**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Resident Self-Administration of Medication, Facility A failed to adequately assess one out of 60 sampled residents (R) (R71) for self-administration of medication. This had the potential to result in serious health complications, including medication misuse or overdose, and compromise the safety and well-being of the resident. Findings include: A review of the facility's policy titled Resident Self-Administration of Medication, dated 7/1/2023 under section titled Purpose revealed, The purpose of the Self-Administration of Medication Policy is to develop guidelines about facility staff expectations in the nursing home to honor resident's request for Self-Administration of Medications whenever assessed as appropriate to keep resident at their highest level of functioning. Under the section titled Policy revealed, If a resident requests to self-administer medication(s), it is the responsibility of the interdisciplinary team (IDT) (as defined in §483.21(b), F657, Comprehensive Care Plans) to determine that it is safe before the resident exercises that right. A resident may only self-administer medications after the IDT has determined which medications may be self-administered .The decision that a resident has the ability to self-administer medication is subject to periodic assessment by the IDT, based on changes in the resident's medical and decision-making status .If self-administration is determined not to be safe, the IDT should consider, based on the assessment of the resident's abilities, options that allow the resident to actively participate in the administration of their medications to the extent that is safe (i.e., the resident may be assessed as not able to self-administer their medications because they are not able to manage a locked box in their room, but they may be able to get the medications from the nurse at a designated location and then safely self-administer them). A review of electronic health record (EHR) for R71 revealed she was admitted to the facility with diagnoses including but not limited to peripheral neuropathy, mood and anxiety disorder. A review of R71's quarterly Minimum Data Set (MDS) dated [DATE] documented in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. A review of R71's care plan with a start date of 10/24/2024 revealed, there was no care plan for self-administration of medication. A review of R71's physician orders revealed, there was no order for self-administration of medications. During an interview and observation on 2/11/2025 at 11:34 am with the R71, two [name] inhalers (used to treat or prevent bronchospasms) was observed at R71's bedside table. R71 revealed that she had them for 10 years and had been at the facility for about four months. She stated, the inhalers had been brought in with her upon admission. R71 further stated that the staff was aware of the inhalers and did not tell her she couldn't have them. An observation on 2/12/2025 at 10:21 am in R71's room revealed, two [name] inhalers was observed at R71's bedside table. R71 stated, that she used them when she needed them. An interview and observation on 2/12/2025 at 10:26 am with Certified Nursing Assistant (CNA) DD revealed that this was her first time seeing the inhalers at the resident's bedside table. CNA DD explained that if she notices medication at the bedside, she must inform the floor nurse, and the nurse would take the medication. An interview and observation on 2/12/2025 at 10:37 am with Licensed Practical Nurse (LPN) EE revealed that the resident was not allowed to have the inhalers at the bedside. LPN DD explained that if the resident needed them, they would typically keep the inhalers in the cart. She stated that a physician's order would be required to keep medications at bedside. LPN DD further mentioned that a self-administration assessment would be needed for the resident to self-administer medication. An interview on 2/12/2025 at 10:41 am with Registered Nurse (RN)/ Unit Manager CC revealed, that residents who self-administer medication must be assessed and demonstrate proper usage. RN CC stated that they also require the medication order to include a notation for self-administration. RN CC further clarified that residents were not supposed to have medication at the bedside, and over-the-counter medications were discouraged due to the potential for drug interactions. An interview on 2/13/2025 at 11:14 am with the Director of Nursing (DON) revealed, that if medication was found at the bedside, the nurse or unit manager must be notified, and the attending physician would be contacted. The DON stated the physician would determine if the resident was allowed to self-administer the medication. If approved, the nurse and unit manager would provide patient education to ensure the resident understands and follows the medication directions. The family would also be notified, and an order would be written. DON confirmed R71 should not have had the inhalers at the bedside, as there was no diagnosis for the medication at the time of admission, and it was not communicated to the staff. The DON stated some possible negative outcomes include contraindications, drug interactions, potential overdose, or over-sedation, especially if the resident was already receiving similar medication. The DON stated his expectation was that