] expand the use of PPE [Personal Protective Equipment] to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing .EBP are indicated for residents with any of the following.wounds .indwelling medical devices. 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Dementia, and Dysphagia. Review of the Minimum Data Set assessment dated [DATE], revealed Resident #15 scored a 3 on the Brief Interview for Mental Status assessment, which indicated he had severely impaired cognition and had a feeding tube. Review of the Physician Order dated 4/27/2026 revealed .Enhanced Barrier Precautions. Review of the Physician Order dated 5/18/2026, revealed .Alprazolam [a medication for anxiety] Oral Tablet 0.5 MG [milligram] .Give 1 tablet via [by] Peg-tube [percutaneous endoscopic gastrostomy (PEG) a soft, flexible tube that delivers nutrition, fluids, and medications directly into the stomach] in the afternoon for Anxiety . Observation and interview in Resident #15's room on 6/2/2026 at 2:39 PM, revealed Licensed Practical Nurse (LPN ) A performed hand hygiene, pulled the Alprazolam from the North Medication Cart's drawer, put the medication in a medication cup, added water to the medication cup, and poured water in a plastic cup. After the medication was dissolved in the water, LPN A performed hand hygiene, donned gloves, and gathered supplies. LPN A entered Resident #15's room, paused the enteral feeding, disassembled the enteral tubing connection from the peg site tubing and placed the enteral tubing over the enteral feeding pole. LPN A listened for placement with a stethoscope, LPN A connected the syringe to the peg site, checked for residual (is the amount of liquid remaining in the stomach), returned 7 cc (cubic centimeters) of the residual back into the stomach with the syringe, poured 30 cc of water into the syringe and administered it by gravity. LPN A poured the medication into the syringe and administered it by gravity, poured 30 cc of water into the syringe and administered it by gravity, removed the syringe, and connected the enteral tubing to peg tube. LPN A entered the resident's bathroom, placed the cups in the trash, rinsed the syringe with water and placed on a paper towel barrier. LPN A removed her gloves, washed her hands and returned to the medication cart. LPN A was asked what should she have worn when giving medication through the peg site. LPN A stated, Gloves. LPN A failed to wear proper PPE when administering medication through the peg tube. During an interview on 6/3/2026 at 2:23 PM, the Director of Nursing (DON) was asked what should staff wear when administering medication through a peg tube. The DON stated, They should wear gown and gloves.

Based on policy review, medical record review, observation, and interview, the facility failed to revise care plans for 2 of 24 (Resident #16, and #91) sampled residents reviewed for care planning. The findings include: 1. Review of the facility's policy titled .Clinical Comprehensive Care Plan Policy, dated 3/1/16 (2016), revealed .information gathered from the Minimum Data Set [MDS], family and Resident interview/assessments to develop, review and revise the Resident's Comprehensive Plan of Care. The Comprehensive Plan of Care will be individualized and include measurable objectives and timetables to meet the Resident's medical, nursing, mental and psychological needs .develops and maintains a comprehensive plan of care for each Resident that identifies the Resident's unique problems/weaknesses, strengths, preferences, goals and interventions for Resident's to attain the highest level of functioning . 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses of Atrial Fibrillation, Respiratory Failure, Pneumonia, and Post-Traumatic Stress Syndrome. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated he had moderate cognitive impairment and was coded for oxygen. Review of the Physician's order dated 10/3/2023 revealed .O2 [oxygen] at 2L [Liters] via NC [nasal cannula] to keep sats [saturation] =/> [equal to or greater than] than 92% [percentage] May titrate up to 5L . Review of the Care Plan dated 10/10/2023 revealed Resident #16 did not have a care plan to address the oxygen. Observations in the Resident's room on 10/16/2023 at 9:31 AM, and 10/18/2023 at 3:18 PM, revealed Resident #16 had oxygen binasal cannula (medical device to provide supplemental oxygen therapy) in place. 3. Review of medical record revealed Resident # 91 was admitted to the facility on [DATE], with diagnoses of Dementia, Post-Traumatic Stress Disorder, Depression, Diabetes, and Psychosis. Review of the quarterly MDS dated [DATE], revealed Resident #91 had a BIMS score of 14, which indicated he was cognitively intact. Review of the Physician's Orders dated 6/19/2023, revealed .Apixaban [used to treat and prevent blood clots] Oral Tablet 5 MG [milligrams] .Give 1 tablet by mouth two times a day . Review of the Care Plan with a revision date of 8/7/2023, revealed Resident #91 did not have a care plan to address the anticoagulant medication. During an interview on 10/19/23 at 11:44 AM, the Director of Nursing (DON) was asked should oxygen be on Resident #16's care plan. The DON stated Yes. The DON was asked should anticoagulant medications be on Resident #91's care plan. The DON stated, Yes ma'am.

Based on policy review, observation, and interview, the facility failed to ensure proper infection control practices when 1 of 14 staff members (Certified Nursing Assistants (CNA) #7) handled the residents food with bare hands, when 1 of 14 staff members (CNA #2) placed a dirty tray back on the tray cart with clean trays, and when 1 of 14 staff members (CNA #5) failed to perform hand hygiene during dining observation. The findings include: 1. Review of the facility's policy titled .Handwashing/Hand Hygiene, dated 4/4/2018 revealed .Hand washing/hand hygiene is regarded by this organization as the single most important means of preventing the spread of infections. Most germs that cause serious infections in healthcare are spread by people's actions. Hand hygiene is a great way to prevent infections .All personnel shall follow the organization's handwashing/hand hygiene procedures to prevent the spread of infection and disease to other personnel, residents and visitors .After handling items potentially contaminated .Before and after handling food .Before and after direct resident contact .Before and after assisting a resident with meals .After handling soiled or used linens . 2. Observation in a resident's room on 10/16/2023 at 11:57 AM, revealed CNA #7 opened a wrapped sandwich, removed the sandwich from the wrapper and placed the sandwich on the tray with their bare hands. Observation on 10/16/2023 at 12:14 PM, revealed CNA #2 removed a dirty meal tray from a resident's room and placed it back on the cart with 3 clean unserved meal trays. During an interview on 10/16/2023 at 12:15 PM, CNA #2 was asked should she have placed a dirty tray back on the clean dining cart. CNA #2 stated, No .I didn't know what to do .he refused the rest of it . 3. Observation in a resident's room on 10/18/2023 at 5:15 PM, revealed CNA #5 picked up a pillow from the floor, placed it on the resident's bed, opened drawers looking for an item, and touched the privacy curtain. CNA #5 failed to wash her hands and preceded to open the straw, placed the opened straw in a glass, and then laid the opened straw on the meal tray. CNA #5 poured water into the glass, picked up the opened straw and gave the resident a drink. CNA #5 failed to perform hand hygiene after handling contaminated items in the environment before assisting with the tray setup. During an interview on 10/19/2023 at 12:17 PM, the Director of Nursing (DON) was asked should staff handled items in environment and then setup the meal trays without performing hand hygiene. The DON stated, .No, they should perform hand hygiene . The DON was asked should a tray that has been carried into a resident's room be brought back out and placed back on the clean dining cart with clean trays. The DON stated, .No, the tray should not be placed back on the clean dining cart with clean trays . The DON was asked should the staff member handle the resident's food with their bare hands. The DON stated, .No, they should not .

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, Time and Attendance Reports, staff screening logs, and interview, the facility failed to properly prevent and/or contain COVID-19 when 53 of 173 staff members (Environmental Services Staff #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13, Registered Nurse (RN) #1, #2, #3, and #4, Licensed Practical Nurse (LPN) #1, #2, #3, #4, #5, #6, #7, and #8, Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, and #29) failed to complete screenings prior to working on 13 of 13 days (10/29/2021, 10/30/2021, 10/31/2021, 11/1/2021, 11/2/2021, 11/3/2021, 11/4/2021,11/5/2021, 11/6/2021, 11/7/2021, 11/8/2021, 11/9/2021, and 11/10/2021) reviewed. This could have potentially affected the 103 residents residing in the facility. The findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless of their vaccination status .so that they can be properly managed .Options could include .individual screening on arrival at the facility .before entering the facility. Review of the facility's policy titled, Occupational Health- COVID-19, dated 3/6/2020, revealed .Employees will be screened prior to starting a shift by having their temp [temperature] taken, as well as being screened for recent travel, signs or symptoms or exposure . Review of the Employee Screening Logs and Time and Attendance Reports from 10/29/2021 - 11/10/2021, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 10/29/2021 - Environmental Services Staff #4, #5, and #6; CNA #1, #2, and #3; RN #4. b. 10/30/2021 - Environmental Services Staff #1, #2, and #3; CNA #4 and #5. c. 10/31/2021 - CNA #1, #6, #7, and #8. d. 11/1/2021 - Environmental Services Staff #1 and #5; RN #4. e. 11/2/2021 - Environmental Services Staff #12 and CNA #10. f. 11/3/2021 - Environmental Services Staff #3, #10, and #12; CNA #11 and #29; LPN #1, #2, #3 and #4. g. 11/4/2021 - Environmental Services Staff #10 and #13; CNA 1, #4, #11 #12, #13, #14, and #15; RN #2. h. 11/5/2021 - Environmental Services Staff #3, #4, #5, #9, and #10; CNA #13, #12, and #16; LPN #5, #6, #7; RN #4. i. 11/6/2021 - Environmental Services Staff #11; CNA #16, #17, #18, and #19. j. 11/7/2021 - Environmental Services Staff #3, #4, #5, #6, and #7; CNA #18, #21, and #22. k. 11/8/2021 - Environmental Services Staff #3, #4, #5, #6, and #7; CNA #10, #16, #24, and #23; LPN #8; RN #1. l. 11/9/2021 - Environmental Services Staff #8 and #10; CNA #25, #26, and #27; RN #2, #3, and #4. m. 11/10/2021 - Environmental Services Staff #1, #2, #3, and #10; CNA #12, #20, and #28. During an interview on 11/17/2021 at 8:52 PM, the Director of Nursing (DON) stated, .the staff is supposed to stop and get screened in each day .they get temp [temperature] taken .screen for signs and symptoms of respiratory illness or exposure to COVID 19 .it's done by the nursing department .if no one is there to screen .we are called to front by Receptionist .all staff members should be screened before entering the building .

