Every finding on record at Willowbrooke Court SC Ctr at Tryon Estates

Based on observations and staff interviews, the facility failed to discard food items with signs of spoilage and liquid nutritional supplements that were past the expiration date in 1 of 1 walk-in cooler and label and date prepared food items in 1 of 1 reach-in cooler. These practices had the potential to affect food and drink items served to the residents. Findings included: a. An initial observation of the walk-in cooler on [DATE] at 8:50 AM revealed the following: a) A bag of fresh parsley dated ,d+[DATE] that had a dark brown, slimy substance on some of the parsley leaves. b) A tray containing 30, eight-ounce cartons of liquid nutritional supplements with an expiration date of [DATE]. During an interview on [DATE] at 8:50 AM, the Nutrition Services Manager confirmed the bag of fresh parsley had visible signs of spoilage on some of the leaves, the nutritional supplements were past the expiration date and stated both should have been removed from the cooler and discarded. The Nutrition Services Manager stated that all dietary staff were responsible for checking the cooler and discarding any food items with signs of spoilage or past the expiration date. During an interview on [DATE] at 4:54 PM, the Administrator revealed she expected dietary staff to check the coolers and discard any items that were expired or had visible signs of spoilage. b. An initial observation of the reach-in cooler on [DATE] at 8:57 AM revealed an unlabeled and undated clear storage container with plastic wrap covering the top that was half-way filled with a white liquid mixture with brown specks throughout the liquid. During an interview on [DATE] at 8:57 AM, the Nutrition Services Manager revealed the liquid in the container was a mixture for making French Toast. She was unsure when the mixture was prepared and stated the container should have been labeled with the name of the product, date prepared and use by date. During an interview on [DATE] at 4:54 PM, the Administrator revealed she expected dietary staff to label and date all prepared food items stored in the kitchen coolers and/or refrigerators.

Based on observations and staff interviews the facility failed to remove an expired medication prior to being prepared for resident administration on 1 of 2 medication carts reviewed for medication storage (Willowbrooke Medication Cart). Findings included: During an observation on [DATE] at 9:22 AM Nurse #1 removed a package of [MEDICATION(S)] (medication used to lower blood pressure) from the medication cart and compared the label to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 9:22 AM Nurse #1 was asked to review the expiration date on the package of [MEDICATION(S)] and revealed the medication had expired on [DATE]. Nurse #1 removed the medication from the cup she was preparing and appropriately discarded it. Nurse #1 stated she should have reviewed the expiration date before preparing to administer the [MEDICATION(S)]. An interview was conducted with Director of Nursing (DON) on [DATE] at 11:06 AM. The DON revealed third shift checked the medication carts for expired medicine three times a week, but she didn't know the exact date when the Willowbrooke Cart was last checked. The DON stated reviewing expiration dates was part of the check before administering medications to residents and would expect Nurse #1 to check the expiration date on the label prior to removing it from the package. An interview was conducted on [DATE] at 11:07 AM with the Administrator. The Administrator stated he would expect Nurse #1 to review the medication label for the expiration date and not remove the medicine as if ready to administer when the medication had expired.