staff should immediately notify the nurse or unit manager if any medication was found at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, review of the facility's document titled, [Name] Bed Hold Notice Facility B failed to provide a written bed hold notices for one out of two residents (R) (R179) reviewed for hospitalization. This failure had the potential to place R179 at risk of possible denial of re-admission and loss of their room following a transfer to the hospital. The sample size was 60 residents. Findings include: Review of the facility's document titled, [Name] Bed Hold Notice dated 2/10/2025 under the section titled Please provide to the Resident or Representative revealed, Please review the information provided below to understand the financial obligations related to your decision to hold or release your bed at [Name of facility] Under the section titled Bed Hold Details revealed, Medicaid will provide payment for residents for up to seven nights of bed hold during hospitalization. Medicaid residents are provided up to eight days per year of Therapeutic leave (other than hospitalization). If a hospital stays or therapeutic leave extends beyond the time limitation for Medicaid residents, payment arrangements can be made for continuing to hold a resident's bed by contacting the [NAME] Office. If arrangements are not made and hospitalization or therapeutic leave exceeds the Medicaid guideline discharge will occur. An opportunity for readmission will be provided pending availability if they require services provided by the facility and care needs can be met. Review of R179's Discharge Minimum Data Set (MDS) dated [DATE] revealed, Section A (Identification Information) documented R179 was discharged to a short-term hospital with an anticipated return. Review of R179's Discharge MDS dated [DATE] revealed, Section A (Identification Information) documented R179 was discharged to a short-term hospital with an anticipated return. Review of Progress Notes dated 10/3/2024 revealed, R179's Case Manager (CM) communicated to the Transitional Team Coordinator (TTC) a request for a bed hold. Review of Progress Note dated 10/18/2024 revealed, R179 had a seven-day bed hold beginning at midnight. Review of R179's electronic health records (EHR) revealed no evidence of bed hold notices provided to the resident or representative upon transfers. Interview on 2/12/2025 at 12:27 pm with the Administrator confirmed they did not have a bed hold notice for R179 nor did they provide any written bed hold notices for resident that goes out to the hospital. He stated that the Bed Hold Policy was in the admission packet. He continued to state the nurses would contact the family representative via phone and inform them about the resident being sent out and reinstate the bed hold policy to see if they would like to pay after the seven days. From there they can accept or deny the responsibility of the payment that exceeds seven days. If the resident does not have a bed hold the facility will offer the next available bed to the resident. Interview on 2/12/2025 at 4:35 pm with Licensed Practical Nurse (LPN) EE stated she was responsible for completing the bed hold notice when a resident was being sent out. She stated that the family was presented with the bed hold policy on admission and given a form to sign for consent for bed holds. She stated, she was not aware it needed to be signed at the time of transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, Facility B failed to ensure that one of 14 residents (R) (R150) receiving respiratory therapy, nebulizer mask was covered or properly stored. This deficient practice had the potential to put R150 at risk for increased respiratory infections. Findings include: Review of the electronic health records (EHR) revealed, R150 was admitted to the facility with diagnoses of chronic obstruction pulmonary disease (COPD), chronic respiratory failure with hypoxia (reduced oxygen in the blood), acid reflex, and chest congestions. Review of R150's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Patterns) a Brief Interview of Mental Status (BIMS) score of 14 which indicated his cognition was intact; Section O (Special Treatments and Programs) revealed, R64 received oxygen therapy. Review of R150's physicians orders revealed, orders for albuterol (Proventil) 2.5 milligrams (mg)/ 3 milliliters (mL) (0.083 percent) nebulizer solution 2.5 mg; albuterol (HFA) (ProAir/Proventil/Ventolin HFA) 90 microgram (mcg)/arcuation inhaler one puff and fluticasone-vilanterol 100-25 mcg/dose Diskus inhaler one puff. During an observation on 2/11/2025 at 11:45 am revealed R150's nebulizer mask was not covered or properly stored. During an observation on 2/11/2024 at 8:25 am revealed R150's nebulizer mask was in his dresser not covered or properly stored. During an interview and observation on 2/12/2025 at 5:07 pm with the Unit Manager (UM) AA revealed that the Saturday supervisor and Certified Nurse Assistants (CNAs) were responsible for doing spot check on items to ensure that they were properly covered, labeled and dated. UM AA confirmed R150's nebulizer mask was not covered or properly stored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and a review of the facility's policy titled Laboratory Services-12-1022-POC Glucose Testing with [Name] Glucometer, Facility A failed to discard expired Glucometer Control Solution Level 3, that was stored in one of four medication carts (Hall 300 medication cart). This deficiency created a risk of the expired solution being used, potentially compromising the accuracy and functionality of the glucometer, which could lead to unreliable blood glucose readings. Review of the undated facility policy Laboratory Services-12-1022-POC Glucose Testing with [Name] Glucometer under the section titled III. Equipment and Supplies revealed, D. [Name] glucose control solutions: Levels 1 and 3 .2. Unopened reagent bottles are good until the expiration dated printed on the container. 