Based on policy review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when unsecured sharps were observed in 4 of 68 resident rooms (Room #4, #16, #15, and #19) for 6 of 103 sampled residents (Resident #4, #11, #42, #68, #98, and #106) observed for accident hazards. The findings include: Review of the facility's policy titled, .Accident Policy, dated 5/30/2018, revealed .The [Named Long Term Care Facility] will strive to ensure that Residents environment remains as free of accident hazards as possible .Accident refers to any unexpected or unintentional incident, which may result in injury or illness to a Resident .Avoidable accident means that an accident occurred because a facility failed to identify environmental hazards, identify a Resident's individual risk for accidents .implement interventions . Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Stage 3 Chronic Kidney Disease, Depression, Anxiety, Dysphagia, Hypertension, and Heart Failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #42 was cognitively intact. Review of the medical record, revealed Resident #98 was admitted to the facility on [DATE] with diagnoses of Intracranial Injury, Anxiety, [CONDITION(S)], Depression, [CONDITION(S)], Hypertension, Cerebral Vascular Accident, and [CONDITION(S)]. Review of the admission MDS dated [DATE], revealed Resident #98 had severe cognitive impairment. Observation in Resident #42 and #98's shared bathroom (Room #4) on 11/15/2021 at 9:39 AM and 3:19 PM, revealed 6 disposable razors in a cup. Observation in Resident #42 and #98's shared bathroom (Room #4) on 11/16/2021 at 8:05 AM and 3:27 PM, revealed 5 disposable razors in a cup. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, [CONDITION(S)], [CONDITION(S)], Hypertension, Heart Disease, and Dysphagia. Review of the admission MDS dated [DATE], revealed Resident #11 had severe cognitive impairment. Observation in Resident #11's bathroom (Room #15) on 11/15/2021 at 10:07 AM and 3:23 PM, and on 11/16/2021 at 8:53 AM and 4:26 PM, revealed a wash basin containing an opened package with 8 disposable razors and 9 loose disposable razors on the sink counter. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Cerebral Vascular Accident, [CONDITION(S)], [CONDITION(S)], Anxiety, Depression, [CONDITION(S)], and Amnesia. Review of the quarterly MDS dated [DATE], revealed Resident #4 had moderately impaired cognition. Review of the medical record, revealed Resident #106 was admitted to the facility on [DATE] with diagnoses of Polyosteoarthritis, Depression, Heart Failure, and Chronic Kidney disease. Review of the quarterly MDS dated [DATE], revealed Resident #106 was cognitively intact. Observation in Resident #4 and Resident #106's shared bathroom (Room #16) on 11/15/2021 at 10:17 AM, revealed a gray wash basin containing 2 razors on the right side of the sink. Observation in Resident #4 and Resident #106's shared bathroom (Room #16) on 11/15/2021 at 11:18 AM and 3:25 PM, and on 11/16/2021 at 1:15 PM, revealed a gray wash basin containing 1 razor and 4 replaceable razor cartridges on the left side of the sink. Review of the medical record, revealed Resident #68 was admitted to the facility on [DATE] with diagnoses of Diabetes, Hypertension, [CONDITION(S)] of the Liver, Cerebral Vascular Accident, [CONDITION(S)], and [CONDITION(S)]. Review of the quarterly MDS dated [DATE], revealed Resident #68 was cognitively intact. Observation in Resident #68's bathroom (Room #19) on 11/15/2021 at 11:27 AM and 3:26 PM, and on 11/16/2021 at 9:33 AM and 4:30 PM, revealed a gray wash basin with 3 disposable razors on the sink counter. During an interview on 11/17/2021 at 8:29 AM, the Director of Nursing (DON) confirmed razors should not be left in residents' bathrooms.

Based on policy review, medical record review, observation, and interview, the facility failed to assess 1 of 6 sampled residents (Resident #85) for self-administration of medications. The findings include: Review of the facility's policy titled, Self-Administration of Drugs, dated 2/20/2003, revealed .Residents who wish to self-administer medications will be evaluated by the attending Physician and the Interdisciplinary Team (IDT) for safety .Document the assessment findings in the residents medical record .Residents who are deemed safe to self-administer medications will be provided with a locked box to keep medications secure . Review of the medical record, revealed Resident #85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #85 had a Brief Interview for Mental Status (BIMS) of 14, which indicated he was cognitively intact. Observation in the resident's room on 11/16/2021 at 8:38 AM, revealed Resident #85 had an unidentified nebulizer treatment in progress and there were no staff present in the room. At 8:41 AM, Licensed Practical Nurse (LPN) #6 entered the room and removed the nebulizer treatment. The facility was unable to provide a self-administration assessment for nebulizer treatments for Resident #85. During an interview on 11/17/2021 at 8:26 AM, the Director of Nursing (DON) confirmed the nurse should stay with the resident during the nebulizer treatment unless the resident has had a self-administration assessment.

Based on medical record review and interview, the facility failed to ensure 1 of 5 nurses (Licensed Practical Nurse (LPN #6) administered medications according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the medical record, showed Resident #85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #85 was cognitively intact. Review of the Care Plan with a revision date of 10/18/2021, revealed .at risk for respiratory distress .Give meds [medications] as ordered and observe effectiveness . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Observation in the resident's room on 11/16/2021 beginning at 8:38 AM, revealed Resident #85 had a nebulizer treatment in progress. During an interview on 11/17/2021 at 7:37 PM, the Director of Nursing (DON) confirmed all medication orders should be entered in the computer. The DON confirmed medications should not be administered without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #85] went out to the hospital and it was a prn [as needed] order, the order fell off when he came back .he's always had breathing treatments .a lot of this is they [staff] know their patients and they [staff] know the fact that they've had an order . The DON confirmed that there was not a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on policy review, observation, and interview, the facility failed to ensure medications were labeled and stored appropriately when unsecured medications were observed in 1 of 68 resident rooms (Resident #29's room) which could have potentially affected the 3 identified wandering residents (Resident #8, #74, and #94) in the facility. The findings include: Review of the facility's policy titled, Storage and Expiration of Medications, Biologicals ., dated 12/1/2007, revealed .Facility should ensure that all medications and biologicals .are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . Observation in the resident's room on 11/16/2021 at 7:33 AM, revealed the following medications on Resident #29's over bed table: a. 2 boxes of 2.1-ounce tubes of [MEDICATION(S)] Cream 0.025 percent (%). b. 1 box of [MEDICATION(S)]/Salmeterol inhaler. The facility identified 3 wanderers (Resident #8, #78, and #94) who could have potentially been affected by unsecured medications left unattended in the resident's room. During an interview on 11/17/2021 at 8:26 AM, the Director of Nursing (DON) confirmed medications should not be left at the bedside unattended.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by improper storage of food, unlabeled, undated and unsealed food, dirty fans in the walk in cooler, and a dirty deep fat fryer. The facility had a census of 129 residents, with 124 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's Food Storage policy dated 5/1315 documented, .Food should be covered, labeled, and dated when prepared and stored . The refrigerator must be clean .FROZEN FOOD .should be stored .with appropriate labeling and dating . 2. Observations in the kitchen on 3/4/19 beginning at 7:50 AM, revealed the following: a. 5 pancakes on a metal table next to the toaster without a barrier b. 1 bag of biscuits in the walk in the freezer not labeled or dated c. 1 bag of cheese in the walk in cooler not sealed d. 2 fans in the walk in cooler had a brown substance on them e. dirty black grease in the deep fat fryer f. 2 buns in a plastic bag lying on the counter not labeled or dated Interview with the Dietary Manager on 3/4/19 at 8:03 AM, in the Kitchen, the Dietary Manager was asked when the deep fat fryer was last cleaned. The Dietary Manager stated, Clean it on Friday, unless it looks like this. We will clean it today. Observations in the kitchen on 3/6/19 at 10:50 AM, revealed the following: a. 15 glasses of water, 15 glasses of tea, and 1 glass of chocolate milk on trays uncovered in the walk in cooler b. 2 fans in the walk in cooler had a brown substance on them c. 1 bag of waffles in the walk in freezer not labeled or dated d. 9 packages of pancakes in the walk in freezer not labeled or dated e. 3 packages of pastries not labeled or dated f. 1 bag of sugar cookies not labeled or dated g. 1 large bag of meatballs not labeled or dated h. dirty black grease in the deep fat fryer Interview with the Dietary Manager on 3/7/19 at 9:15 AM, in the Dining Room, the Dietary Manager was asked if it was acceptable to have dust on the fans in the walk in cooler. The Dietary Manager stated, No, ma'am. The Dietary Manager was asked if food should be labeled and dated. The Dietary Manager stated, Yes, ma'am. The Dietary Manager was asked if pancakes should be laid on a metal table without a barrier. The Dietary Manager stated, Better to have a .liner under it (pancakes). The Dietary Manager was asked if food stored in the walk in cooler should be sealed. The Dietary Manager stated, Yes, ma'am. The Dietary Manager was asked if glasses of liquids stored in the walk in cooler should be covered. The Dietary Manager stated, Yes. ma'am.

Based on policy review, observation, and interview, the facility failed to properly dispose of medications past the expiration date and failed to label and date opened multi-dose vials for 2 of 7 (Back West and Front East Medication Carts) medication storage areas. The findings include: The facility's STORAGE AND EXPIRATIONS OF MEDICATIONS . policy with a revised date of [DATE] documented, .Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened . The facility's GENERAL DOSE PREPARATION AND MEDICATION ADMINISTRATION policy with a revised date of [DATE] documented, .Facility staff may record the expiration date based on the label of medications .Check the expiration date on the medications .facility staff should not administer a medication if the medication or prescription label is missing .Facility staff should enter the date opened on the label of medication with shortened expiration dates .insulin's . Observations at the Back West Medication Care on [DATE] at 9:06 AM, revealed 2 multi-dose vials of [MEDICATION NAME] open and not dated, 2 tubes of Mupirocin ointment 2% open and not dated, a tube of [MEDICATION NAME] cream open and not dated, and a bottle of Geri-Lanta open with an expiration date of ,[DATE]. Observations at the Front East Medication Cart on [DATE] at 9:20 AM, revealed a tube of [MEDICATION NAME] cream with no name and not dated, a tube of [MEDICATION NAME] Cream open and not dated, a bottle of Artificial Tears open and undated, a bottle of [MEDICATION NAME] nasal spray open and not dated, a Tresbis flex pen open and undated, and a bottle of Geri-Lanta opened with an expiration date of ,[DATE]. Interview with the Licensed Practical Nurse (LPN) #1 on [DATE] at 9:06 AM, at the Back West Medication Cart, LPN #1 confirmed the multi-dose vials of [MEDICATION NAME], Mupirocin 2% (percent) ointment, and [MEDICATION NAME] cream should have been labeled and dated. LPN #1 also confirmed the bottle of Geri-Lanta with an expiration date of ,[DATE] should have been discarded. Interview with LPN #2 on [DATE] at 9:20 AM, at the Front East Medication Cart, LPN # 2 confirmed the opened [MEDICATION NAME] cream, Artifical Tears, [MEDICATION NAME], and Tresbis flex pen should have been dated and the Geri-Lanta with an expiration date of ,[DATE] should have been discarded. Interview with the Director of Nursing (DON) in the DON office on [DATE] at 10:02 AM, the DON confirmed the opened medications should have been dated, the medication should have been labeled and the expired medication should have been discarded.

Based on policy review, observation, and interview, the facility failed to ensure food was prepared and served in a sanitary manner by 2 of 6 dietary staff members (Dietary Aide #1 and 2) observed with unrestrained hair. The facility reported a census of 122 on 4/4/17. There were 122 residents that received a supper tray from the kitchen that could potentially be affected. The findings included: 1. The facility's .DIETARY POLICIES . policy documented, .guidelines for the personal hygiene of dietary staff to promote a safe and sanitary department must be followed .The .net should be worn to contain the hair and cover the head .Hair must be appropriately restrained .Beards .and other facial hair should be appropriately covered . 2. Observations in the kitchen on 4/4/17 at 5:04 PM, revealed dietary aide #1 with a full beard and no beard cover while food was being plated. 3. Observations in the kitchen on 4/4/17 at 5:14 PM, revealed dietary aide #2 had exposed hair around her face and neck while on the tray line. Interview with the Registered Dietician (RD) in the kitchen on 4/4/17 at 5:15 PM, the RD was asked if dietary aide #2 had hair out of her hairnet. The RD stated, Yes. The RD was asked if it was appropriate for dietary aide #1 to have his beard uncovered while in the kitchen. The RD stated, No.

Based on policy review, observation, and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective ongoing quality program that identified, developed, implemented, and monitored appropriate plans of action to correct issues. The findings included: 1. The QAA Committee failed to ensure food was stored, prepared, distributed and served under sanitary conditions related to dining. Refer to F371 The deficient practice of F371 is a repeat deficient practice for failure to ensure food was stored, prepared, distributed and served under sanitary conditions. The facility was cited F371 on the recertification survey on 1/12/16. 2. Interview with the Quality Assurance (QA) Nurse on 4/5/17 at 1:25 PM, in the QA Nurse's office, the QA Nurse was asked if hair restraints had been QA'd. The QA Nurse stated, .it was when we were tagged for hair nets last year's survey and I monitored it according to our POC (Plan of Correction) .but it hasn't recently been QA'd .I'm surprised at the kitchen staff .I would think they would have been on their toes while there was a survey going on .