Based on observation and staff interview the facility failed to keep cold salads made with mayonnaise at 41 degrees Fahrenheit or below at the time of meal service. Findings included: On 07/12/18 11:26 AM, food temperatures started to be taken of foods being served to residents for the lunch meal which was scheduled to be served at 11:30 AM. The potato salad was observed in single serving bowls that were on a tray in the refrigerator, located in the small kitchen service area. The interior temperature of the refrigerator was at 44 degrees Fahrenheit. Dining Staff #1 indicated the potato salad was ready to be served directly from the refrigerator to the residents sitting at tables in the dining room. On 07/12/18 at 11:35 AM, a calibrated thermometer was used to take the temperature of the potato salad which registered 48 degrees Fahrenheit. Dining Staff #1 stated the potato salad could not be served. The Assistant Director of Culinary and Nutrition was interviewed 07/12/18 02:14 PM. She did not indicate a temperature had been taken of the potato salad prior to leaving the main kitchen. She had been made aware the potato salad, ready for service, was 48 degree at lunchtime. The Assistant Director of Culinary and Nutrition specified cold salads made with mayonnaise were to be kept under 40 degrees Fahrenheit before they left the kitchen for delivery to residents. She further indicated allowing salads made with mayonnaise and egg to rise above 41 degrees Fahrenheit for extended periods of time could lead to bacteria formation which could potentially make residents sick. During an interview on 07/13/18 01:30 PM, the Administrator stated that the culinary team immediately took a new refrigerator/freezer combination unit after discovering the temperature of the potato salad. She further stated it was her expectation that the food would be the correct temp, and if not, it would not be served.

Based on observations, record reviews, resident interviews, family interview, and staff interviews, the facility failed to place call bells within the reach for 2 of 23 sampled residents. (Residents #1 and #20). The findings included: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current care plan, addressing activities of daily living skills, last updated 04/08/14 included the intervention to remind the resident to call for assistance and keep call light in reach. Resident #1 was observed with her call cord out of reach as follows: *Resident #1 was observed on 04/14/14 at 10:28 AM in a wheelchair in her room with the call light hooked on call box located on the wall out of her reach. *On 04/14/14 at 3:04 PM, Resident #1 was in her personal chair dozing and the call cord was attached to the box on the wall out of her reach. *On 04/15/14 at 9:01 AM, Resident #1 was in her personal chair reading the paper and the call cord was attached to the box on the wall out of her reach. *On 04/15/14 at 10:50 Am while sitting in her personal chair with the call cord attached to the box on the wall out of her reach. *Resident #1 was in her personal chair in her room with the call cord attached to the box on the wall out of her reach on 04/15/14 at 1:55 AM. On 04/15/14 at 1:55 AM, Resident #1 was asked by the surveyor how she called for someone if she needed assistance. She responded "lots of different ways" but was unable to articulate a way. The surveyor showed her the call cord and asked if she knew what the call cord was for and she used her hands to simulate pushing the call button down to activate it. On 04/16/14 at 8:44 AM, Resident#1 was in her personal chair with the call cord attached to her pants. When asked if she knew what the call bell was, she responded it called someone. Nursing Assistant (NA) #2 stated at 04/16/14 at 8:55 AM the call cord should be where residents could reach them. She further stated she brought Resident #1 back from the dining room this morning and placed the call cord on her lap. She could not comment on why the call cord was hanging on the wall the previous couple of days. NA #3 stated on 04/16/14 at 8:56 AM that this morning she noted the call cord was on the wall and she had moved it down to her bed. Interview with the Director of Nursing on 04/16/14 at 11:35 AM revealed call cords should be within the resident ' s reach. She further stated she did not think Resident #1 knew how to activate the call cord due to her dementia. On 04/16/14 at 1:53 PM, Resident #1 ' s family member stated he was sure the resident knew what the light was used for. 2. Resident #20 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] coded her as being cognitively intact and requiring extensive assistance with all activities of daily living skills. On 04/15/14 at 10:48 AM, Resident #20 was in her room in her wheelchair on the window side of the bed where her personal chair was located. At this time the call bell was observed out of sight, located on the opposite side of the bed, on the top side rail which was lowered. The bed was made and the call cord would not be easily accessed. At this time, Resident #20 was asked about the accessibility of the call cord. She stated that when staff make the bed and the side rails are put down, then she cannot access the call bell. At 10:55 AM on 04/15/14, Resident #20 asked nurse aide (NA) #2 who came into the room to move the call cord where she could reach it. NA #2 stated she did not make Resident #20's bed this date and did not know who did. On 04/15/14 at 1:48 AM, NA #4 stated she did not know who made Resident 320's bed this morning. On 04/16/14 at 8:42 AM, Resident #20 stated that "often" when staff make her bed in the morning, the call cord is left out of reach. She further stated "it seems like everyday" the call cord is out of reach. Nursing Assistant (NA) #2 stated at 04/16/14 at 8:55 AM the call cord should be where residents could reach them. She further stated she thought the call cord itself was too short for good accessibility. NA #3 stated at 04/16/14 at 8:56 AM that often the call cord was placed on the right (door) side of the bed on that side rail when Resident #20 was in bed. If the call cord was left on that side once she was out of bed, it would be inaccessible to her. NA #3 stated the call cord would be accessible if positioned on the left (window) side of the bed. Interview with the Director of Nursing on 04/16/14 at 11:35 AM revealed call cords should be within the resident's reach.