3. When opened, the bottles are good for 90 days or until the manufacturer's expiration date, whichever comes first. MUST BE LABELED WITH NEW EXPIRATION DATE. An observation on [DATE] 8:20 am of the medication cart on Hall 300 revealed, an expired unopened Glucometer Control Solution Level 3 with an expiration date of [DATE] was found on the medication cart right upper drawer with other diabetic related supplies. When the surveyor asked Licensed Practical Nurse (LPN) AA about it, she stated that it was still acceptable to use because if it were no longer effective, the glucometer would display an error message and prevent testing. In an interview on [DATE] at 9:06 am, with the Unit Manager for Hall 300, Registered Nurse (RN) BB, she revealed that expired control solution must be discarded. In an interview on [DATE] at 9:30 am, with Unit Manager for Hall 100, RN, CC she stated that expired control solutions should not be used. In an interview on [DATE] at 10:44 am, with the Director of Nursing (DON), he confirmed that expired control solutions must be discarded, as they may compromise the accuracy and proper functioning of the glucometer, leading to unreliable blood glucose readings. In an interview on [DATE] at 1:45 pm, the DON showed the surveyor the medication cart and the carrying case for the [Name] Glucometer that was stored on the side of the medication cart. The case contained all the control testing supplies, with control bottles labeled with expiration dates. The DON stated he was unsure why the expired control solution #3 was kept in the medication cart drawer, even though he assured the surveyor that it would not be used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of facility's policy titled, Nutrition Food and Supply Storage Procedures, Facility A failed to properly discard expired food items, label food items with expiration dates, and properly refrigerate opened food items. This deficient practice had the potential to result in foodborne illness affecting 77 out of 82 residents who receive food orally at Facility A. Findings include: Record review of facilities policy titled, Nutrition Food and Supply Storage Procedures dated 7/1/2023, under section titled, Purpose revealed, All food, non-food items and supplies used in food preparation shall be stored in such manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. (A.) General Storage .2. The use-by date is the last date that a food can be consumed; do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use-by date should be discarded. 3. Cover, label and date unused portions and open packages. Use the [NAME] orange label; complete all sections on the label. (B.) Dry Storage .7. Date and rotate items; first in, first out (FIFO). 8. Remove from storage any items for which the expiration date has expired. Return for credit if possible. (C.) Refrigerated Storage .4. Date and rotate items; first in, first out (FIFO). Discard food past the use-by expiration date. (D.) Frozen Storage .9. Date and rotate items; first in, first out (FIFO). Discard food past the use-by expiration date. An observation was conducted on 2/11/2025 at 9:00 am with the Executive Chef (EC) and continued at 9:10 am with the Dietary Kitchen Manager (DKM) and the following expired items were found in the pantry: -There were 44 bottles of [Name] compact therapeutic shake (vanilla) with an expiration date of 11/1/2024. -There were 16 bottles of [Name] therapeutic nutrition (chocolate) with an expiration date of 2/1/2025. -There was one bag of [Name] flour tortillas with an expiration date of 2/5/2025. -There were four cans of [Name] coconut milk, all of which expired on 3/23/2024. -There were three bags of [Name] oats and honey granola cereal, all of which had an expiration date of 1/29/2025. The following unlabeled and unrefrigerated items were also observed in the pantry: -There were three loaves of opened bread, which were unlabeled and not dated. -There was one bag of croutons, which was opened and not labeled or dated. -There was one bag of [Name] pecan pieces, which was opened and not labeled or dated. -There was one bag of vanilla wafers with no expiration date. -There was one bottle of pancake & waffle syrup [Name] with an expiration date of 12/9/2024. -There was one bottle of light unsulfured molasses with an expiration date of 10/30/2024. -There was one bottle of [Name] jelly, which was opened and found unrefrigerated in the pantry. An observation was conducted on 2/11/2025 at 9:51 am with the DKM and the following items were observed in the freezer: -There were four packets of [Name] flour tortillas, which had an expiration date of 12/21/2024. -There were two packets of burgers, which were unlabeled or dated. -There