**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, review of the facility's investigation file, review of the facility's report to Alabama Department of Public Health (ADPH) Online Incident Reporting System, and a review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure a Certified Nursing Assistant (CNA)/Employee Identifier (EI) #4, did not verbally abuse Resident Identifier (RI) #1 on 12/13/2022, after RI #1 called EI #4, stupid and a bitch. CNA, EI #3, who witnessed the interaction between RI #1 and EI #4 on 12/13/2022, did not intervene even though she knew it was abuse when she overheard EI #4 calling RI #1 a mother fuc . EI #3 stated she was afraid of EI #4, due to EI#4's temper. This deficient practice affected RI #1, one of four residents sampled for abuse. Findings Include: Cross reference F 607. On 12/22/2022, the facility submitted a Facility Reported Incident through the ADPH Online Incident Reporting System. The report's summary of the incident documented that the incident was reported to the Director of Nursing (DON) that RI #1 was sitting at nurses desk in his/her chair when he/she called CNA, EI #4 a bitch and she called him/her a mother fuc . and kicked his/her wheelchair. A facility policy titled Abuse, Neglect and Exploitation dated 11/27/2017 documented: Policy: Each resident has the right to be free from abuse . Residents must not be subject to abuse by anyone, including . facility staff .Policy Explanation and Compliance Guidelines: . 3. Verbal Abuse means the use of oral . language that willfully includes disparaging and derogatory terms to residents . regardless of their age, ability to comprehend, or disability . RI #1 was admitted to the facility on [DATE] and had diagnoses to include Hemiplegia and Hemiparesis following Cerebral Infarction affection right dominant side and unspecified Dementia. A review of RI #1's Minimum Data Set, with an assessment reference date of 11/10/2022, documented a Brief Interview of Mental Status score of 4/15 which indicated RI #1 was cognitively impaired. The facility investigation summary documented that on December 22, 2022 at 3:30 PM (EI #3), CNA, reported to EI #2, DON/Abuse Coordinator, that she observed EI #4, CNA, on 12/13/2022, prior to midnight interacting inappropriately with RI #1 in the hallway near the nurses desk. EI #3 reported she witnessed RI #1 call EI #4 a bitch and then EI #4 called RI #1 a mother Fuc . and kicked at his/her wheelchair. RI #1was interviewed on 12/22/2022 at 6:00 PM, but he/she did not recall the incident. EI #4 was immediately placed on suspension and terminated on 12/23/2022. A witness statement handwritten by EI #3, CNA, documented on 12/13/2022 before midnight RI #1 was wanting to get out of bed and EI # 4, CNA, was told to get him/her up. EI #3 stated EI #4 was agitated when getting him/her up. When RI #1 was in the hall in his/her wheelchair he/she kept going to the nurses station door and trying to open it. EI #4 pulled RI #1 back and locked his/her wheelchair. RI #1 called her a bitch and she cussed back at him/her calling him/her a mother fuc . and kicked his/her wheelchair. An interview was conducted with EI #3, CNA, on 04/11/2023 at 2:00 PM. EI #3 was asked to recall the incident she observed between EI #4 and RI #1. EI #3 stated she was working the third shift on 12/13/2022, when the incident occurred. She stated EI #4 got RI #1 up from the bed to his/her wheelchair with no problem. EI #3 stated EI #4 rolled RI #1 in the hallway and RI #1 started cussing calling EI #4 a bitch and stupid. EI #3 stated EI #4 was acting like she was mad by her body language and her face was red. EI #3 stated RI #1 was attempting to go behind the nurses desk and EI #4 rolled him/her away from the desk and locked the wheelchair. RI #1 called EI #4 a bitch and then EI #4 called RI #1 a mother fuc . and kicked his/her wheelchair on the left wheel. EI #3 stated RI #1 had no injury and no further incidents were observed during the shift. She further stated RI #1 remained on the hall, ambulated around the unit in the wheelchair and remained calm. EI #3 was asked if she considered this incident to be abuse and she said she knew it was not right, but she had to think on it, due to being afraid of EI #4's temper and attitude. EI #3 stated she told her coworker EI #5 about the incident when they worked the third shift together and reported it to the facility on [DATE]. An interview was