Based on policy review, observation and interview, the facility failed to maintain or enhance resident dignity and respect by 2 of 46 staff members (Registered Nurse (RN) #1 and Housekeeper #1) who referred to residents as feeders. The findings included: 1. The facility's Dignity and Quality of Life Policy policy documented, .Staff will further respect residents by not referring to them as .feeders . 2. Observations in the East hallway on 4/3/17 at 11:21 AM, revealed Housekeeper #1 took a tray into Resident #108's room. Upon entering the room and standing in front of the resident, Housekeeper #1 stated, Oh, he's a feeder. Housekeeper #1 went back out into the hallway and asked the other staff in a loud voice, Is he a feeder? 3. Observations in the East hallway on 4/3/17 at 11:33 AM, revealed RN #1 referred to the residents as feeders to the state surveyor. Interview with the Director of Nursing (DON) on 4/5/17 at 1:22 PM, in the conference room, the DON was asked if it was appropriate to refer to residents as feeders. The DON stated, No.

Based on observations and interviews, the facility failed to ensure food was prepared and served in a sanitary manner as evidenced by 10 of 10 dietary staff members (Dietary staff #1, 2, 3, 4, 5, 6, 7, 8 the Registered Dietician (RD) and the Food Services Director) had exposed hair from hair restraints and a staff member's beard was not covered. The facility had a census of 137, with 134 of those residents receiving a meal tray from the kitchen. The findings included: 1. Observations in the kitchen on 1/10/16 at 8:00 AM, revealed Dietary staff members #1, 2, 3, and 4 wore a hair restraint, but their hair was not completely covered. 2. Observations in the main dining room on 1/10/16 at 11:05 AM, revealed Dietary staff member #5 wore a hair net while serving from the buffet table, but her hair was not completely covered. 3. Observations in the kitchen on 1/11/16 at 3:00 PM, revealed the Registered Dietician (RD) and the Food Services Director (FSD) wore a hair restraint, but their hair was not completely covered. The FSD had facial hair and was not wearing a beard cover. 4. Observations in the kitchen on 1/12/15 at 10:50 AM, revealed the RD, FSD, and Dietary staff members #1, 6, 7, and 8 wore a hair restraint, but their hair was not completely covered. The FSD had facial hair and was not wearing a beard cover. 5. Interview with the RD and FSD on 11/12/16 at 11:55 AM, in the kitchen, the RD and FSD were asked if you would expect hair to be completely covered by a hair restraint. The RD stated, Yes. The RD and FSD were asked if you would expect facial hair to be covered by a beard cover. The FSD stated, Yes.

Based on policy review, observation, and interview, it was determined the facility failed to ensure medications were not stored past the expiration date in 6 of 10 (West wing middle medication cart, West wing medication storage room, West wing north medication cart, West wing south medication cart, East wing north medication cart, East wing south medication cart) medication storage areas. The findings included: 1. Review of the facility's medication storage policy documented, "...Outdated, contaminated, or deteriorated medications... are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy, if a current order exists..." 2. Observations on the west wing middle hall on 5/8/13 at 9:00 AM, revealed the west wing middle medication cart contained a bottle of Flunisolide SPR 0.025 percent (%) with an expiration date of 12/12 and a tube of Artificial Tears ointment with an expiration date of 2/13. During an interview on the west wing middle hall on 5/8/13 at 9:05 AM, Nurse #4 was asked to look at the bottle of Flunisolide SPR 0.025% with an expiration date of 12/12 and a tube of Artificial Tears ointment with an expiration date of 2/13. Nurse #4 verified the expiration dates of 12/12 and 2/13. Nurse #4 stated, "It (Flunisolide SPR and Artificial Tears ointment) is expired." Nurse #4 was asked who was responsible for ensuring the medications on the medication carts are not expired. Nurse #4 stated, "The nurses are supposed to check them (expiration dates)." 3. Observations in the west wing medication storage room on 5/8/13 at 10:49 AM, revealed an opened bottle of Zinc 50 milligrams (mg) with an expiration date of 1/12. During an interview in the west wing medication storage room on 5/8/13 at 10:49 AM, Nurse #2 was asked to look at the opened bottle of Zinc 50 mg with an expiration date of 1/12. Nurse #2 verified the expiration date of 1/12. Nurse #2 stated, "Looks like it's (Zinc 50 mg) expired." 4. Observations on the west wing north hall on 5/8/13 at 1:50 PM, revealed a bottle of Liquid Acetaminophen with an expiration date of 2/13 stored in the west wing north medication cart. During an interview on the west wing north hall on 5/8/13 at 1:50 PM, Nurse #5 verified the expiration date of 2/13 on a bottle of Liquid Acetaminophen stored in the west wing north medication cart. 5. Observations on the west wing south hall on 5/8/13 at 1:56 PM, revealed two bottles of Artificial Tears with expiration dates of 10/12 stored in the west wing south medication cart. During an interview on the west wing south hall on 5/8/13 at 1:56 PM, Nurse #2 verified the expiration date of 10/12 on the two bottles of Artificial Tears. 6. Observations on the east wing north hall on 5/8/13 at 2:10 PM, revealed a bottle of Artificial Tears with an expiration date of 10/12 stored in the east wing north medication cart. During an interview on the east wing north hall on 5/8/13 at 2:10 PM, Nurse #6 verified the expiration date of 10/12 on the bottle of Artificial Tears. 7. Observations on the east wing south hall on 5/8/13 at 2:20 PM, revealed a bottle of Artificial Tears with an expiration date of 10/12 and a tube of Clotrimazole and Betamethasone Dipropionate Cream 1% / 0.05% with an expiration date of 10/12 stored in the east wing south medication cart. During an interview on the east wing south hall on 5/8/13 at 2:20 PM, Nurse #7 verified the expiration dates of 10/12 on the bottle of Artificial Tears and the expiration date of 10/12 and the tube of Clotrimazole and Betamethasone Dipropionate Cream 1%/0.05%. 8. During an interview in the conference room on 5/8/13 at 2:03 PM, the Director of Nursing (DON) was asked who is responsible for ensuring that expired medications are not left in the medication storage rooms and medication storage carts. The DON stated, "...The nurses are responsible for their carts...(Named Nurse #8) does the med (medication) rooms... Expired medications should be removed"

Based on policy review, observation and interview, it was determined the facility failed to ensure dignity was maintained for 1 of 3 (Resident # 75) sampled residents with a Foley catheter on 2 of 3 days during the survey. The findings included: Review of the facility's "Dignity and Quality of Life" policy documented, "...will care for its Residents in a manner and environment that promotes maintenance or enhancement of each Residents quality of life, dignity, and respects full recognition of each Residents individuality. Dignity means that in their interactions with Residents, staff will carry out activities that assist the Resident to maintain and enhance his or her self-esteem and self-worth..." Observations in the west wing south hall on 5/7/13 at 9:30 AM and 9:39 AM, revealed Resident #75 walking with assistance of Certified Nursing Assistant (CNA) #1 down the hall with the catheter bag hanging on the walker without a privacy bag on the catheter bag. Observations in Resident #75's room on 5/8/13 at 9:10 AM, revealed Resident #75 lying in bed on his back with his clothes on and the Foley catheter bag hanging on the trash can beside the bed. There was no privacy bag over the drainage bag. During an interview at the west nurses' station on 5/8/13 at 9:05 AM, Nurse #1 was asked if all Foley catheters must have a privacy bag. Nurse #1 stated, "Yes... sometimes it (the catheter bag) hangs on the walker when the staff walks them (residents)..." Nurse #1 was then asked if the drainage bag should have a privacy bag. Nurse #1 stated, "Yes." During an interview in Resident #75's room on 5/8/13 at 9:15 AM, Nurse #2 was asked if it is acceptable for a Foley catheter bag to be hanging on the trash can. Nurse #2 stated, "No ma'am."

Based on medical record review and interview, it was determined the facility failed to revise the comprehensive care plan to reflect new interventions for falls for 1 of 26 (Resident #139) sampled residents of the 37 residents included in the stage 2 review. The findings included: Medical record review for Resident #139 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive care plan dated 2/22/13 documented, "...Focus... I am at risk for falls d/t (due to) I require assist with transfer and ambulation... 6/21/12 Low bed to matt... All interventions effective to prevent injury... 1/13/13 Fall (without symbol) injury Low bed to Matt... All interventions in place & (and) effective to prevent injury..." Review of the comprehensive care plan dated 2/22/13 revealed no new interventions were put in place after falls on 6/21/12 and 1/13/13. During an interview in the Minimum Data Set (MDS) coordinator's office on 5/8/13 at 10:49 AM, Nurse #3 was asked who was responsible for updating the care plan with new interventions after a resident fall occurs. Nurse #3 stated, "...different ones (staff members)... the nurses would... then MDS reviews them for the care plan..." Nurse #3 was asked why no new interventions were documented on Resident #139's care plan for the falls that occurred on 6/21/12 and 1/13/13. Nurse #3 stated, "...because he fell to the matt and he had no injury... if he had gotten hurt we would have put a new intervention in place... he didn't get injured... his interventions worked to prevent injury... we didn't need to add a new one..." During an interview in the training room on 5/8/13 at 10:55 AM, the Clinical Consultant stated, "There has to be an intervention if there was a fall." During an interview in the copier room on the administrative office hall on 5/8/13 at 10:57 AM, the Director of Nursing was asked to review Resident #139's care plan for interventions for falls the resident had on 6/21/12 and 1/13/13. The DON was asked if the interventions were appropriate. The DON stated, "That is not an appropriate intervention."

Based on policy review, medical record review, observation, and interview, it was determined the facility failed to provide appropriate treatment and services by allowing a urinary draining device to hang from a trash can and allowing a urinary drainage device tubing to touch the floor for 2 of 3 (Residents #75 and 109) sampled residents reviewed of the 6 residents with urinary catheters included in the stage 2 review. The findings included: 1. Review of the facility's "Urinary Incontinence Policy" documented, "...Urinary Catheters... All staff will receive periodic education regarding the care of urinary catheters..." 2. Medical record review for Resident #75 documented an admission date of [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #75's room on 5/8/13 at 9:10 AM, revealed Resident #75 lying in bed on his back with his clothes on and the Foley catheter bag hanging on the trash can beside the bed. During an interview in Resident #75's room on 5/8/13 at 9:15 AM, Nurse #2 was asked if it is acceptable for a Foley catheter bag to be hanging on the trash can. Nurse #2 stated, "No ma'am." During an interview in the conference room on 5/8/13 at 9:30 AM, Certified Nursing Assistant (CNA #1) confirmed Resident #75 only gets up with a staff member assisting and the staff member takes care of his catheter bag. 3. Medical record review for Resident #109 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated 4/10/13 documented, "...Provide Catheter Care Every Shift and As Needed... Change Indwelling Catheter Every month and As Needed... Indwelling Urethral Catheter To Remain In Due To DX (Diagnosis): [MEDICAL CONDITION]" Review of the urine culture dated 4/6/13 documented an infection with organism of Proteus Mirabilis. Review of the urine culture dated 4/26/13 documented an infection with the organisms of Proteus Mirabilis and [MEDICATION NAME] Species. Observations in Resident #109's room on 5/7/13 at 8:15 AM, 10:00 AM, and 4:00 PM, and on 5/8/13 at 9:00 AM, revealed Resident #109 lying in bed with the catheter tubing laying on the floor. During an interview in the conference room on 5/8/13 at 11:00 AM, the Director of Nursing (DON) was questioned if the Foley tubing should be on the floor. The DON stated, "No, should not... they (staff members) should coil the tubing into the privacy bag... will inservice the staff on this again... started using longer tubing because the residents did not like the shorter tubing, and have told the staff to try to coil into the privacy bag so it will not rest on the floor..." During an interview in the conference room on 5/8/13 at 1:30 PM, the Nurse Consultant was asked for the facility's policy for positioning of the catheter. the Nurse consultant stated, "No policy for care of the catheter related to positioning, they (staff members) should just know..."