was one bag of whipped cream with an expiration date of 9/24/2024. -There was one bag of blue cheese with an expiration date of 1/28/2025. An observation was conducted on 2/11/2025 at 9:45 am with the DKM and the following items were observed in the cooler: -There was one bottle of [Name] (chocolate) with an expiration date of 2/1/2025. -There was one container of [Name] cottage cheese with an expiration date of 2/6/2025. An interview was conducted on 2/11/2025 at 9:54 pm with the EC, and he revealed when asked who oversees checking for expired foods and labeling and dating items, he stated that the freezer might have been neglected but the pantry was checked often. The EC further stated that all staff have assignments, and each shift comes in and checks for cleanliness, organization, and the dating and labeling of items in the cooler, pantry, and freezer. The EC also mentioned that his expectations was for the staff to be more diligent, and that maybe they need to be micromanaged. The EC highlighted that one negative outcome of expired food and unlabeled items was that expired foods could be served to residents. An interview was conducted on 2/13/2025 at 11:27 am with the DKM, revealed her expectations for staff members are for more training and increased accountability from staff. DKM stated that there was currently too much inventory, which becomes confusing, and emphasized the need for more training on the first in, first out method. DKM also mentioned that both she and the EC were responsible for checking employees to ensure they were fulfilling their assignments. DKM further stated that a possible negative outcome of expired or improperly labeled food was the risk of foodborne illness spreading to the floor, potentially affecting every resident. An interview was conducted on 2/13/2025 at 11:33 am with the Administrator, who expect staff to follow guidelines for refrigerating, labeling, and checking expired items. The Administrator also emphasized that improper refrigeration and expired food could lead to foodborne illness, posing a significant risk to the residents' health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure that activities of daily living (ADL) care was provided for two dependent residents (R) (R#482 and R#60) related to baths/showers. R#482 and R#60 resided in Facility B. The sample size was 70. Findings include: 1. Review of the medical record revealed R#482 was admitted to the facility 12/15/21, with the diagnoses to include but not limited to, colonic mass, right tibia/fibula fracture, stage V chronic kidney disease with dialysis, end stage renal disease (ESRD), diabetes (DM), and chronic obstructive pulmonary disease (COPD). Interview on 8/30/22 at 11:24 a.m., R#482 revealed that she had not received a shower in the last two weeks. Review of the shower log and electronic documentation revealed that R#482 received a bath/shower on 5/31/22, 6/9/22, 6/16/22, 6/28/22, 7/5/22, 7/12/22, 7/16/22, 7/26/22, 7/28/22, 8/2/22, 8/9/22 and refusal on 8/30/22. Further review of records revealed that R#482 was admitted to the hospital on [DATE] and returned to the facility on 6/15/22. R#482 was also admitted to the hospital on [DATE] and returned to the facility on 8/22/22. Review of a shower log revealed that R#482 bath days are Tuesday, Thursday, and Saturday. Interview on 9/1/22 at 11:24 a.m. the Director of Nursing (DON) confirmed that baths or showers was given on these dates. Further interview with the DON revealed that her expectation is to honor resident's preferences related to receiving baths. The DON further revealed that the Certified Nursing Assistant (CNA) that is responsible for bathing R#482 failed to document bathing as required and failed to document refusals of baths. 2. Review of the medical record revealed R#60 was admitted to the facility on [DATE], with diagnoses to include but not limited to, atrial fibrillation, congestive heart failure, renal disease, and respiratory failure, Review the most recent MDS quarterly assessment dated [DATE] revealed R#60 has a Brief Interview Mental Status (BIMS) score of 15, which indicates that R#60 was cognitively intact. Rejection of Care on the MDS revealed no behaviors documented. R#60 required extensive assistance with ADL's. During initial screening on 8/30/22 at R#60 revealed that she has not had a shower for one month. Review of the shower logs for R#60 revealed no evidence that R#60 was offered a shower on 7/5/22, 7/12/22, 7/14/22, 7/16/22, 7/19/22, 7/21/22, 7/26/22, 8/9/22, and 8/30/22. R#60 refused a shower on 7/26/22. Review of the progress notes revealed that there was no documentation indicating R#60 was offered a shower. During an interview on 8/31/22 10:05 a.m., CNA AA revealed that R#60 was offered shower on the following days, 7/5/22, 7/12/22, 7/14/22, 7/16/22, 7/19/22, 7/28/22, 8/2/22, 8/9/22, 8/2/22, 8/13/22, 8/18/22, 8/23/22, and 8/30/22. Interview on 9/1/22 at 9:23 a.m., Unit Manager (UM) BB, revealed that his expectation from the shower team is to provide showers/baths for residents on their scheduled shower days and that it is documented on the shower log. Interview on 9/1/22 at 10:40 a.m. the DON revealed her expectation from the shower team is to give baths/showers as scheduled. She stated that residents are scheduled to receive showers two to three days a week and documentation should reflect