conducted with EI #2, Abuse Coordinator on 04/12/2023 at 11:00 AM. EI #2 said she became aware of the incident involving RI #1 on 12/22/2022 when EI #3 reported the abuse. EI #3 told EI #2 that on 12/13/2022 she witnessed EI #4 call RI #1 a mother fuc . and kick at his/her wheelchair after RI #1 called her a bitch. EI #2 said she considered this to be verbal abuse. EI #2 said she believed the incident happened and that is why EI #4 was terminated. She further said the only evidence she had the abuse occurred was the statement from EI #3 and EI #4's past behavior towards her coworkers and toward her work at the facility. EI #2 stated EI #4 was brought in for a statement on 12/23/2023 but she refused to provide a written statement and verbally denied the abuse occurred. An interview was conducted with EI #1, Administrator on 04/12/2023 at 5:26 PM. EI #1 was asked when she became aware of an incident involving RI #1. EI #1 said when the DON/Abuse Coordinator, was notified she EI #1 was notified. EI #1 said she was present when EI #3 and EI #5 were interviewed and was shocked they did not report the incident immediately. EI #1 said the allegation of verbal abuse should have been reported immediately after it was witnessed to protect the resident from further abuse ********************************* This deficiency was cited as a result of the investigation of complaint/report number AL00042761.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, review of the facility's investigation file and a review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure staff implemented one of the seven components of the abuse policy. A Certified Nursing Assistant (CNA) failed to report an allegation of verbal abuse to the abuse coordinator after she witnessed the abuse on 12/13/2023 in accordance with the facility policy. This affected RI #1 one of four residents sampled for abuse. Cross reference F600. Findings include: A facility policy titled Abuse, Neglect and Exploitation dated 11/27/2017 documented: . Each resident has the right to be free from abuse . Policy Explanation and compliance Guidelines: 1. The Abuse coordinator in the facility is the Director of Nursing. Report allegations or suspected abuse, neglect or exploitation immediately to: Director of Nursing . Administrator . Other Officials in accordance with State Law . Verbal Abuse mean the use of oral, written or gestured language that willfully includes disparaging and derogatory term to resident .regardless of their age, ability to comprehend, or disability . RI #1 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis following Cerebral Infarction affection right dominant side and unspecified Dementia. A review of RI #1's 5-Day Minimum Data Set, with an assessment reference date of 11/10/2022 documented a Brief Interview of Mental Status score of 4/15 which indicated RI #1 was cognitively impaired. The facility investigation summary and conclusion documented that on December 22, 2022 at 3:30 PM (EI #3), Certified Nursing Assistant (CNA), reported to EI #2, Director of Nursing (DON)/Abuse Coordinator, that she observed EI #4, CNA, on 12/13/2022, prior to midnight interacting inappropriately with (RI #1) in the hallway near the nurses desk. EI # 3 reported she witnessed RI #1 call EI # 4 a bitch and then EI # 4 called RI # 1 a Mother Fuc . and kicked at his/her wheelchair. RI #1 was interviewed on 12/22/2022 at 6:00 PM, but he/she did not recall the incident. EI #4 was immediately placed on suspension and terminated on 12/23/22. During the investigation it was determined EI #3 made EI #5, CNA, aware of the incident involving RI #1 on 12/17/22 when they worked together. Both EI #3 and EI #5 were given verbal written warning for failing to follow the policy and procedure for reporting suspected abuse. A witness statement handwritten by EI #3, CNA, documented: .On 12/13/22 before midnight RI #1 was wanting to get out of bed and EI # 4, CNA, was told to get him/her up. EI #4 was agitated when getting him/her up. When RI #1 was in the hall in his/her wheelchair he/she kept going to the nurses station door and trying to open it. EI #4 pulled RI #1 back and locked his/her wheelchair. RI #1 called her a bitch and she cussed back at him/her, called him/her a mother fuc . and kicked his wheelchair . An interview was conducted with EI #3, CNA, on 4/11/23 at 2:00 PM. EI #3 was asked what she should do if she witnessed abuse of any