Based on record review and staff interviews, the facility failed to provide indication for increasing the dose of [MEDICATION NAME], an antidepressant, from 5 milligrams (mg) to 10 mg daily for 1 of 5 sampled resident reviewed for unnecessary medications (Resident #13). The findings included: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #13 had intact cognition with the Brief Interview for Mental Status (BIMS) score of 9 out of 15. The MDS further indicated Resident #13 displayed little or no interest in doing things, feeling tired or having little energy but did not indicate feeling down, depressed, or hopeless. The MDS revealed Resident #13 received an antidepressant within the last 7 days. The annual Care Area Assessment (CAA) dated 07/23/13 triggered psychosocial well-being related to Resident #13 had little interest or pleasure in doing things. Resident preferred to spend most of her time in her room lying in bed. The CAA further revealed Resident would eat her meals in the dining room and would go on lunch outings if prompted and this was not a new concern for the resident and the facility would proceed to care planning. The CAA also triggered for [MEDICAL CONDITION] drug use related to Resident [DIAGNOSES REDACTED]. The CAA did not trigger for mood problems for Resident #13. The quarterly MDS dated [DATE] revealed Resident #13 had a BIMS score of 11 out of 15 which indicated intact cognition and further revealed resident received antidepressant medication within the last 7 days. Resident #13 required extensive assistance with transfer and limited assist with locomotion. Resident was feeling tired and had little or no energy but did not indicate feeling down, depressed, or hopeless. A review of the care plan initiated on 12/11/12 and last updated on 4/1/14 stated Resident #13 had a problem with depression with [MEDICAL CONDITION]/anxiety requiring [MEDICAL CONDITION] drug use and included 2 goals: will have at least 6 hours uninterrupted sleep and will maintain weight. Interventions to achieve goal included: medication as ordered, monitor for side effects of medication, decrease external stimuli, notify MD/Geriatric Nurse Practitioner (GNP) as needed, consult with psychologist, allow resident to vent feelings, and encourage activities outside of room. A review of Resident #13's medical record from 01/01/14 to 04/16/14 revealed there were no psychologist notes. Behavior monitoring sheets that indicated any incidences of withdrawn, [MEDICAL CONDITION]-difficulty falling and staying asleep from months of January, February, and March of 2014 indicated no instances of withdrawn behavior and one instance of [MEDICAL CONDITION] on 02/18/14. Nurse's notes on 02/24/14 revealed that resident did not want to propel self in wheel chair and did not want to do as much for self as previously and [MEDICATION NAME] 5 mg was increased to 10 mg every day related to depression. Nurse practitioner progress note dated 02/24/24 indicated that Resident #13 would continue all other medications and increased [MEDICATION NAME] from 5 mg to 10 mg every day. Nurse practitioner's progress note further revealed Resident #13 denied any anxiety or depression and provided no indication for the increased dose of [MEDICATION NAME]. A telephone interview with the Nurse Practitioner on 04/16/14 at 2:30 PM with the Director of Nursing (DON) present revealed that Nurse Practitioner did not remember Resident #13 and shared that she may have received information from the staff that prompted her to increase the [MEDICATION NAME] and that she may have been interrupted by someone and that may be the reason why she did not document the indication for the increase of [MEDICATION NAME] in her progress notes. Nurse Practitioner further shared that she does not remember why she increased the dose of [MEDICATION NAME] and stated that she would do better with her documentation. Interview with DON on 04/16/14 at 2:45 PM revealed that she did not see any documentation in the Resident #13's medical record regarding depression symptoms or behaviors to support the increase in the [MEDICATION NAME] dose except for one note, written on 02/24/14, regarding Resident #13 not wanting to propel self in the wheel chair and not wanting to do as much for self. DON shared that perhaps she may change behavior monitoring sheet to offer more choices for nurses to document type of behavior.