that. She stated the process is to notify the unit manager if a resident refuses a bath/shower, who will then talk to the resident. She revealed that the facility does not have a shower policy or procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide evidence that restorative nursing services were provided for passive range of motion (PROM) and active range of motion (AROM) as recommended by Physical Therapy (PT) and Occupational Therapy (OT) for bilateral upper extremities (BUE) and for splint or brace for one Resident (R) (R#113) of one reviewed for restorative nursing. R#113 resided in Facility B. The sample size was 70. Findings include: Review of the medical record revealed that R#113 was admitted to the facility on [DATE] with diagnoses of traumatic quadriplegia, swelling of upper extremities, and complex regional pain syndrome of upper extremities. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that R#113 is cognitively intact. The MDS revealed he is totally dependent requiring two person plus assist for bed mobility and transfers and has limited range of motion in bilateral upper and lower extremities. Further review revealed R#113 received restorative nursing for passive and active range of motion (ROM) two of seven days during the assessment period. Review of the care plan updated 5/20/22 revealed activities of daily living (ADLs) deficit with interventions that include certified nursing assistant (CNA) to provide restorative nursing as ordered and CNA to apply splints, rolls, slings, ROM as ordered. Review of PT and OT notes for R#113 revealed that on 2/8/21 (PT) and (OT) referred R#113 to the Restorative Nursing Program and provided recommended activities. Updated recommendations by PT dated 5/19/22 include active and passive ROM, splint or brace assist and wheelchair mobility and use of an OmniCycle. Review of Restorative Program form from PT dated 4/4/22 and OT dated 5/19/22 revealed goals are to maintain current ROM and strength, prevent contractures of joints in bilateral upper extremities (BUEs), improve independence and endurance for wheelchair mobility. Documented R#113 was to receive two activities from a provided list every day and to be sure all activities were completed at least once a week. The list of activities include: 1. Provide ROM exercises to both arms and legs in all joints, all ranges 10 repetitions each. 2. Bring resident to the rehabilitation gym to use the OmniCycle with his arms on the Neuro setting, level four resistance, with use of ace wraps to secure hands to handlebars as instructed. Can complete this activity for 15 minutes. 3. Provide assist as needed for resident to propel wheelchair both forward and backward for 75-100 feet each direction. 4. Apply bilateral resting hand splints at night for 6-8 hours (on in PM/off in AM). Review of the documented Restorative Care Flowsheet Data in the electronic medical record (EMR) dated 5/28/22 through 8/28/22, revealed documentation that R#113 received restorative nursing services for active and passive ROM exercises, splint and/or brace assistance, transfers, chair mobility and OmniCycle use on some days, but not on all days, with some days having only removal of BUE splints documented. Observation of and interview on 8/30/22 at 10:05 a.m., R#113 was sitting in a wheelchair and observed to have limited ROM and contractures in BUE. He was not wearing splints or any other devices, nor were their handrolls in his hands. He stated he is scheduled to receive restorative nursing services daily but added that he does not receive it every day. He revealed some weeks he only receives restorative nursing one day a week. He stated that he would like to receive restorative nursing daily and he believe that therapy ordered daily restorative nursing services. He revealed he usually wears upper extremity splints at nighttime only. Observation of and interview on 8/31/22 at 10:58 a.m., R#113 was sitting in a wheelchair. He was observed to have limited ROM and contractures in BUE. He did not have handrolls in his hands nor was he wearing splints. R#113 revealed he does not receive restorative nursing daily and has not gone to use the OmniCycle in weeks. He revealed he does roll his wheelchair very short distances in his room daily and requires assist with more than minimal movement of wheelchair. Interview on 8/31/22 at 10:20 a.m., CNA EE revealed she normally does restorative nursing services at the facility, but revealed other CNAs are trained to provide restorative nursing services in her absence. She revealed she follows recommendations from the therapy departments for restorative nursing services. She revealed that she maintains a notebook with restorative nursing recommendation and orders from therapy departments. During further interview, she stated she documents restorative nursing services in the electronic medical record (EMR). She further revealed she is often assigned a different assignment due to staffing shortages. Interview on 8/31/22 at 11:05 a.m., Registered Nurse (RN) Unit Manager (UM) CC revealed OT and PT will screen residents and provide written recommendations for restorative nursing care and restorative nursing staff follows the recommendations. She stated there is one restorative CNA for each unit (two units in facility) and every effort is made to avoid re-assigning the restorative CNAs