type. EI #3 stated she should report the incident immediately. EI #3 was asked to recall the incident she observed between EI #4 and RI #1. EI #3 stated she was working the third shift on 12/13/22, when the incident occurred. She stated after RI #1 was gotten up from bed he/she was in the hallway and then near the nurses desk. RI #1 was attempting to go behind the nurses desk and EI # 4 rolled him/her away from the desk and locked the wheelchair. RI #1 called EI # 4 a bitch and then EI #4 called RI #1 a mother fuc . and kicked his/her wheelchair on the left wheel. EI #3 stated RI #1 had no injury and no further incidents were observed during the shift. She further stated RI #1 remained on the hall, ambulated around the unit in the wheelchair and remained calm with no new behavior observed the remainder of the shift. EI #3 was asked if she considered this incident to be abuse and she said she knew it was not right, but she had to think on it, due to being afraid of EI #4's temper and attitude. EI #3 stated she told her coworker EI #5 about the incident when they worked the third shift together on station one and then reported the incident to the facility two or three days later on 12/22/22. EI #3 said the abuse policy instructed her to report abuse and she should have reported the incident immediately to ensure abuse did not happen to other residents. An interview was conducted with EI #2, Abuse Coordinator on 4/12/23 at 11:00 AM. EI #2 said she became aware of the incident involving RI # 1 on 12/22/22 when EI #3 reported the abuse. EI #3 told EI #2 that on 12/13/22 she witnessed EI # 4 call RI # 1 a Mother Fuc . and kick at his/her wheelchair after RI #1 called her a bitch. EI #2 said she considered this to be verbal abuse and reported the abuse to the state agency and began the investigation. EI #2 said she felt like the incident happened and that is why EI #4 was terminated. EI #2 said EI #3 should have reported the abuse immediately after it happened. She said abuse should be reported immediately to stop future abuse and for the well being of the resident. When asked about EI #5's role in the incident involving RI # 1 she said when EI #3 told EI #5 about the incident involving RI #1 she should have reported the abuse allegation immediately. EI #2 said EI #3 and EI #5 did not follow the abuse policy of reporting abuse immediately after witnessing abuse and being told the abuse occurred. An interview was conducted with EI #1, Administrator on 4/12/23 at 5:26 PM. EI #1 was asked when she became aware of an incident involving RI #1. EI #1 said when EI #2 was notified she was notified. EI #1 said she was present when EI # 3 and EI #5 were interviewed and was shocked they did not report the incident immediately. EI #1 said the allegation of verbal abuse should have been reported immediately after it was witnessed to protect the resident from further abuse. EI #1 said the abuse policy was not followed because the policy instructed to report all abuse immediately. EI #1 further said both EI #3 and EI #5 were trained on the abuse policy and knew to report abuse. ********************************* This deficiency was cited as a result of the investigation of complaint/report number AL00042761.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a Significant Change Minimum Data Set (MDS) was completed when Resident Identifier (RI) #23 was discharged from hospice on 5/1/21. This affected one of two residents sampled for Hospice. Findings Include: A review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, reveled . An SCSA (Significant Change in Status Assessment) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD (Assessment Reference Date) must be within 14 days from one of the following; 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill. RI # 23 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI # 23's Physician Orders dated 5/1/21 documented: . Discharge from . Hospice services . A review of RI # 23's medical record did not reveal a Significant Change MDS when RI # 23 was discharged from Hospice on 5/1/21. On 7/15/21 at 9:21 AM, an interview was conducted with the MDS coordinator Employee Identifier (EI) #1. EI #1 was asked, was RI # 23 on Hospice. EI #1 replied, RI #23 was discharged from hospice. EI #1 was asked, when was RI #23 discharged from hospice. EI #1 replied, 5/1/21 or 5/2/21. EI #1 was asked, did you complete a significant change MDS. EI #1 