Based on policy review, observation and interview, it was determined the facility failed to ensure a safe environment as evidenced by a too small unsecure sharps containers with used razors accessible in the sharps container holder in 1 of 3 (west wing north hall shower room) common shower rooms. The findings included: Review of the facility's "Infection Control, Standard Precautions" policy documented, "...Occupational Health and Bloodborne Pathogens... d. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers located as close as practicable to the area in which the items were used..." Observations in the west wing north hall shower room on 5/6/13 at 9:00 AM, on 5/7/13 at 5:45 PM, and on 5/8/13 at 8:30 AM, revealed a too small sharps container in a holder on the inside of the door with the top open (top was missing) with used razors laying inside the holding container accessible to the residents. During an interview in the west hall south on 5/8/13 at 9:05 AM, Nurse #1 was asked about the sharp container on the shower door without a top and razors laying loosely. Nurse #1 stated, "That's not the right one (sharps container), we have them to fit..." Nurse #1 was asked if the small needle box in the holder with razors laying around the bottom outside the sharps container without a top was acceptable. Nurse #1 stated, "No, that is not acceptable."

Based on review of the Tennessee Certified Nursing Assistant (CNA) Candidate Handbook, policy review, observation and interview, it was determined the facility failed to perform proper peri-care on 1 of 3 (Resident #143) sampled residents of the 40 residents reviewed with urinary tract infections in the last 30 days. The findings included: Review of the "Tennessee CNA Candidate Handbook VERSION 4.5 OCT (October) 1,2009" documented, "2. Identifies that hands should be washed... 5. Raises the bed to appropriate height... 6. Fills basin with comfortably warm water. Place basin on overbed table or bed side stand... 7. Raises side rail opposite working side of bed... 8. Turns resident toward raised side rail... or raises hips and places waterproof pad under buttocks... 9. Puts on gloves. 10. Exposes perineum only. 11... physically separating the labia. 12. Using water and soapy washcloth, cleans one side of labia from top to bottom using a clean portion of a washcloth with each stroke. 13. Cleans other side of labia from top to bottom using a clean portion of a washcloth with each stroke. 14. Cleans vaginal area from top to bottom using clean portion of washcloth with each stroke..." Review of the facility's "GIVING FEMALE PERINEAL CARE" policy documented, "...Cover the overbed table with paper towel. Arrange items on top of them... Raise the bed for body mechanics... Decontaminate your hands. Put on gloves... Separate the labia. Clean downward from front to back with one stroke..." Observation in Resident #143's room on 2/10/12 at 11:20 AM, revealed the supplies were on the overbed table without a paper towel or other barrier according to their policy. CNA #1 washed her hands, applied gloves, opened the bedside table door, opened the closet door, assisted Resident #143 to bed, lowered the residents pants and opened the diaper. CNA #1 then started pericare without changing gloves and wiped the vaginal area twice without opening labia or changing area of washcloth for the second wipe to area. Resident #143 was turned on her right side to clean the rectal area when the resident voided on herself and the pad. CNA #1 did not start the pericare over to remove the urine the resident had voided on her perineal area and upper legs. During an interview in the west hall on 2/10/12 at 11:20 AM Nurse #1 was asked what she would have expected of the perineal care. Nurse #1 stated, "...When she (Resident #143) urinated during cleaning, (CNA #1) should have started over..."

Based on policy review, review of "2006 American Society of Consult Pharmacists and Med-Pass", review of the facility's dining times, medical record review, observation and interview, it was determined the facility failed to ensure the medication error rate was less than five percent (%) for Residents #11, 12, 17, 18, 19, 46 and Random Resident (RR #2). Four (4) of 8 (Residents #12, 17, 18 and 19) residents observed receiving insulin had medication errors with insulin administration. Six (6) of 13 nurses (Nurses #2, 3, 5, 6, 9 and 10) made 10 errors out of 49 opportunities for error which resulted in a medication error rate of 20%. The failure to administer insulin as ordered by the physician and the failure to administer insulin within 30 minutes of meals placed diabetic residents in immediate jeopardy. The immediate jeopardy began 7/29/09. The facility remained out of compliance at a scope and severity level "E" (a pattern deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that the policies and procedures and training implemented by the facility could be reviewed by the Quality Assurance (QA) Committee. The findings included: 1. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of the physician's orders dated 7/5/09 documented "[MEDICATION NAME] R 100 UNITS/ML AS DIRECTED ACCORDING TO THE SLIDING SCALE...251- (to) 300 = (amount of insulin to be administered) 6 UNITS..." The current orders dated 7/5/09 did not include an order for [REDACTED]. Observations in Resident #12's room on 8/3/09 at 4:03 PM, revealed Nurse #3 administered [MEDICATION NAME] R 6 units (U) subcutaneous (SQ) in the right abdomen. Observations of the evening meal on the West Hall on 8/3/09 revealed the meal tray was not served to Resident #12 until 5:17 PM. Resident #12 did not take the first bite of the meal until 5:22 PM, 1 hour and 19 minutes after administration of the insulin. The administration of the insulin more than 30 minutes before the meal resulted in medication error #1. Observations in Resident #12's room on 8/4/09 at 4:15 PM, revealed Nurse #2 administered [MEDICATION NAME] 4 mg by mouth to Resident #12. This resulted in medication error #2. During an interview in the conference room on 8/5/09 at 2:40 PM, the Director of Nursing (DON) stated, "I don't see an order for [REDACTED]. 2. Medical record review for Resident #17 documented an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of physician's orders dated 2/5/09 documented, "[MEDICATION NAME] R 100 UNITS/ML 10 UNITS SQ THREE TIMES 30 MIN (MINUTES) BEFORE MEALS." Observations in Resident #17's room on 8/3/09 at 4:35 PM, revealed Nurse #10 administered [MEDICATION NAME] R 10 U SQ in Resident #17's abdomen. Observations in the main dining room on 8/3/09 revealed the meal tray was not delivered to Resident #17 until 5:35 PM. The delivery of Resident #17's meal tray one hour after the administration of [MEDICATION NAME] R 10 U SQ resulted in medication error #3. 3. Medical record review for Resident #18 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders dated 7/5/09 documented, "[MEDICATION NAME] R 100 UNITS/ML AS DIRECTED ACCORDING TO SLIDING SCALE. SLIDING SCALE (REGULAR) 60-100= ORANGE JUICE 101-250= NO INSULIN 151-200= 2 UNITS 201-250= 4 UNITS 251-300= 6 UNITS 301-350= 8 UNITS 351-400= 10 UNITS > (greater than) 401 = NOTIFY MD (Medical Doctor)." Review of "2006 American Society of Consult Pharmacists and Med-Pass" documented [MEDICATION NAME] R should be administered 30 minutes prior to meals. Review of the facility's dining times documented, "...Dinner...Main...5:20 PM." Observations in Resident #18's room, on 8/3/09 at 4:15 PM, revealed Nurse #10 administered [MEDICATION NAME] R Insulin 12 U SQ to Resident #18 due to an accucheck reading of 432. There was no physician order to administer 12 units of Novilin R insulin. Observations in the main dining room on 8/3/09 revealed the dinner tray was not delivered to Resident #18 until 5:30 PM. The delivery of Resident #18's dinner tray one hour and 15 minutes after administration of sliding scale insulin. The administration of inuslin without an order and the failure to serve the meal winthin 30 minutes resulted in medication error #4. During an interview in the conference room on 8/5/09 at 2:40 PM, the Director of Nursing (DON) was asked about where the MD notification of blood sugars of 401 or greater would be documented. The DON stated, "They (Nurses) document on the back of the blood sugar sheet." 4. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a unsigned physician's order dated 7/28/09 by the nurse documented an order for [REDACTED]...201-250=4 units..." Observations in Resident #19's room on 8/3/09 at 4:12 PM, revealed Nurse #3 administered [MEDICATION NAME] 4 U SQ in Resident #19's right abdomen. Observations of the evening meal on the West Hall on 8/3/09 revealed the meal tray was not served to Resident #19 until 5:42 PM, 1 hour and 30 minutes after administration of the insulin. The administration of the insulin more than 30 minutes before the meal resulted in medication error #5. 5. Review of the facility's medication administration policy documented, "7.1 GENERAL GUIDELINES... PROCEDURES Medication Administration...7. When administering potent medications in liquid form or those requiring precise measurement, such as [MEDICATION NAME], devices provided by the manufacturer or obtained from a supplier, (e.g.(for example) oral syringes) are used to allow accurate measurement of doses." Medical record review for Resident #11 documented an admitted 1/1/09 with [DIAGNOSES REDACTED]. Review of the physician's orders dated 7/5/09 documented an order for [REDACTED]. Observations of medication administration in Resident #11's room on 8/4/09 at 9:20 AM, revealed Nurse #5 poured 7.5 cubic centimeter (cc) (330 mg) of [MEDICATION NAME] in a graduated medicine cup and crushed a Multivitamin plus (+) Iron tablet and administered both medications by Percutaneous Endoscopic Gastrostomy tube. The administration of [MEDICATION NAME] 330 mg (7.5 cc) instead of the 325 mg (7.38 cc) as ordered by the physician resulted in medication error #6. The administration of the Multivitamin + Iron instead of the Thera Tab as ordered resulted in medication error #7. During interview in the hallway outside room E29 on 8/4/09 at 3:35 PM, Nurse #5 stated "I gave the Multivitamin with iron. That's what we give when Thera Tab is ordered." During an interview in the East nurses' station on 8/4/90 at 3:45 PM, the Pharmacy Consultant stated, "going to ask the doctor to write the order for 7.5 cc. It would be 7.386 cc. We need to take the 325 mg off and it say 7.5 cc. Will make sure that order gets clarified." 6. Medical record review for Resident #46 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order dated 7/8/09 documented "MULTIVITAMIN W (with) MIN (minerals) 1 TABLET BY MOUTH EVERY DAY... ^ (increase) [MEDICATION NAME] to 10 mg 1 po (by mouth) q (every) 12 (hours) starting 8/2." Observation in Resident #46's room on 8/5/09 at 7:35 AM, revealed Nurse #6 administered Multivitamin 1 tab and [MEDICATION NAME] 5 mg by mouth to Resident #46. The failure to administer a Multivitamin with Minerals resulted in medication error #8. The failure to administer the [MEDICATION NAME] 10 mg resulted in medication error #9. During an interview regarding the administration of the Multivitamin with Minerals in the hallway across from Room E4 on 8/5/09 at 9:30 AM, Nurse #6 stated, "Right now that's it until the other ones (medications) come in." When asked about the [MEDICATION NAME] change of order Nurse #6 stated, "that doesn't start yet." When Nurse #6 checked the order she stated, "You're right." 7. Medical record review for RR #2 documented an admitted 9/5/07 with [DIAGNOSES REDACTED]. Review of the physician's orders dated 7/5/09 documented, "AKWA TEARS DROPS 1 DROPS(s) INTO LEFT EYE THREE TIMES DAILY." Observations in RR #2's room on 8/3/09 at 1:25 PM, revealed Nurse #9 administered one drop of AKWA Tears in RR #2's right eye. The administration of the eye drop in the wrong eye resulted in medication error #10. During an interview on the West Corridor, on 8/5/09 at 9:15 AM, Nurse #9 stated, "The order is wrong, it (eye drop) needs to go in the right eye. I will get it clarified." 8. The failure to administer insulin within 30 minutes of meals placed diabetic residents in immediate jeopardy. The immediate jeopardy existed from 7/29/09 to 8/12/09. On 8/12/09 the facility presented the survey team an acceptable allegation of compliance as follows: a. On 8/5/09 the Staff Development Coordinator, conducted an inservice with all Licensed Nurses regarding insulin administration, facility policy and procedure for blood glucose checks, insulin protocol and physician notification of blood glucoses below 60 and above 400. On 8/5/09 the facility Medical Director and two attending physicians re-approved the facility insulin protocol. b. On 8/6/09 the attending physicians were notified of errors by the Management Nurses. On 8/6/09, the Staff Development Nurse began an in-depth inservice for all Licensed Nurses regarding Medication Administration and Diabetes and Insulin Administration. A re-education will take place within 3 months conducted by the Tennessee State Veterans Home University training system. Educational content was approved by the Medical Director. On 8/6/09 the facility Management Nurses began the process of clarifying / verifying all insulin orders for accuracy. 100 percent (%) of all residents had received clarification/verification by 8/7/09. c. On 8/10/09 the facility Management Nurses began observing Licensed Nurses perform blood glucose checks and insulin administration. d. On 8/11/09 a skills fair was conducted by the Staff Development Masters prepared Registered Nurse and sister facility Certified Diabetic Educator. The content included insulin administration with return demonstration, physician notification, professional standards and facility policy for insulin administration and blood glucose checks with return demonstration. e. On 8/12/09, the Staff Development Coordinator re-educated all Licensed Nurses regarding professional standards of care. f. The Admissions Coordinator will alert the Director of Nurses of all new Diabetic admissions, regardless of type of Diabetes. A log will be kept of notification. The Director of Nurses or designee will audit all new admissions for order transcription accuracy, blood glucose checks/insulin log accuracy and physician notification when blood glucose is outside the prescribed parameters. Newly admitted Diabetics will be audited at 100 percent (%) for 3 months. The Director of Nurses or designee will report finding to Quality Improvement Committee for review. The committee will reserve the right to extend the auditing time frame. g. The Director of Nurses or designee (s) will audit 100% of all Diabetic medical records for accuracy and physician notification weekly times 4 then monthly for 3 months and report finding to Quality Improvement Team for review. The Regional Nurses will review at least 15 Diabetic medical records monthly and findings will be reported to the facility Administrator, Director of Nurses and Executive Director. h. Resident #20 was examined by the facility Medical Director and attending physician on 8/12/09. A plan of care was updated and agreed upon by facility Medical Director and attending physician. i. The Pharmacy Consultant will continue to perform monthly medication pass observations with emphasis on Insulin Administration. This will continue for 6 months or as needed. j. The facility Compliance Nurse, Quality Improvement Nurse and Staff Development Coordinator will perform monthly medication pass reviews on alternating shifts for 3 months and then quarterly as part of an on-going Quality Improvement Plan. The results of the medication passes will be reported to the Quality Improvement Team for review. After receiving the facility's acceptable allegation of compliance the surveyors verified that the corrective actions had been put in place to abate the immediate jeopardy. The surveyors verified the corrective actions by conducting an additional medication administration pass for observations of correct insulin administration and timely meal service, observed facility administrative staff monitoring nurses administering medications, reviewed inservice records and interviewed staff to verify the staffs knowledge of information received during the inservices. The immediate jeopardy was abated as of 8/12/09. The facility remains out of compliance at a scope and severity of "E".