Based on observation, record review, facility documentation, staff and resident interview the facility failed to provide a complete Care Area Assessment related to the use of an indwelling urinary catheter for 2 of 12 sampled residents (Residents #24 and #20). The findings included: 1. Resident #24 was admitted on [DATE] and the [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #24 had intact cognition with the Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS further revealed that Resident #24 was coded with an indwelling catheter. A review of the annual Care Area Assessment (CAA) dated 01/28/14 revealed that Resident #24 had a urinary catheter for [MEDICAL CONDITION]. No other urinary issues related to the indwelling catheter were addressed in the CAA. The CAA did not address whether the facility would proceed to care plan. The CAA did not include Resident #24's strengths and weaknesses, causes and effects, risk factors, complications, or how multiple triggered conditions might affect the need or care of the catheter. There was no analysis in the CAA as to what the care plan would address. Interview on 04/16/14 with Assistant Director of Nursing (ADON) who completed the MDS revealed that she expected the CAA to paint a picture of the whole resident. 2. Resident #20 was most recently readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] coded her with intact cognition, requiring extensive assistance with toileting and having an indwelling urinary catheter. The Care Area Assessment (CAA) dated 11/12/13 did not include a comprehensive analysis of the description of the problem, the resident's strengths and weaknesses, the causes and contributing factors and the risk factors relating to the use and need of the indwelling urinary catheter. The CAA included a checklist that indicated Resident 320 also had pain, restricted mobility, [MEDICAL CONDITION] bladder and diabetes, however, no description of these areas was included as to how they related to the use or need for an indwelling urinary catheter. The CAA summary stated "Resident has foley cath (catheter) r/t (related to) [MEDICAL CONDITION] bladder. Will proceed to care plan." Observations on 04/15/14 at 10:48 Am revealed Resident 320 had an indwelling urinary catheter in place. Resident #20 stated at this time that she had the catheter since being hospitalized as she could not pass urine. Interview with the MDS coordinator on 04/16/14 at 10:53 AM revealed the CAA information drove the care plan. She stated she looked at the CAA originally written by the restorative nurse and made sure the [DIAGNOSES REDACTED]. She stated the main thing for this CAA was for the reason the catheter was in use. Interview with the Director of Nursing on 04/16/14 at 11:32 AM revealed the CAA should have had more information.

Based on observation and staff interview, the facility failed to remove outdated thickened dairy drink, and failed to ensure kitchenware was dry before stacking for storage. Findings included: 1. During an observation on 02/25/2013 at 4:08 PM, the Diary/Meat cooler contained 52 single-serving boxes of a thickened dairy product with a use by date of December 2012. During an interview on 2/27/13 at 10:30 AM, the Nutritional Services Manager said it was her expectation that the Dietary Aides and Stock Clerk would check expiration dates and remove outdated products as needed. On 02/27/2013 at 4:31 PM, the Administrator said it was her expectation that expired stock in the kitchen would be discarded. 2. On 02/25/2013 at 4:16 PM, dessert dishes were stacked and ready for service. Upon examination, the center of the top plate had moisture droplets over an area approximately the size of a 50 cent piece. The dishwashing service was observed on 02/26/2013 at 9:40 AM. As soon as the dishes came out of the dishwasher the Dietary Aide removed them from the tray and stacked them together while still wet. Two large mixing bowls were also taken immediately from the dishwasher and stacked on top of another large mixing bowl in a final storage area. At 10:02 AM, the mixing bowls were separated and were still dripping water. On 02/26/2013 at 10:02 AM, the Nutritional Services Manager and the Culinary Director both indicated it was their expectation that dishes and pots would be dry before being stacked together. On 02/27/2013 at 4:31 PM, the Administrator said it was her expectation that dishware would be dry before being stored for service.