replied, we are in the process of doing one now for July, the ARD was open now. EI #1 was asked, when RI #23 was discharged should he/she have had a significant change. EI #1 replied, yes. EI #1 was asked, why did RI #23 not have a significant change. EI #1 replied, she just missed it. EI #1 was asked, what was the reason you would do a significant change. EI #1 replied, in case there was a decline or improvement, or need more care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #36's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/02/2021, did not code RI #36 as receiving an Anticoagulant medication during this assessment period. This deficient practice affected RI #36, one of 31 residents whose MDS assessments were reviewed. Findings include: A review of the Centers for Medicare & (and) Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019, revealed the following: . Coding Instructions . NO410E, Anticoagulant (e.g. (for example), warfarin, heparin, or low-molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period . Do not code antiplatelet medications such as . clopidogrel here . RI #36 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis to include Atherosclerotic Heart Disease. A review of RI #36's Quarterly MDS assessment, with an ARD of 05/03/2021, revealed RI #36 received an Anticoagulant during this 7-day look back assessment period. A review of RI #36's April and May 2021 eMAR (electronic Medication Administration Record) revealed RI #36 received the following: . PLAVIX 75 MG (milligrams) (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS . According the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instruction 3.0 User's Manual Plavix (Clopidogrel) should not be coded as an anticoagulant medication. On 07/15/2021 at 10:57 AM, the surveyor conducted an interview with Employee Identifier (EI) #1, the RN (Registered Nurse)/MDS Coordinator. The surveyor asked EI #1, when looking at RI #36's medical records, which anticoagulant medication was RI #36 receiving. EI #1 said RI #36 was on Plavix but it is an Antiplatelet. When asked what the RAI classified Plavix as, EI #1 said an Antiplatelet. The surveyor asked EI #1 why it would be important to code the MDS accurately. EI #1 said for accurate patient care and billing purposes. When asked was the Plavix coded accurately, EI #1 said No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of [NAME] & [NAME] Fundamentals of Nursing, the facility failed to ensure Resident Identifier (RI) #99's tube feeding bottle and water bag were labeled. This affected one of five residents sampled for tube feeding. Findings Include: A review of [NAME] & [NAME] Fundamentals of Nursing, Ninth Edition, copyright 2017, Chapter 45 Nutrition, page 1082, revealed: . SAFETY GUIDELINES FOR NURSING SKILLS . When performing the skills in this chapter, remember the following points to ensure safe, individualized patient care. * Label enteral equipment with patient name and room number; formula name, rate, and date and time of initiation; and nurse initials . RI #99 was readmitted to the facility on [DATE] with a diagnosis of Dysphagia, oropharyngeal phase. RI #99's Order Summary dated Jul (July) 5,2021 revealed, .Enteral Feed Order every shift Glucerna 1.5 a@ (at) 40 mL/hr (milliliters per hour) over 23 hours . start date [DATE] . H2O flush at 23 ml/hr over 23 hours via peg tube per pump . start dated [DATE] . On [DATE] at 10:56 a.m., the surveyor observed RI #99's tube feeding infusing. There was no date, time or initials on RI #99's tube feeding or water bag. On [DATE] at 12:30 p.m. the surveyor observed RI #99's tube feeding infusing and noted there was no label with the date or time noted on RI #99's tube feeding or water bag. On [DATE] at 4:00 p.m., the surveyor again observed there was no label with the date and time noted on RI #99's tube feeding and water bag. On [DATE] at 4:04 p.m., an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN). EI #2 was asked what was wrong with the tube feeding and water bag hanging for RI #99. EI #2 replied, it did not have a label, date, or initials, on the tube feeding or water bag. EI #2 was asked should the tube feeding, and water bag be labeled prior to infusing. EI #2 replied, yes. EI #2 was asked, how could the unlabeled tube feeding, and water bag potentially harm the resident. EI #2 replied, RI #99 could receive expired tube feeding that could make him/her sick. EI #2 was