Based on policy review, review of "2006 American Society of Consult Pharmacists and Med-Pass", review of the facility's dining times, medical record review, observation and interview, it was determined the facility failed to ensure the medication error rate was less than five percent (%) for Residents #11, 12, 17, 18, 19, 46 and Random Resident (RR #2). Four (4) of 8 (Residents #12, 17, 18 and 19) residents observed receiving insulin had medication errors with insulin administration. Six (6) of 13 nurses (Nurses #2, 3, 5, 6, 9 and 10) made 10 errors out of 49 opportunities for error which resulted in a medication error rate of 20%. The failure to administer insulin as ordered by the physician and the failure to administer insulin within 30 minutes of meals placed diabetic residents in immediate jeopardy. The immediate jeopardy began 7/29/09. The facility remained out of compliance at a scope and severity level "E" (a pattern deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that the policies and procedures and training implemented by the facility could be reviewed by the Quality Assurance (QA) Committee. The findings included: 1. Medical record review for Resident #12 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of the physician's orders dated 7/5/09 documented "[MEDICATION NAME] R 100 UNITS/ML AS DIRECTED ACCORDING TO THE SLIDING SCALE...251- (to) 300 = (amount of insulin to be administered) 6 UNITS..." The current orders dated 7/5/09 did not include an order for [REDACTED]. Observations in Resident #12's room on 8/3/09 at 4:03 PM, revealed Nurse #3 administered [MEDICATION NAME] R 6 units (U) subcutaneous (SQ) in the right abdomen. Observations of the evening meal on the West Hall on 8/3/09 revealed the meal tray was not served to Resident #12 until 5:17 PM. Resident #12 did not take the first bite of the meal until 5:22 PM, 1 hour and 19 minutes after administration of the insulin. The administration of the insulin more than 30 minutes before the meal resulted in medication error #1. Observations in Resident #12's room on 8/4/09 at 4:15 PM, revealed Nurse #2 administered [MEDICATION NAME] 4 mg by mouth to Resident #12. This resulted in medication error #2. During an interview in the conference room on 8/5/09 at 2:40 PM, the Director of Nursing (DON) stated, "I don't see an order for [REDACTED]." 2. Medical record review for Resident #17 documented an admission date of [DATE] with the [DIAGNOSES REDACTED]. Review of physician's orders dated 2/5/09 documented, "[MEDICATION NAME] R 100 UNITS/ML 10 UNITS SQ THREE TIMES 30 MIN (MINUTES) BEFORE MEALS." Observations in Resident #17's room on 8/3/09 at 4:35 PM, revealed Nurse #10 administered [MEDICATION NAME] R 10 U SQ in Resident #17's abdomen. Observations in the main dining room on 8/3/09 revealed the meal tray was not delivered to Resident #17 until 5:35 PM. The delivery of Resident #17's meal tray one hour after the administration of [MEDICATION NAME] R 10 U SQ resulted in medication error #3. 3. Medical record review for Resident #18 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders dated 7/5/09 documented, "[MEDICATION NAME] R 100 UNITS/ML AS DIRECTED ACCORDING TO SLIDING SCALE. SLIDING SCALE (REGULAR) 60-100= ORANGE JUICE 101-250= NO INSULIN 151-200= 2 UNITS 201-250= 4 UNITS 251-300= 6 UNITS 301-350= 8 UNITS 351-400= 10 UNITS > (greater than) 401 = NOTIFY MD (Medical Doctor)." Review of "2006 American Society of Consult Pharmacists and Med-Pass" documented [MEDICATION NAME] R should be administered 30 minutes prior to meals. Review of the facility's dining times documented, "...Dinner...Main...5:20 PM." Observations in Resident #18's room, on 8/3/09 at 4:15 PM, revealed Nurse #10 administered [MEDICATION NAME] R Insulin 12 U SQ to Resident #18 due to an accucheck reading of 432. There was no physician order to administer 12 units of Novilin R insulin. Observations in the main dining room on 8/3/09 revealed the dinner tray was not delivered to Resident #18 until 5:30 PM. The delivery of Resident #18's dinner tray one hour and 15 minutes after administration of sliding scale insulin. The administration of inuslin without an order and the failure to serve the meal winthin 30 minutes resulted in medication error #4. During an interview in the conference room on 8/5/09 at 2:40 PM, the Director of Nursing (DON) was asked about where the MD notification of blood sugars of 401 or greater would be documented. The DON stated, "They (Nurses) document on the back of the blood sugar sheet." 4. Medical record review for Resident #19 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a unsigned physician's order dated 7/28/09 by the nurse documented an order for [REDACTED]...201-250=4 units..." Observations in Resident #19's room on 8/3/09 at 4:12 PM, revealed Nurse #3 administered [MEDICATION NAME] 4 U SQ in Resident #19's right abdomen. Observations of the evening meal on the West Hall on 8/3/09 revealed the meal tray was not served to Resident #19 until 5:42 PM, 1 hour and 30 minutes after administration of the insulin. The administration of the insulin more than 30 minutes before the meal resulted in medication error #5. 5. Review of the facility's medication administration policy documented, "7.1 GENERAL GUIDELINES... PROCEDURES Medication Administration...7. When administering potent medications in liquid form or those requiring precise measurement, such as [MEDICATION NAME], devices provided by the manufacturer or obtained from a supplier, (e.g.(for example) oral syringes) are used to allow accurate measurement of doses." Medical record review for Resident #11 documented an admitted 1/1/09 with [DIAGNOSES REDACTED]. Review of the physician's orders dated 7/5/09 documented an order for [REDACTED]. Observations of medication administration in Resident #11's room on 8/4/09 at 9:20 AM, revealed Nurse #5 poured 7.5 cubic centimeter (cc) (330 mg) of [MEDICATION NAME] in a graduated medicine cup and crushed a Multivitamin plus (+) Iron tablet and administered both medications by Percutaneous Endoscopic Gastrostomy tube. The administration of [MEDICATION NAME] 330 mg (7.5 cc) instead of the 325 mg (7.38 cc) as ordered by the physician resulted in medication error #6. The administration of the Multivitamin + Iron instead of the Thera Tab as ordered resulted in medication error #7. During interview in the hallway outside room E29 on 8/4/09 at 3:35 PM, Nurse #5 stated "I gave the Multivitamin with iron. That's what we give when Thera Tab is ordered." During an interview in the East nurses' station on 8/4/90 at 3:45 PM, the Pharmacy Consultant stated, "going to ask the doctor to write the order for 7.5 cc. It would be 7.386 cc. We need to take the 325 mg off and it say 7.5 cc. Will make sure that order gets clarified." 6. Medical record review for Resident #46 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order dated 7/8/09 documented "MULTIVITAMIN W (with) MIN (minerals) 1 TABLET BY MOUTH EVERY DAY... ^ (increase) [MEDICATION NAME] to 10 mg 1 po (by mouth) q (every) 12 (hours) starting 8/2." Observation in Resident #46's room on 8/5/09 at 7:35 AM, revealed Nurse #6 administered Multivitamin 1 tab and [MEDICATION NAME] 5 mg by mouth to Resident #46. The failure to administer a Multivitamin with Minerals resulted in medication error #8. The failure to administer the [MEDICATION NAME] 10 mg resulted in medication error #9. During an interview regarding the administration of the Multivitamin with Minerals in the hallway across from Room E4 on 8/5/09 at 9:30 AM, Nurse #6 stated, "Right now that's it until the other ones (medications) come in." When asked about the [MEDICATION NAME] change of order Nurse #6 stated, "that doesn't start yet." When Nurse #6 checked the order she stated, "You're right." 7. Medical record review for RR #2 documented an admitted 9/5/07 with [DIAGNOSES REDACTED]. Review of the physician's orders dated 7/5/09 documented, "AKWA TEARS DROPS 1 DROPS(s) INTO LEFT EYE THREE TIMES DAILY." Observations in RR #2's room on 8/3/09 at 1:25 PM, revealed Nurse #9 administered one drop of AKWA Tears in RR #2's right eye. The administration of the eye drop in the wrong eye resulted in medication error #10. During an interview on the West Corridor, on 8/5/09 at 9:15 AM, Nurse #9 stated, "The order is wrong, it (eye drop) needs to go in the right eye. I will get it clarified." 8. The failure to administer insulin within 30 minutes of meals placed diabetic residents in immediate jeopardy. The immediate jeopardy existed from 7/29/09 to 8/12/09. On 8/12/09 the facility presented the survey team an acceptable allegation of compliance as follows: a. On 8/5/09 the Staff Development Coordinator, conducted an inservice with all Licensed Nurses regarding insulin administration, facility policy and procedure for blood glucose checks, insulin protocol and physician notification of blood glucoses below 60 and above 400. On 8/5/09 the facility Medical Director and two attending physicians re-approved the facility insulin protocol. b. On 8/6/09 the attending physicians were notified of errors by the Management Nurses. On 8/6/09, the Staff Development Nurse began an in-depth inservice for all Licensed Nurses regarding Medication Administration and Diabetes and Insulin Administration. A re-education will take place within 3 months conducted by the Tennessee State Veterans Home University training system. Educational content was approved by the Medical Director. On 8/6/09 the facility Management Nurses began the process of clarifying / verifying all insulin orders for accuracy. 100 percent (%) of all residents had received clarification/verification by 8/7/09. c. On 8/10/09 the facility Management Nurses began observing Licensed Nurses perform blood glucose checks and insulin administration. d. On 8/11/09 a skills fair was conducted by the Staff Development Masters prepared Registered Nurse and sister facility Certified Diabetic Educator. The content included insulin administration with return demonstration, physician notification, professional standards and facility policy for insulin administration and blood glucose checks with return demonstration. e. On 8/12/09, the Staff Development Coordinator re-educated all Licensed Nurses regarding professional standards of care. f. The Admissions Coordinator will alert the Director of Nurses of all new Diabetic admissions, regardless of type of Diabetes. A log will be kept of notification. The Director of Nurses or designee will audit all new admissions for order transcription accuracy, blood glucose checks/insulin log accuracy and physician notification when blood glucose is outside the prescribed parameters. Newly admitted Diabetics will be audited at 100 percent (%) for 3 months. The Director of Nurses or designee will report finding to Quality Improvement Committee for review. The committee will reserve the right to extend the auditing time frame. g. The Director of Nurses or designee (s) will audit 100% of all Diabetic medical records for accuracy and physician notification weekly times 4 then monthly for 3 months and report finding to Quality Improvement Team for review. The Regional Nurses will review at least 15 Diabetic medical records monthly and findings will be reported to the facility Administrator, Director of Nurses and Executive Director. h. Resident #20 was examined by the facility Medical Director and attending physician on 8/12/09. A plan of care was updated and agreed upon by facility Medical Director and attending physician. i. The Pharmacy Consultant will continue to perform monthly medication pass observations with emphasis on Insulin Administration. This will continue for 6 months or as needed. j. The facility Compliance Nurse, Quality Improvement Nurse and Staff Development Coordinator will perform monthly medication pass reviews on alternating shifts for 3 months and then quarterly as part of an on-going Quality Improvement Plan. The results of the medication passes will be reported to the Quality Improvement Team for review. After receiving the facility's acceptable allegation of compliance the surveyors verified that the corrective actions had been put in place to abate the immediate jeopardy. The surveyors verified the corrective actions by conducting an additional medication administration pass for observations of correct insulin administration and timely meal service, observed facility administrative staff monitoring nurses administering medications, reviewed inservice records and interviewed staff to verify the staffs knowledge of information received during the inservices. The immediate jeopardy was abated as of 8/12/09. The facility remains out of compliance at a scope and severity of "E".