Based on observation, record review, resident interview and staff interviews, the facility failed to anchor a catheter tubing to prevent excessive tension for 1 of 2 sampled residents with indwelling catheters. Findings included: The facility policy for indwelling catheter care (dated June 2009) included, "Attach the catheter to the resident's upper thigh using a leg strap." Resident #25 had [DIAGNOSES REDACTED].#25 was moderately cognitively impaired and required extensive assistance from staff for dressing and transfers. A physician's orders [REDACTED]. The Care Plan, updated on 02/19/2013, included daily catheter care. On 02/27/2013 at 10:51 AM, Resident #25 was observed as he was transferred onto the toilet via a mechanical lift by Nurse Aides (NA) #1 and #2. When his trousers were removed it was observed that the indwelling catheter tubing was not secured to his thigh. Resident #25 indicated he could feel the tension on his bladder from the extended tubing during transfers with the mechanical lift. NA #1 said that the resident only had the catheter for a few weeks and that she didn't usually anchor the tubing to the resident's thigh. NA #2 said she knew where the leg straps were kept and she left to get one for the resident. On 02/27/2013 at 1:17 PM, Nurse #1 was interviewed about securing the tubing of an indwelling catheter. Nurse #1 said, "They (catheter tubing) should have some kind of an anchor." On 02/27/2013 at 4:47 PM the Director of Nursing said the tubing of an indwelling catheter, "Should be secured to the leg so it doesn't pull."

Based on medical record review and staff interviews the facility failed to test stool for blood for one (1) of one (1) sampled resident. (Resident #16) The findings are: Resident #16 had [DIAGNOSES REDACTED]. Resident #16 had a problem area on her current care plan dated 2/6/12, "Prone to bleeding related to [MEDICATION NAME] (a medication used to thin blood) usage." Approaches to address this problem included: [MEDICATION NAME] as ordered, Labs as ordered, Monitor for increased bruising or active bleeding and report to physician/nurse practitioner as needed. Resident #16 was assessed on the quarterly assessment dated [DATE] with moderate cognitive impairment. Review of physician orders [REDACTED]. Further review of the medical record of Resident #16 revealed the resident's stools had not been checked for occult blood. The medical record of Resident #16 revealed a nurses note dated 4/5/12 at 3:33 PM by licensed nurse (LN) #2 which noted labs (including hemoglobin and hematocrit) were called to the nurse practitioner and the nurse practitioner gave a telephone order to check stool for occult blood for three days. On 5/9/12 at 3:55 PM LN #2 stated she remembered talking to the nurse practitioner and received the telephone order to check stools for occult blood for three days. LN#2 stated she would have written the need to check stool for occult blood on the nursing clipboard. LN#2 stated she would have asked the nursing assistants to place a "hat" (a disposable container used to collect urine/stool samples) in the resident's bathroom to obtain a stool sample. LN#2 stated she worked with Resident #16 very little since 4/5/12 and, because of this, could not explain why the test was not done. LN#2 reviewed the April 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. LN#2 verified all dated entries beside this notation on the resident's April MAR indicated [REDACTED] Review of nursing notes in the medical record of Resident #16 revealed only one entry regarding the need to check stools for occult blood. This note was written by LN #3 on 4/7/12 at 12:52 PM, "Hats were placed in resident's toilet to obtain stool sample. Nursing assistant stated that resident had took them out and said, oh those are not for me. Unable to obtain sample." On 5/9/12 at 3:25 PM LN#3 stated she reviewed the nursing clipboard to identify resident needs at the beginning of every shift. LN#3 stated she remembered Resident #16 removed the "hat" from the commode on 4/7/12 so a stool sample was not obtained. LN#3 stated she had worked with Resident #16 since that time and could not explain why other attempts were not made to check stool samples. LN#3 