asked what should have been done prior to infusing the tube feeding. EI #2 replied, both should have been labeled prior to infusing. On [DATE] at 4:20 p.m., an interview was conducted with EI #3, a Registered Nurse/ Unit Manager. EI #3 was asked, what she observed when looking at RI #99's tube feeding. EI #3 replied, there was no label with the date and time on either bag. EI #3 was asked, when was the tube feeding and water bag hung. RI #3 replied they were hung this morning. EI #3 was asked what was the potential concern with not having the bags labeled on the tube feeding. EI #6 replied, the tube feeding could go bad if it has not been dated and timed. The tube feeding could run too long causing the resident to get sick.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and the nursing manual titled, Fundamentals of Nursing, the facility failed to ensure the physician orders were followed for Resident Identifier (RI) #75 for stool specimens to be collected times three for Clostridium Difficile. The deficient practice affected one of the 39 sampled residents whose physician's orders were reviewed. Findings include: A review of the nursing manual titled, Fundamentals of Nursing, Ninth Edition by [NAME] and [NAME], Chapter 23 page 311, revealed . Health Care Providers' Orders. Nurses follow health care providers' orders . RI # 75 was admitted to the facility on [DATE] with the diagnosis of unspecified diarrhea. The Surveyor reviewed the resident's medical record and discovered the physician's order written on 11/24/2019 for stool specimens to be collect three times for Clostridium Difficile (dated 11/24/2019) and Lomotil Tablet 2.5-0.025 mg (Diphenoxylate Atropine) Give two tablets by mouth every six hours as needed for diarrhea. The resident's Medication Administration Record (MAR) revealed RI # 75 received medication for loose stools. There were no lab reports for stool specimens or documentation of collected stools for C-Diff. On 12/05/19 at 11:31 a.m., the Surveyor conducted an interview with Employee Identifier (EI) # 4 Licensed Practical Nurse. EI # 4 was asked, were the physician's order written on 11/24/19 followed to collect stool specimens for C- Diff on RI # 75. EI # 4 replied, she did not collect the specimens because RI # 75 wore adult diapers and when RI # 75 had a bowel movement the following day 11/25/19, it was just a smear. EI # 4 was asked, were any stool specimens collected since 11/24/19. EI # 4 replied, she had not collected any specimens and had not heard from the facility's 24 hour report of any specimens being collected. EI # 4 was asked, was medication administered to RI # 75 by her to stop loose stools. EI # 4 replied, she did give RI # 75 (one of the Lomotil); RI # 75 complained of having loose stool. EI # 4 was asked, what was the potential harm with the facility not following the physician's orders. EI # 4 replied, potentially delayed the resident's treatment and spread the C-Diff infection. On 12/05/19 at 11:57 a.m., the Surveyor conducted an interview with EI # 3, Registered Nurse Infection Control. EI # 3 was asked, what date was the order for RI # 75 stool for C-Diff. EI # 3 replied, 11/24/19. EI # 3 was asked, what was potential harm with the facility not following the physician's order and obtaining stool specimens from RI # 75 for C-Diff. EI # 3 replied, possible delayed treatment for the resident and possibility to spread the C-Diff infection. On 12/05/19 at 12:09 p.m., the Surveyor interviewed EI #1, Primary Physician. EI # 1 was asked, did he recall writing an order for RI # 75 for stools times three for C-Diff. EI # 1 replied, yes he did. EI # 1 was asked, why did he write the order for RI # 75. EI# 1 replied, to ensure RI # 75 did not have any infection because RI # 75 recently was discharged from the hospital and complaining of diarrhea. EI # 1 was asked, what was the potential harm with the facility not following his physician order. EI # 1 replied, not following his physician order was not wise of the facility. EI # 1 said, because they were unable to ensure they ruled out an infectious disease. EI # 1 continued to say C-Diff spreads quickly in a facility. EI # 1 also said, early diagnosis was key. On 12/05/19 at 12:38 p.m., the Surveyor conducted an interview with EI # 2 Registered Nurse/ Unit Manager of the Rehabilitation Department. EI # 2 was asked, (while she was viewing the facility's records) what did the order read