Based on policy reviews, review of inservice records, review of meal times, review of the "MED-PASS" provided by the American Society of Consultant Pharmacists, medical record review, observations and interviews, it was determined the facility failed to ensure that residents were free of significant medication errors. The nursing staff failed to obtain blood sugars (BS) as ordered, failed to administer correct dosages of sliding scale insulin (SSI) as ordered, failed to administer insulin within 30 minutes of meals and/or failed to obtain signed orders for insulin administration for 20 of 30 (Residents #4, 10, 11, 17, 18, 19, 20, 24, 26, 29, 32, 34, 35, 36, 37, 38, 40, 42, 43 and 46) sampled diabetic residents. The failure to administer insulin as ordered, obtain BS as ordered and/or notify the physician of BS below 60 and/or above 401, placed all residents receiving insulin in immediate jeopardy. The immediate jeopardy began 7/29/09. The facility remained out of compliance at a scope and severity level "E" (a pattern deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that the policies and procedures and training implemented by the facility could be reviewed by the Quality Assurance (QA) Committee. The findings included: 1. Review of the facility's "Medication Administration General Guidelines" policy documented "...b. Medications to be given with meals are to be scheduled for administration at the resident's meal times..." Review of the facility's "Blood Sugar/Sliding Scale Monitoring" policy provided by the facility to be used as the standing order for sliding scale insulins documented, "...1.) A written physician order for [REDACTED].<) 60...Call MD (Medical Doctor) hold any scheduled insulin until verified with MD...IF BS 150- (to) 200...Give 2 units of Regular insulin...If BS 201-250...Give 4 units of Regular Insulin...If BS 251-300...Give 6 units of Regular Insulin...If BS 301-350...Give 8 units of Regular Insulin...If BS 351-400...Give 10 units of Regular Insulin...If BS is greater than 401...Give 12 units of Regular Insulin. Recheck in 2 hrs (hours), if still > (greater than) 401 call MD... 2.) Physician orders for custom sliding scale intervention may be written specifically for individual residents by the Physician and will supercede the facility approved sliding scale... 3.) Signs and symptoms of [DIAGNOSES REDACTED]: a.) Early symptoms: Sweating...Tremor...Pallor... [MEDICAL CONDITION] 4.) Treat [DIAGNOSES REDACTED] promptly with: a.) 4 oz. (ounces) juice, b.) 1 cup skim milk, c.) 4 packets sugar, or d.) [MEDICATION NAME] 1 mg (milligram) (subcutaneously (SQ) or I.M. (intramuscular)) is given if the resident cannot ingest a sugar treatment..." During an interview in the conference room on 8/5/09 at 2:30 PM, the Director of Nurses and the Regional Compliance Nurse was asked what the staff is supposed to use for sliding scale insulin. The Compliance Nurse stated, "...They (nurses) should go with what the order says, unless there's a clarification order to convert to the protocol, they should use the doctor's order... should have a standing order signed by (named medical director)... should be signed by all the doctors..." During an interview in the conference room on 8/5/09 at 4:00 PM, the Compliance Nurse was asked how the staff knows which regular insulin to use. The Compliance Nurse stated, "...I see what you mean...I'll rewrite the policy...I'll call (named medical director) and ask her..." 2. During an interview in the conference room on 8/11/09 at 9:45 AM, the Regional Compliance Nurse stated that the Quality Assessment (QA) process started in March 2009 concerning problems with compliance with diabetic residents. The Regional Compliance Nurse stated, "...That's when they (facility) started terminating people (failing to perform accuchecks as prescribed, notifying physician of low and high blood sugars and administering insulin as ordered) ...did group education...maybe we should do one-on-one..." As a result of the QA findings in March 2009 the facility did a nursing inservice on 3/29/09 as follows: "...Topics ...4. Accucheck & (and) Insulin Policy and Procedure...6. Physician and Family Notification... Accucheck and Insulin Policy and Procedure... 1. Accuchecks are to be performed as prescribed. The Accucheck will be documented on the Accucheck and Insulin flow sheet... If the Accucheck is below 60 or above 401 or as stated by the Physician, YOU MUST NOTIFY THE ATTENDING PHYSICIAN AND DOCUMENT. Document that the MD was notified and what the results of the notification are. FAILURE TO DO THIS WILL RESULT IN DISCIPLINARY ACTION LEADING VERY QUICKLY TO TERMINATION... 2. Scheduled Insulin will be given as directed. If there is a reason to hold the insulin, YOU WILL NOTIFY THE ATTENDING PHYSICIAN AND DOCUMENT THE NOTIFICATION AND THE RESULTS OF THE NOTIFICATION. THERE IS NO EXCEPTION TO THIS RULE. 3. Sliding Scale Insulin will be administered as prescribed. IF THE ACCUCHECK IS TOO HIGH FOR THE PRESCRIBED DOSE, THEN YOU WILL NOTIFY THE ATTENDING PHYSICIAN AS PER POLICY. AGAIN, THERE IS NO EXCEPTION TO THIS RULE... Physician and Family Notification: 1. Licensed Nurses will notify Physician's and families/responsible parties of change in Resident condition. This is a federal requirement and not up for discussion. Not only is it a federal requirement, it is required of you by the Nurse Practice Act that you document the notification... Accountability: All Licensed Nurses will be held accountable for their actions or inactions... bad care is stopping, apathy is stopping..." Review of the June 2009 Consultant Pharmacist's Monthly Report documented "...Inservice on medication pass...insulin...Things to address: Sliding scale insulin scheduled before meals should not be given more than thirty minutes before a meal. Please make sure times of administration on MARs (Medication Administration Record) are consistent with meal times..." A memorandum attached to the report to "Nursing Staff" dated 6/3/09 documented, "...Subject: Time of Insulin Administration... Please make sure that the sliding scale regular insulin ordered before meals is not given more than thirty minutes before scheduled meal times. On the June MARs there are several insulin doses charted as given at 4PM which would be more than thirty minutes before the evening meal trays come out. Please wait to give the insulin until meal trays will be out within thirty minutes. If a meal tray is late then you must give a snack to a resident who has already received insulin. This also applies to all insulin mixtures that contain regular insulin (e.g. (for example) [MEDICATION NAME] 70/30 and [MEDICATION NAME] 70/30)." Review of the facility's "INSULIN" pharmacy inservice dated 6/8/09 documented "...Rapid acting insulins - [MEDICATION NAME], Humalog, [MEDICATION NAME] - need to be given 5- (to) 15 minutes prior to food... ALWAYS specify the insulin to be used on the sliding scale when you write the order..." Review of the facility's "INSULIN ADMINISTRATION TIMES" documented "...Rapid-acting: [MEDICATION NAME], Humalog, [MEDICATION NAME] Resident must have meal tray or snack within 10-15 minutes, or physician can order after meal administration... Short-acting: Regular ([MEDICATION NAME]) Resident must have a meal tray or snack within 30 minutes..." During an interview with the Consultant Pharmacist on 8/12/09 at 8:35 AM, the Consultant Pharmacist stated that had identified a problem with insulins around the first of June 2009. The Consultant Pharmacist stated that during the inservice she did in June 2009, she had told the facility staff that "...the insulin times should be changed according to meals (times)...Told them AC (before meals) should be scheduled at meal times...can't give (insulin) one hour before the meals...go by the normal med times..." Insulin dosage times were not changed per the pharmacy recommendation/ inservice to correspond to the individual resident's meal times until after the Survey team identified the problem and notified the facility on 8/5/09. Review of a July 2009 inservice provided by the facility on "Documentation" documented "...Accuchecks and Glucose Documentation: All Licensed Nurses will utilize the orange Glucose monitoring form. The Licensed Nurse will observe the stated ranges and notify the attending Physician when the glucose is outside the prescribed range. There is no exception to this and any offender will be reprimanded, leading to termination for repeat offenders. The Licensed Nurse will document the MD notification on the back of the glucose monitoring form and will also document the MD response..." 3. Review of the facility "Dining Times" documented "...Dinner... 4:50 PM North ...5:00 PM East 1 ...5:15 PM West Assist...5:20 PM Main... 5:30 PM West Hall... 5:45 PM East Hall... 6:00 PM East 2..." During an interview in the conference room on 8/12/09 at 10:15 AM, the Certified Dietary Manager (CDM) was asked what the diabetic diet consists of. The CDM stated, "...get a consistent carb (carbohydrate) diet... consistent amount of carbs per day... get the same thing as everyone else... desserts...may get fruit instead... depends on the carb count..." 4. Review of the "MED-PASS" provided by the American Society of Consultant Pharmacists for typical dosing administration related to meals documented "...Humalog...15 minutes before or immediately after [MEDICATION NAME]...5-10 minutes before meals... [MEDICATION NAME] R (regular) [MEDICATION NAME] R...30 minutes before [MEDICATION NAME] 70/30 (70% [MEDICATION NAME] insulin/30% Regular insulin)..." 5. Medical record review for Resident #20 documented an admitted 2/10/09 with [DIAGNOSES REDACTED]. Review of the physician's order initiated 2/10/09 documented "...ACCUCHECKS BEFORE MEALS AND AT BEDTIME ...6AM...11AM...4:30AM...8PM... SLIDING SCALE...150 - 200 = (amount of insulin to be administered) 2 UNITS...201 - 250 = 4 UNITS...251 - 300 = 6 UNITS...301 - 350 = 8 UNITS...351 - 400 = 10 UNITS...