verified the notation to check stool for occult blood for three days remained on the nurses clipboard as a current need for Resident #16. LN #3 stated on 5/9/12 (after the omission was brought to the attention of staff) she checked a stool sample for Resident #16 and the negative results (as well as the delay in testing) were reported to the nurse practitioner. On 5/9/12 at 3:45 PM LN#4 stated she had worked with Resident #16 several times since 4/5/12. LN#4 verified the need to check stools for occult blood was on the nursing clipboard as well the April and May 2012 MAR indicated [REDACTED]. LN #4 stated she reviewed the nursing clipboard prior to every shift to identify any needs and couldn't explain why stools for Resident #16 had not been checked for occult blood. On 5/10/12 at 12:05 PM nursing assistant (NA) #1 stated she was very familiar with Resident #16 as she often worked with her. NA#1 stated nurses would inform her to put a "hat" in a residents bathroom if there was a need for a urine or bowel sample. NA#1 stated she did not recall being asked to place a "hat" in the bathroom of Resident #16 in the past month. NA#1 stated that although Resident #16 could toilet independently she "pretty much knew her schedule" and could have reminded Resident #16 to use the "hat" so a stool sample could have been obtained. On 5/9/12 at 2:10 PM the Director of Nursing (DON) stated when a physician/nurse practitioner ordered to check stool for occult blood this would be done by nurses at the facility. The DON stated a "hat" would be placed in the bathroom of a resident to obtain a sample for the test. The DON stated the need for the test would be placed on the nursing clipboard. The DON stated the clipboard is the communication tool used by nurses every shift to document specific resident needs. The DON stated she would expect nurses to note on the clipboard if they were able to check a stool sample so oncoming nurses would know how many additional samples needed to be checked. The DON reviewed the nursing clipboard and medical record of Resident # 16 and stated the resident's stool had not been checked for occult blood. The DON stated the need to check stools for occult blood for Resident #16 remained on the nursing clipboard and she would have expected nursing staff to complete the test as ordered.

Based on observations, interviews, and record reviews, the facility failed to removed facial hair for two (2) of eight (8) sampled female residents dependent on staff for personal care. (Resident #12 and #30) The findings are: 1. Resident # 12 had [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed moderately impaired cognition and extensive assistance required for personal hygiene. The MDS also revealed no rejection of care or other behaviors. On 5/8/12 at 8:45 a.m., Resident #12 was observed with multiple hairs scattered across her chin. The hairs were light-colored and approximately 1/8 inch (") in length. On 5/9/12 at 4:35 p.m., Resident #12 was observed in her room talking with her personal sitter. Multiple, light-colored hairs approximately 1/8" in length were observed scattered across Resident #12's chin. When asked about the presence of the chin hairs, Resident #12 stated, "It definitely bothers me. I don't like it." Interview at that time with the personal sitter revealed she did no personal hygiene care for Resident #12. On 5/10/12 at 9:20 a.m., Resident #12 was observed with multiple hairs scattered across her chin. Review of the shower schedule revealed Resident #12 received showers on the evening shift on Mondays and on the day shift on Fridays. Interviews were conducted with the two Nursing Assistants (NA) who provided care to Resident #12 on 5/10/12. During an interview on 5/10/12 at 9:35 a.m., NA #1 revealed the nursing assistants' responsibilities included nail care and removing facial hair for female residents. NA #1 said Resident #12 was shaved "every once in awhile" but she did not have a lot of facial hair and until recently, she had used tweezers to remove her own chin hairs. Interview with NA #2 on 5/10/12 at 9:40 a.m. revealed NAs were supposed to remove facial hair for female residents whenever it was visible. During an interview on 5/10/12 at 9:55 