to other areas, but that there are times when they are re-assigned. Interview on 8/31/22 at 11:15 a.m., Licensed Practical Nurse (LPN) DD revealed that she is the supervisor for the restorative CNAs. She stated that other CNAs are trained to provide restorative nursing services in the absence of the regular restorative CNAs. She stated the facility does not have a restorative nursing policy. She further stated that monthly team meetings with herself, and restorative CNAs are held to discuss resident progress, participation, and their needs. She also revealed that if the residents' needs change, she requests an evaluation from the therapy departments. Interview on 9/1/22 at 9:00a.m., LPN DD stated that the other CNAs are trained to provide restorative nursing services as needed. She stated that the two designated restorative nursing CNAs are sometimes re-assigned to other duties depending on the needs of the facility. She revealed she and the CNAs meet monthly to discuss resident status and determine if any changes are needed to be recommended to therapies. She revealed the CNAs and any staff providing restorative nursing services are to document services that were provided in the EMR under the Restorative Care Flowsheet Data flowsheet section for restorative nursing. Record review of the Restorative Care Flowsheet Data flowsheet section for restorative nursing documentation for the past 3 months was reviewed with LPN DD at this time. She verified services were not documented as being provided per therapies recommendations. Interview on 9/1/22 at 11:10 a.m., Director of Nursing (DON) revealed the facility does not have a restorative nursing policy or procedure. She revealed PT and OT evaluate and provide a written individualized program for each resident that needs restorative nursing services. She stated that she requests assistance from therapists or LPN's if restorative CNAs are unavailable to provide restorative nursing services. She revealed the LPN supervisor, and the restorative CNAs meet monthly to discuss resident needs. She revealed it is her expectation that restorative nursing services are provided as recommended by PT and OT and that services are documented in the restorative nursing flowsheet in the EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for R#140 revealed she was admitted with a diagnosis of dementia and Alzheimer's. Review of R#140's Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS), of a 5, which indicated that resident was severely cognitive impaired. Review of Section G: Functional status on the Annual MDS dated [DATE] revealed that R#140 was an extensive assist for personal hygiene (mouth care) with one-person physical assist. R#140 had severe cognitive impairment and required staff assistance with her ADL's including personal hygiene. Reviewed on R#140 of the Care Plan dated 3/22/19 revealed the R#140 presents carious appearing upper teeth. R#140 is missing some teeth from top but has partial and her natural teeth are on the bottom. She needs staff assistance with her Oral hygiene and denture care. CNA will encourage resident to wear dentures for meals. CNA will provide care and remove any food after each meal. Interview on 5/7/19 at 7:35 a.m. with CNA DD, revealed that she documented ADLs in the electronic computerized system that was located at the nurse's station. Continued interview revealed that CNA DD, stated that mouth care was not documented separately in the computerized system. During interview with Certified Nursing Assistant (CNA) CC on 5/7/19 at 9:05 a.m., she stated that ADL care documentation is entered in the computer system. Continued interview revealed that mouth care was to be completed after each meal and as needed (PRN). Further interview with CNA CC, revealed that she had not completed mouth care on R#140 after breakfast this morning. She indicated that she is going to complete it after lunch. During interview with Licensed Practical Nurse (LPN) Unit Manager AA on 5/7/19 at 4:30 p.m., she verified that R#140 had food particles on her teeth. Review of R#140's ADL flowsheet updated on 4/22/19 revealed R#140's teeth were brown in color and teeth care was not done per ADL sheet and Flow sheet, Unit Manager and DON verified that the staff did not perform this care per their flowsheet. Refer to F677 Based on observation, record review, resident and staff interview, the facility failed to implement the skin integrity care plan related to the nurse assessing skin integrity as needed for one resident (R)(R#66), and failed to implement the care plan related to staff provision of oral hygiene for one out of two residents reviewed for oral care (R#140). Both residents resided in Facility A. The sample size was 29 residents. Findings include: 1. During interview with R#66 on 5/6/19 at 1:05 p.m., he stated that he had been awake all night itching, and that the facility did not have anything effective to treat it. On 5/7/19 at 8:57 a.m., R#66 was in bed, and was observed to have linear scratch marks to his left lower leg, with redness to the surrounding skin. Review of R#66's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that he had a Brief Interview for Mental Score (BIMS) of 6 (a BIMS score between 0 and 7 indicates severe cognitive impairment). Review of R#66's skin integrity care plan revealed that he was at risk for skin tears and