dated 11/24/19. EI # 2 replied, stool for C-Diff times three. EI# 2 was asked, who signed the order off acknowledging it was received. EI # 2 replied, she did. EI # 2 was asked, what was meant by the order. EI # 2 replied, it meant they were ordered to collect stool specimens from RI # 75 for C-Diff. EI # 2 was asked, was the stools collected for C-Diff from RI # 75. EI # 2 replied, no. EI # 2 was asked, why were the physician's orders not followed and the stool specimens collected on 11/24/2019. EI # 2 replied, there was not enough stool for a specimen. EI # 2 was asked, was the resident given (an as needed) medication to stop diarrhea/ stool on 11/24/2019. EI # 2 replied, yes ma'am. EI # 2 was asked, what time frame are stool specimens obtained once an order was received. EI # 2 replied, the facility liked to obtain specimens as soon as possible, within days. EI # 2 was asked, (while reviewing RI # 75 MAR documentation for the week of 12/1/19) what days did RI # 75 receive medication to stop loose stools. EI # 2 replied, 12/1 - 12/4/19. EI# 2 was asked, what shifts did RI # 75 receive an as needed medication to stop loose stools. EI # 2 replied, all shifts. EI # 2 was asked, what was the potential harm for RI # 75 that the facility did not follow the physician orders collecting the stool specimens. EI # 2 replied, if RI# 75 had C-Diff it could have spread to employees and other patients.

Based on observation, interviews and a review of the facility policy titled, Destruction of Unused Drugs, the facility failed to ensure one and one-half bottle of expired Bismuth (8 ounce) and an expired bottle of Simethicone 80 mg tablets were not left on medication carts beyond the expiration dates. This deficient practice was observed on two of nine total medication carts. Findings Include: A review of the facility policy's titled Destruction of Unused Drugs, dated 11/27/2017, revealed the following: . Policy Interpretation and Implementation . 3. Non-controlled medications will be audited and inspected for expiration dates on a monthly basis . if a medication is found to be expired the nurse will follow facility procedure on destruction of non-controlled medication. On 11/1/2018 at 11:34 AM, the surveyor conducted a medication cart review on the 800 Hall. Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), was also present. One and one-half bottle of Bismuth (8 ounce bottle) was observed with an expiration date of August 2018. The surveyor asked EI #2 who was responsible for checking the medication carts for expired medications. EI # 2 stated all nurses working the carts were responsible. EI #2 agreed the Bismuth was expired. The surveyor asked EI # 2 what was the potential harm for using expired medications. EI # 2 stated residents would probably not get their full dose since the medication is expired. On 11/1/2018 at 11:41 AM, the surveyor conducted a medication cart review on the 700 Hall. EI # 3, LPN, was also present. A bottle of Simethicone 80mg/milligram was observed with an expiration date of September 2018. This medication bottle had an open date of 10/26 written on it. The surveyor asked who was responsible for checking medication carts for expired medications. EI # 3 stated the nurse working on the cart was responsible. EI #3 agreed the Simethicone was expired. The surveyor asked EI# 3, what was the potential harm of using expired medication. EI #3 said the medication may be ineffective. On 11/1/2018 at 12:50 PM , the surveyor asked EI #4, RN/DON (Registered Nurse/Director of Nursing), who was responsible for checking medication carts for expired medications. EI #4 stated the pharmacy technicians come monthly and check the carts and the nurses working on the carts should also catch any expired medications.

Based on observation and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) did not drop a carton of milk onto the floor, then return it to the refrigerator. This had the potential to affect all residents receiving supplements from the refrigerator at Station 2. Findings Include: On 10/31/18 at 2:59 PM Employee Identifier (EI) #5, a CNA, was observed to drop a container of milk on the floor, pick it up and then return it to the refrigerator at Station 2. The surveyor asked EI #5 what should be done if a container of milk is dropped on the floor. EI #5 said she should have disposed of it because placing the milk back into the refrigerator could cause contamination.