a.m., Licensed Nurse (LN) #1 said if the residents would allow it to be done, female residents should be shaved during their bathing time. Interview with the Director of Nursing (DON) on 05/10/12 at 1:15 PM revealed nursing assistants (NAs) are expected to remove female residents' facial hair as needed on shower days. 2. Resident #30 had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) completed 04/10/12 revealed Resident #30 had severely impaired cognition and required limited assistance with with personal hygiene. Rejection of care was not noted during the 7-day look back period for the quarterly MDS. A Care Area Assessment (CAA) Summary for activities of daily living (ADLs) function completed on 11/08/11 stated Resident #30 required limited to extensive assistance with ADLs. The CAA Summary further stated Resident #30's general weakness and Dementia interfered with her ability to perform ADLs. A care plan, last reviewed on 04/17/12, stated Resident #30 required assistance with ADLs due to general weakness and weakness from a right [MEDICAL CONDITION]. The intervention was to assist with ADLs as needed. Review of the shower schedule revealed Resident #30 received showers every Tuesday and Friday on the 7:00 AM to 3:00 PM shift. Observations of Resident #30 on 05/08/12 at 9:58 AM revealed multiple chin hairs, 1/4 inch ('') to 1/2" in length, scattered across her chin. A subsequent observation on 05/09/12 at 10:00 AM revealed multiple chin hairs, 1/4" to 1/2" in length, scattered across her chin. On 05/10/12 at 9:37 AM, Resident #30 was observed while sitting in her room reading the newspaper. Multiple chin hairs, 1/4" to 1/2" in length, were noted scattered across her chin. An interview with the Director of Nursing (DON) on 05/10/12 at 1:15 PM revealed nursing assistants (NAs) are expected to remove female residents' facial hair as needed on shower days. The DON observed Resident #30's chin hairs at the completion of the interview and asked an NA to take Resident #30 to her room and ask for permission to remove the facial hairs. During an interview on 05/10/12 at 1:45 PM NA #1 confirmed she cared for Resident #30 frequently and had assisted her with ADLs on 05/10/12 but did not notice the length of her chin hairs. NA #1 further stated she usually checked female residents for facial hair on shower days and plucked or shaved depending on the residents preference.

Based on observations, staff interviews, and review of facility documentation, the facility failed to discard expired medications in one (1) of one (1) medication rooms. The findings are: Review of the facility's undated "Medication Storage in the Facility" policy revealed outdated medications were to be immediately removed from stock and disposed of according to procedures for medication destruction. Review of the facility's undated "Vials and Ampules of Injectable Medications" policy revealed the date of opening and the initials of the first person to use the vial of medication should be recorded on multi-dose vials. Observation of the refrigerator in the medication room on 2/24/11 at 1:10 p.m. revealed a vial of Lorazepam with an expiration date of 5/2010 and two (2) vials of Hepatitis-B vaccine with expiration dates of 10/23/10 available for use. Continued observation of the medication refrigerator also revealed one (1) opened and used multi-dose vial of Lorazepam that was not expired but was without the date of opening or initials of the person who first used the vial. During an interview on 2/24/11 at 1:30 p.m., the Assistant Director of Nursing (ADON) stated nurses are supposed to initial and date the vials of medications when they are opened. The ADON also reported a pharmacy technician checks for expiration dates and said the last review was 12/29/11. On 2/24/11 at 1:40 p.m., the Director of Nursing (DON) revealed nurses were responsible for checking for expired medications. She stated she assigned the task of checking for expired drugs to particular nurses and posted the assignments on their schedule. In a follow-up interview on 2/24/11 at 2:45 p.m., the DON said she expected nurses to label and date medications they opened and stated, "It's nursing practice to date and initial when opened."