>400 = 12 UNITS..." Review of Resident #20's BS flow sheet for May 2009 documented 124 opportunities for BS to be checked. The top of the May 2009 flow sheet for SSI documented "...Call MD if BS < 60 or > 400 Chart on Back..." There were 37 opportunities that there was no documentation that a BS was obtained. There were 12 with the wrong doses of insulin given. The BS with the incorrect SSI were as follows: a. 5/8/09 at 11:00 AM - BS was (=) 231, Insulin given = 0, correct dose = 4 units (U). b. 5/8/09 at 4:30 PM - BS = 323, Insulin given = 4, correct dose = 8 U. c. 5/12/09 at 6:00 AM - BS = 160, Insulin given = 0, correct dose = 2 U. d. 5/12/09 at 11:00 AM - BS = 294, Insulin given = 0, correct dose = 6 U. e. 5/13/09 at 6:30 AM - BS = 156, Insulin given = 0, correct dose = 2 U. f. 5/13/09 at 11:00 AM - BS = 310, Insulin given = 0, correct dose = 8 U. g. 5/14/09 at 6:30 AM - BS = 159, Insulin given = 0, correct dose = 2 U. h. 5/14/09 at 11:00 AM - BS = 255, Insulin given = 0, correct dose = 6 U. i. 5/18/09 at 11:00 AM - BS = 193, Insulin given = 0, correct dose = 2 U. j. 5/19/09 at 11:00 AM - BS = 394, Insulin given = 0, correct dose = 10 U. k. 5/20/09 at 6:30 AM - BS = 224, Insulin given = 0, correct dose = 4 U. l. 5/29/09 at 4:00 PM - BS = 366, Insulin given = 8, correct dose = 10 U. The administration of the wrong doses of insulin resulted in significant medication errors. The top of Resident #20's May 2009 flow sheet for SSI documented "...Call MD if BS < 60 or > 400 Chart on Back (facility protocol)..." There were 5 documented BS that were below 60 as follows: a. 5/5/09 at 6:30 AM - BS = 54. b. 5/8/09 at 6:30 AM - BS = 42. c. 5/18/09 at 6:30 AM - BS = 37. d. 5/19/09 at 6:30 AM - BS = 40. e. 5/22/09 at 6:30 AM - BS = 50. There was no documentation of interventions put in place for low BS, there was no documentation of any follow-up on the low BS and there was no documentation the physician was notified of these low blood sugars. There were 6 documented BS that were above 400 with no documentation that the BS was rechecked, and no documentation that the physician was notified. The BS were as follows: a. 5/8/09 at 8:00 PM - BS = 413. b. 5/11/09 at 4:00 PM - BS = 430. c. 5/13/09 at 8:00 PM - BS = 404. e. 5/14/09 at 8:00 PM - BS = 434. f. 5/20/09 at 4:00 PM - BS = 460. g. 5/28/09 at 4:00 PM - BS = 405. Review of Resident #20's BS flow sheet for June 2009 documented 120 opportunities for BS to be checked. There were 10 opportunities that there was no documentation that a BS was obtained. There were 16 with the wrong doses of insulin given. The BS with the incorrect SSI were as follows: a. 6/5/09 at 9:00 PM - BS = 123, Insulin given = 2, correct dose = 0 U. b. 6/9/09 at 6:30 AM - BS = 188, Insulin given = 0, correct dose = 2 U. c. 6/12/09 at 11:00 AM - BS = 144, Insulin given = 2, correct dose = 0 U. d. 6/15/09 at 6:30 AM - BS = 247, Insulin given = 0, correct dose = 4 U. e. 6/15/09 at 12:00 Noon - BS = 379, Insulin given = 8, correct dose = 10 U. f. 6/15/09 at 5:00 PM - BS = 350, Insulin given 10, correct dose 8 U. g. 6/16/09 at 6:30 AM - BS = 393, Insulin given 0, correct dose 10 U. h. 6/17/09 at 6:30 AM - BS = 184, Insulin given 0, correct dose 2 U. i. 6/18/09 at 6:30 AM - BS = 297, Insulin given 0, correct dose 6 U. j. 6/19/09 at 6:30 AM - BS = 184, Insulin given 0, correct dose 2 U. k. 6/20/09 at 6:30 AM - BS = 255, Insulin given 0, correct dose 6 U. l. 6/23/09 at 6:30 AM - BS = 333, Insulin given 0, correct dose 8 U. m. 6/24/09 at 6:30 AM - BS = 315, Insulin given 0, correct dose 8 U. n. 6/25/09 at 6:30 AM - BS = 207, Insulin given 0, correct dose 4 U. o. 6/25/09 at 10:00 PM - BS = 291, Insulin given 4, correct dose 6 U. p. 6/27/09 at 6:30 AM - BS = 233, Insulin given 0, correct dose 4 U. The administration of the wrong doses of insulin resulted in significant medication errors. The top of Resident #20's June 2009 flow sheet for SSI documented "...Call MD if BS < 60 or > 400 Chart on Back (facility protocol)..." There were 3 documented BS that were below 60 with no documentation of interventions taken to bring the BS up, and no documentation that the physician was notified. The 3 BS were as follows: a. 6/5/09 at 6:30 AM - BS = 50. b. 6/6/09 at 11:00 AM - BS = 56. c. 6/6/09 at 5:00 PM - BS = 56, no BS obtained at 9:00 PM. There were 9 documented BS that were above 400 with no documentation that the BS was rechecked, and no documentation that the physician was notified. The BS were as follows: a. 6/4/09 at 9:00 PM - BS = 410. b. 6/10/09 at 5:00 PM - BS = 495. c. 6/11/09 at 9:00 PM - BS = 441. d. 6/14/09 at 5:00 PM - BS = 456, no BS obtained at 9:00 PM. e. 6/16/09 at 5:00 PM - BS = 407. f. 6/16/09 at 9:00 PM - BS = 434. g. 6/18/09 at 5:00 PM - BS = 405. h. 6/22/09 at 5:00 PM - BS = 500, no BS obtained at 9:00 PM. i. 6/30/09 at 5:00 PM - BS = 422. Review of Resident #20's physician's recertification orders dated 7/1/09 documented "[MEDICATION NAME] R...9 UNITS SQ WITH LUNCH... [MEDICATION NAME] 70-30...22 UNITS...EVERY MORNING..." A telephone order dated 7/1/09 documented "...Give Regular insulin 6 units before supper...Cont. (continue) sliding scale insulin per protocol for accuchecks..." A physician's progress note dated 7/1/09 documented "...Accucheck low (86) fasting but high rest of time. Will (decrease) [MEDICATION NAME] & add fixed dose of insulin..." A progress noted dated 7/22/09 documented "...BGL (blood glucose level) OOC. (out of control) Will ^ 7/30 insulin to 32 units... Cont. Abx (antibiotics)..." A telephone order dated 7/22/09 documented "...Increase morning 70/30 (insulin) to 32 units Continue insulin c (with) meals and basal insulin s (without) change..." A physician's progress note dated 7/27/09 documented "...Pt (patient) sent to ED (Emergency Department) for dehydration... Na (Sodium) 146..." A telephone order dated 7/28/09 documented "... (change) Regular Insulin at Lunch and Dinner to 10 units...(change) SSi to Standard Sliding Scale..." A telephone order dated 7/30/09 documented "...Cont. using standard sliding scale & hold all scheduled insulins until further notice..." A telephone order dated 7/31/09 documented "...Insulin 70/30 32 units at breakfast... [MEDICATION NAME] 8 units at bedtime... Hold above & scheduled insulin if pt does not eat... Regular insulin 9 units at lunch... Regular insulin 6 units at supper...Do accu (check) TID (three times a day)..." Review of Resident #20's BS flow sheet for July 2009 documented 123 opportunities for BS to be checked. The top of the July 2009 flow sheet for SSI documented "...Call MD if BS < 60 or > 400 Chart on Back..." There were 4 opportunities that there was no documentation that a BS was obtained. There were 12 with the wrong doses of insulin given. The BS with the incorrect SSI were as follows: a. 7/2/09 at 9:00 PM - BS = 329, Insulin given 0, correct dose 8U. b. 7/4/09 at 6:00 AM - BS = 128, Insulin given 2, correct dose 0U. c. 7/4/09 at 9:00 PM - BS = 250, Insulin given 6, correct dose 4U. d. 7/5/09 at 9:00 PM - BS = 200, Insulin given 4, correct dose 2U. e. 7/6/09 at 9:00 PM - BS = 112, Insulin given 2, correct dose 0U. f. 7/12/09 at 6:00 AM - BS = 137, Insulin given 2, correct dose 0U. g. 7/19/09 at 6:00 AM - BS = 139, Insulin given 2, correct dose 0U. h. 7/19/09 at 9:00 PM - BS = 300, Insulin given 8, correct dose 6U. i. 7/24/09 at 6:00 AM - BS = 226, Insulin given 0, correct dose 4U. j. 7/24/09 at 4:30 PM - BS = 194, Insulin given 4, correct dose 2U. k. 7/25/09 at 6:00 AM - BS = 209, Insulin given 0, correct dose 4U. l. 7/27/09 at 4:00 PM - BS = 135, Insulin given 2, correct dose 0U. The administration of the wrong doses of insulin resulted in significant medication errors. Review of Resident #20's BS done on 7/29/09 at 6:30 AM, documented a BS of 68, and the resident was given 32 units of [MEDICATION NAME] 70/30. Review of the breakfast meal times for Resident #20 documented the meal trays come to the East hall beginning at 7:50 AM. Review of the nurse's note dated 7/29/09 at 9:58 AM, documented "...Called to room per CNA (Certified Nursing Assistant); Resident observed sweating, tongue hanging out mouth & unresponsive. BS checked reading "LO" oral gluco ([MEDICATION NAME]) given ^ (increased) BS to 20. IM gluco given ^ BS to 74; MD notified of results said to hold all insulins except SSI... Call back in 1 hr (hour) c (with) BS results..." Review of a physician's progress note dated 7/29/09 at 2:45 PM, documented "...Glucose < 20 this AM...did not eat after 32 units 70/30 (insulin) this AM. Will (decrease) insulin..." The administration of 32 units of [MEDICATION NAME] 70/30 insulin with a low blood sugar of 68 without being given any food resulted in a significant medication error and placed Resident #20 in immediate jeopardy. According to the "MED-PASS" provided by the American Society of Consultant Pharmacists, the onset of [MEDICATION NAME] 70/30 is "30 min (minutes)... Give approximately 30 minutes before meal. Each dose targets post-prandial blood sugars as well as basal insulin requirements..." The breakfast meal was not received for one hour and 20 minutes after the fast acting insulin was administered rather than the thirty minutes recommended. The resident displayed the above documented life-threatening symptoms with a blood sugar of less than 20. Observations in Resident #20's room on 8/12/09 at 8:15 AM, revealed Resident #20 had just gotten his breakfast tray and was being fed a pureed diet by a CNA. On 7/16/09 at 12:00 PM Resident #20's BS was 52. There was no documentation of any intervention taken to bring the BS up, and no documentation that the physician was notified of the low BS. The BS on 7/11/09 at 6:00 AM was 69. The resident was given 22 units of [MEDICATION NAME] 70/30 and there was no documentation that the resident ate anything. There were 6 documented BS that were above 400 with no documentation that the BS was rechecked, and no documentation that the physician was notified. The BS were as follows: a. 7/5/09 at 4:45 PM - BS = 404. b. 7/10/09 at 4:30 PM - BS = HI. c. 7/13/09 at 4:00 PM - BS = 473. d. 7/15/09 at 4:00 PM - BS = 429. e. 7/18/09 at 4:00 PM - BS = 408. f. 7/21/09 at 4:00 PM - BS = 403. Review of Resident #20's BS flow sheet for 8/1/09 through 8/10/09 at 11:45 AM, documented 38 opportunities for BS to be checked. The top of the August 2009 flow sheet for SSI documented "...Call MD if BS < 60 or > 400 Chart on Back..." There were 2 with the wrong doses of insulin given. The BS with the incorrect SSI were as follows: a. 8/1/09 at 10:00 PM - BS = 424, Insulin given 0, correct dose 12U. b. 8/2/09 at 6:00 AM - BS = 215, Insulin given 6, correct dose 4U. The administration of the wrong doses of insulin resulted in significant medication errors. Review of the facility "Ordering and Receiving Medications" documented "...New medications, except for emergency or "stat" (now) medications, are ordered as follows...If needed before the next regular delivery, fax/phone the medication orders to the pharmacy immediately upon receipt. Inform the pharmacy of the need for prompt delivery... "Stat" and emergency medications are ordered as follows... During regular pharmacy hours, the emergency or "stat" order is telephoned and faxed to the pharmacy immediately upon receipt. Such medications are delivered and administered within a timely manner... Emergency/STAT medication orders when medication is available in the emergency kit: From the emergency kit, remove the appropriate number of doses to be administered prior to the next regularly scheduled pharmacy delivery..." Review of a physician's telephone order for Resident #20 dated 7/30/09 at 8:25 AM, documented "[MEDICATION NAME] 1mg/kg (milligram per kilogram) IV (intravenous) X (times) 1 (one)..." A telephone order dated 7/31/09 at 3:30 PM, documented "..