bruises due to having thin, fragile skin. Review of an intervention for this care plan dated 9/18/18 revealed that the nurse will assess skin integrity as needed. Nothing was seen in his care plans related to ongoing concerns with a rash and itching. This was confirmed during interview with MDS nurse FF on 5/8/19 at 5:52 p.m. Review of a history of topical medications ordered for R#66 revealed that there were nine orders for topical applications for dry skin, dermatitis, itching and rash between 12/25/18 and 5/9/19. Review of a Nurse's Note dated 3/28/19 at 5:52 a.m. revealed: Very dry, flaky and itchy skin caused res (resident) to keep scratching his body which caused small bleeds all over, especially buttocks, stomach, back, arms and legs. Res was very upset and frustrated as he stated that he c/o (complained of) itching for a very long time and couldn't get any relief. Moisturizing cream was applied to his body several times during the night shift. During interview with R#66 on 5/9/19 at 9:48 a.m., he stated that he did not sleep at all last night due to the burning from the lotion that had been applied to his skin yesterday. Observation of R#66's skin at this time by Licensed Practical Nurse (LPN) Wound Care Nurse GG revealed that he had a scattered rash and/or small scabbed areas on his legs, especially the left posterior upper leg, his abdomen, and chest. When LPN GG removed R#66's incontinent brief, his buttocks were observed to be extremely red and excoriated in appearance, with bright red blood noted from weeping areas of skin on the brief and bed linen. During interview with CNA HH on 5/9/19 at 10:28 a.m., she stated that R#66 was always scratching his skin, and that when she came on duty in the morning there was always blood on his clothes and the sheets from him scratching his bottom, and she had to change him. She stated during further interview that she had told the treatment nurse about this. During interview with LPN II on 5/9/19 at 12:30 p.m., she stated that R#66 scratches himself, and has had rashes for a long time. She stated during further interview that she was not aware of the appearance of the excoriated skin on his bottom. Cross-refer to F 684.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure that oral care was provided for one of four resident (R) R#140 who needed extensive assistance with personal hygiene. R#140 resided in Building A. Findings include: Review of the medical record for R#140 revealed she was admitted with a diagnosis of dementia and Alzheimer's disease. Review of the facility NHL-ADL Sheet revealed R#140 had severe cognitive impairment and required staff assistance with her ADL's including personal hygiene. Review of R#140's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, which indicated that the resident was severely cognitively impaired. Further review of this MDS revealed that R#140 needed extensive assistance for personal hygiene, which includes brushing teeth, with one-person physical assist. Observation on 5/6/19 at 11:00 a.m. revealed that R#140 was missing some of her top teeth, her bottom teeth were brown in color, and she had white debris on the two front teeth. Interview with R#140 at this time revealed that she did not remember if the staff had brushed her teeth today. Further observations on 5/6/19 at 2:34 p.m., and on 5/7/19 at 7:40 a.m., 12:34 p.m., 4:03 p.m., and 4:30 p.m. revealed that resident #140's bottom teeth were brown in color, and she had white debris on the two front teeth. Review of R#140's Activities of Daily Living (ADL) flowsheet updated on 4/22/19 revealed R#140's teeth were brown in color and teeth care was not done per ADL sheet and Flow sheet, Unit Manager and Director of Nursing verified that the staff did not perform this care per their flowsheet. During interview with Licensed Practical Nurse (LPN) Unit Manager AA, on 5/7/19 at 4:30 p.m., she verified that R#140 had food particles on her teeth. During interview with Certified Nursing Assistant (CNA) CC, on 5/7/19 at 9:05 a.m., she stated that ADL care documentation is entered in the computer system. Continued interview revealed that mouth care was to be completed after each meal and as needed (PRN). Further interview with CNA CC, revealed that she had not completed mouth care on R#140 after breakfast this morning. She indicated that she is going to complete it after lunch. Interview on 5/7/19 at 7:35 a.m. with CNA DD, revealed that she documented ADLs in the electronic computerized system that was located at the nurse's station. Continued interview revealed that CNA DD, stated that mouth care was not documented separately in the computerized system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to identify and/or report an area of excoriation with bleeding to the buttocks in a timely manner, and continued itching from rashes, for one resident (R)(R#66), who resided in Facility A. The sample size was 29 residents. Findings include: During interview with R#66 on 5/6/19 at 1:05 p.m., he stated that he had been awake all night itching, and that the facility did not have anything effective to treat it. On 5/7/19 at 8:57 a.m., R#66 was in bed, and was observed to have linear scratch marks to his left lower leg, with redness to the surrounding skin. Review of R#66's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that he had a Brief Interview for Mental Score (BIMS) of 6 (a BIMS score between 0 and 7 indicates severe cognitive impairment). Review of R#66's skin integrity care plan revealed that he was at risk for skin tears and bruises due to having thin, fragile skin. Nothing was seen in his care plans related to ongoing concerns with a rash and itching. This was confirmed during interview with MDS nurse FF on 5/8/19 at 5:52 p.m. Review of R#66's Physician Progress Notes revealed the following: 1/9/19: Hospital Problems: rash (present on admission). Noted with red rash to bilateral buttocks. Ordered Monistat and hydrocortisone creams qs (every shift). 