[MEDICATION NAME] ([MEDICATION NAME]) 1mg/kg at 11:00 daily X 10 days... Start 8/1/09... Start (after Gent ([MEDICATION NAME]) trough drawn)... [MEDICATION NAME] (lab) trough tomorrow (8/1/09 at 11:00...call result to (named MD)..." A telephone order dated 7/31/09 at 3:35 PM, documented [MEDICATION NAME] peak (lab) Monday 8/3/09 1 hour after [MEDICATION NAME] IV completed..." A telephone order dated 8/1/09 at 6:04 PM, documented "...Initiate 1st (first) dose of [MEDICATION NAME]" Review of a laboratory report dated 8/1/09 for Resident #20 documented [MEDICATION NAME] trough result "0.3". Review of the nurses' note date 8/1/09 at 6:05 PM, documented "...(named MD) notified of trough ([MEDICATION NAME]) report 0.3...Inst. (instructed) start [MEDICATION NAME]" The note dated 8/1/09 at 8:25 PM, documented "...(named MD) notified Gent. ([MEDICATION NAME]) did not arrive from pharmacy...MD order to change all previous [MEDICATION NAME] dose times & labs...Notify MD on call when [MEDICATION NAME] arrives & is started. Will give MD orders for further does (doses) & labs. at that time. Call lab results when obtained..." Review of a physician's telephone order for Resident #20 dated 8/1/09 at 8:25 PM, documented "...DC (discontinue) all previous [MEDICATION NAME] times & Give IV [MEDICATION NAME] 1mg/kg dose as soon as it arrives from pharmacy..." A telephone order dated 8/2/09 at 12:15 AM, documented Administer [MEDICATION NAME] 75mg/100ml (milligrams per milliliter) NS (normal saline) per IVPB (IV piggyback) now d/t (due to) arrival from pharmacy..." Review of Resident #20's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the MAR for August 2009 documented the next dose of [MEDICATION NAME] was not given until 12:00 Midnight on 8/2/09. During an interview with the Consultant Pharmacist (CP) in the conference room on 8/12/09 at 8:35 PM, the CP was asked when the pharmacy receives an order for [REDACTED]. The CP was asked if she could find out when the pharmacy received the order for the [MEDICATION NAME]. The CP brought a written statement that documented, "...Order faxed to pharmacy and also called to pharmacy 9:41 AM... (named Pharmacist) gave instructions of mixing for IV administration. Med (medication) was taken from the emergency kit (at the facility)...8/1 (8/1/09) Called to on-call pharmacist 9:26 PM...Pharmacy courier called at 10:03 PM...Medication delivered to (named facility) 11:51 PM...Pharmacy sent following: 7/31...Billed to Emergency Kit...8/1...#3 (doses) ...8/3...#3...8/5...#2... order changed to IM (intramuscular) 8/5...#5..." During a telephone interview with Resident #20's attending physician on 8/11/09 at 11:45 AM, he stated "...there was an issue with getting [MEDICATION NAME] but, I'm sure you've see that..." Observations in Resident #20's room on 8/12/09 at 8:15 AM, revealed the resident was served a pureed diet of eggs, sausage, oatmeal, and bread pudding. During a telephone interview with Resident #20's attending physician on 8/11/09 at 11:45 AM, the MD was asked if he would expect the staff to give the scheduled doses of insulin if the BS were in the 60's or 70's. He stated, "...it would be okay, if he (resident) eats..." The MD further stated "...issues with the (BS) logs being completed... blanks... there is a system's problem..." Nurse #14 failed to hold Resident #20's scheduled dose of [MEDICATION NAME] 70/30 (70 percent (%) NPH - long acting insulin, and 30% Regular insulin - short acting) 32 units after obtaining a BS of 68 on 7/29/09 at 6:30 AM. Resident #20's scheduled breakfast time is 7:50 AM, an hour and 20 minutes after the insulin was given. There was no documentation that the resident was given a snack at the time the insulin was administered, and no documentation of follow-up monitoring of the resident's condition. This resulted in immediate jeopardy when the resident did not eat breakfast and was found unresponsive at 9:30 AM with a BS reading of "LO (below 20)". The facility's staff failure to consistently administer the wrong doses of insulin, failure to follow interventions, document follow-ups and failure to notify the physician of low and elevated BS levels placed all diabetic residents at risk to their safety and wellbeing. 6. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's recertification orders dated for 4/6/09, 5/11/09, 6/2/09 and 7/5/09 documented, "ACCUCHECKS DAILY" and no orders for insulin to be administered. Review of the blood sugar flow sheet for April 2009 recorded 30 opportunities for BS to be checked. There were 8 doses of insulin given. a. 4/3/09 at 6:00 AM - BS = 164, Insulin given = 2 U, no SSI ordered. b. 4/10/09 at 6:00 AM - BS = 177, Insulin given = 2 U, no SSI ordered. c. 4/12/09 at 6:00 AM - BS = 181, Insulin given = 2 U, no SSI ordered. d. 4/16/09 at 6:00 AM - BS = 164, Insulin given = 2 U, no SSI ordered. e. 4/23/09 at 6:00 AM - BS = 157, Insulin given = 2 U, no SSI ordered. f. 4/24/09 at 6:00 AM - BS = 184, Insulin given = 2 U, no SSI ordered. g. 4/28/09 at 6:00 AM - BS = 164, Insulin given = 2U, no SSI ordered. h. 4/30/09 at 6:00 AM - BS = 169, Insulin given = 2 U, no SSI ordered. The administration of insulin with no physician's order resulted in significant medication errors. Review of the the blood sugar flow sheet for May 2009 recorded 31 opportunities for BS to be checked. There were 14 doses of insulin given. a. 5/3/09 at 6:00 AM - BS =178, Insulin given = 2 U, no SSI ordered. b. 5/6/09 at 6:00 AM - BS = 191, Insulin given = 2 U, no SSI ordered. c. 5/10/09 at 6:00 AM - BS = 151, Insulin given =2 U, no SSI ordered. d. 5/11/09 at 6:00 AM - BS = 189, Insulin given = 2 U, no SSI ordered. e. 5/13/09 at 6:00 AM - BS =162, Insulin given = 2 U, no SSI ordered. f. 5/16/09 at 6:00 AM - BS =164, Insulin given = 2 U, no SSI ordered. g. 5/17/09 at 6:00 AM - BS = 171, Insulin given = 2 U, no SSI ordered. h. 5/18/09 at 6:00 AM - BS = 200, Insulin given = 2 U, no SSI ordered. i. 5/20/09 at 6:00 AM - BS = 162, Insulin given = 2 U, no SSI ordered. j. 5/22/09 at 6:00 AM - BS = 160, Insulin given = 2 U, no SSI ordered. k. 5/24/09 at 6:00 AM - BS =167, Insulin given = 2 U, no SSI ordered. l. 5/25/09 at 6:00 AM - BS = 188, Insulin given = 2 U, no SSI ordered. m. 5/27/09 at 6:00 AM - BS = 186, Insulin given = 2 U, no SSI ordered. n. 5/30/09 at 6:00 AM - BS = 164, Insulin given = 2 U, no SSI ordered. The administration of insulin with no physician's order resulted in significant medication errors. Review of the blood sugar flow sheet for June 2009 recorded 30 opportunities for BS to be checked. There were 10 doses of insulin given. a. 6/3/09 at 6:00 AM - BS =166, Insulin given = 2 U, no SSI ordered. b. 6/5/09 at 6:00 AM - BS = 168, Insulin given = 2 U, no SSI ordered. c. 6/12/09 at 6:00 AM - BS = 162, Insulin given = 2 U, no SSI ordered. d. 6/14/09 at 6:00 AM - BS = 166, Insulin given = 2 U, no SSI ordered. e. 6/19/09 at 6:00 AM - BS = 154, Insulin given = 2 U, no SSI ordered. f. 6/21/09 at 6:00 AM - BS = 191, Insulin given = 2 U, no SSI ordered. g. 6/22/09 at 6:00 AM - BS = 156, Insulin given = 2 U, no SSI ordered. h. 6/24/09 at 6:00 AM - BS = 152, Insulin given = 2 U, no SSI ordered. i. 6/28/09 at 6:00 AM - BS = 150, Insulin given = 2 U, no SSI ordered. j. 6/29/09 at 6:00 AM - BS 185, Insulin given = 4 U, no SSI ordered. The administration of insulin with no physician's order resulted in significant medication errors. 7. Medical record review for Resident #10 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a physician's recertification order dated 6/3/09 documented, "[MEDICATION NAME] R 100 UNITS/ML (milliliter) AS DIRECTED ACCORDING TO SLIDING SCALE . SLIDING SCALE <60, call MD, HOLD ANY SCHEDULED INSULIN UNTIL VERIFIED W/(with) MD. 150-200 = 2 UNITS, 201-250 = 4 UNITS, 251-300 = 6 UNITS, 301-350 = 8 UNITS, 351-400 = 10 UNITS > 401 = 12 UNITS, RECHECK IN 2 HOURS AND IF STILL > 401, CALL MD..." Review of the Accucheck/Insulin Log documented the 6/4/09 at 5:00 PM - BS was 150 with no insulin given, the correct insulin dose to be administered was 2U. The failure to administer insulin as ordered resulted in a significant medication error. 8. Medical record review for Resident #11 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's order initiated 1/1/09 documented "...ACCUCHECKS BEFORE MEALS AND AT BEDTIME ...6AM...11AM...4:30 PM...9PM... SLIDING SCALE (REGULAR)...150 - 200 = 4 UNITS...201 - 250 = 6 UNITS...251 - 300 = 8 UNITS...301 - 350 = 10 UNITS...351 - 400 = 12 UNITS...401 - 450 = 14 UNITS...> 450 = 16 UNITS...CALL MD FOR BS >450..." Review of the BS flow sheet for May 2009 recorded 124 opportunities for the BS to be checked. There were 6 with the wrong dose of insulin given, and the BS was not check on 5/29/09 at 9:00 PM. The BS with the incorrect SSI were as follows: a. 5/4/09 at 11:00 AM - BS = 152, Insulin given = 2, correct dose = 4U. b. 5/10/09 at 11:00 AM - BS = 158, Insulin given = 0, correct dose = 4U. c. 5/15/09 at 11:00 AM - BS = 251, Insulin given = 6, correct dose = 8U. d. 5/16/09 at 11:00 AM - BS = 169, Insulin given = 0, correct dose = 4U. e. 5/21/09 at 11