2/6/19: Chief complaint rash with itching to bilateral lower extremities. Multiple scratches noted to bilateral lower extremities. Rash noted with light red in color. New order for Lac-hydrin cream bid (twice a day) to bilateral lower extremities. 4/10/19: Itching: asteatotic eczema-lachydrin (sic) doing better. Rash: present on admission. Patient seems to have rash due to very dry skin. Anhidrotic eczema. We will start Lac-Hydrin on his legs twice daily. Review of R#66's Active Order Sets (Physician Orders) through 5/9/19 revealed current orders for: 12/25/18: Cetaphil Moisturizing Cream topically two times daily as needed for dry skin. 1/29/19: Hydrocortisone 0.5% cream topically two times daily as needed for rash and itching. 5/8/19 at 6:12 p.m.: Ammonium lactate (Lac-Hydrin) 12% lotion to abd (abdomen), legs and bilateral upper extremities topical bid (twice a day). 5/9/19 at 9:02 a.m.: Apply calazime to bil (bilateral) buttocks qshift. 5/9/19 at 10:51 a.m.: Apply triamcinolone ointment to arms, legs, back and abd qshift (every shift) x 7 days. Review of a history of topical medications ordered for R#66 revealed: 12/25/18: Cetaphil Moisturizing Cream topically twice a day PRN (as needed) for dry skin. 1/10/19: Hydrocortisone 2.5% cream topically twice a day for 14 doses for rash (through 1/17/19). 1/10/19: Miconazole 2% cream topically twice a day for 14 doses for rash (through 1/17/19). 1/29/19: Hydrocortisone 0.5% cream topically twice a day PRN for rash, itching. 2/6/19: Ammonium lactate (Lac-Hydrin) 12% lotion topically twice a day for 60 doses for rash (through 3/8/19). 3/13/19: Ammonium lactate (Lac-Hydrin) 12% lotion topically twice a day to bilateral lower extremities for seborrheic dermatitis (discontinued on 3/14/19). 3/13/19: Desonide (Desowen) 0.05% cream topically twice a day for seborrheic dermatitis to right hip for ten doses (through 3/18/19). 5/8/19: Ammonium lactate (Lac-Hydrin) 12% lotion topically twice a day for seborrheic dermatitis to arms, leg and abdomen for 60 doses. 5/9/19: Triamcinolone (Kenalog) 0.1% ointment topically to arms, legs, back and abdomen every shift for 7 days. Review of R#66's wound records revealed: 12/30/18: Scratches to right hip, bleeding from resident scratching. 1/9/19: Bilateral rash buttocks, treatment with hydrocortisone and monistat. 2/6/19: Bilateral lower leg. Skin dry. Several small scabs from scratching. Treatment with Lac-Hydrin. 3/13/19: Dry skin bilateral legs and right hip. Treatment with Desowen and Lac-Hydrin. 5/9/19: Other wound (unspecified). Date first assessed 5/9/19 at 9:19 a.m. Location: Body. Review of Nursing Notes revealed the following: 12/25/18 1:17 p.m.: Res with scabbing and itching continuing to body. New order for cetaphil lotion. 1/6/19 11:20 p.m.: Resident's roommate reported that his roommates arm is bleeding. Noted a medium sized S/T (skin tear) on residents rt. (right) arm. Resident said he was scratching his arm and scratched it too hard. Causing the S/T on his arm. 1/16/19 3:18 p.m.: Resident scratched his right leg causing some red bloody skin. Various scratches covering the entire right lower extremity. 1/29/19 12:00 p.m.: Family reported to nurse that resident was bleeding. Upon entering room noted resident had 1 ST to left wrist and 2 areas on LFA (left forearm) which appeared to be scratches. Resident stated he had been scratching his arm. (Doctor) informed and new orders received for Hydrocortisone cream and one time order for Benadryl. 1/30/19 3:08 p.m.: Resident with scabs all over body from itching. 3/28/19 5:52 a.m.: Very dry, flaky and itchy skin caused res to keep scratching his body which caused small bleeds all over, especially buttocks, stomach, back, arms and legs. Affected areas cleansed with wound cleanser, then normal saline applied, followed by prescribed lotion/cream. Res was very upset and frustrated as he stated that he c/o (complained of) itching for a very long time and couldn't get any relief. Moisturizing cream was applied to his body several times during the night shift. CNA (Certified Nursing Assistant) advised to always change res (resident) TShirt before bedtime. 4/12/19 11:37 a.m.: Hydrocortisone cream 0.05% applied to the entire back and buttocks d/t (due to) itching. His skin is dry and red d/t scratches. 4/26/19 6:31 p.m.: He does scratch d/t itching causes minimum bleeding. 5/8/19 6:13 p.m.: Resident complaining of itching to bilateral arms, legs and abd (abdomen). Resident noted scratching areas. New order received to apply lac-hydrin lotion bid (twice a day). 5/9/19 10:41 a.m.: Upon assessment this a.m. patient refused to let Lac-Hydrin be applied. Lac-Hydrin started yesterday evening for asteatotic eczema exacerbation per doctor. Stated to this nurse that it stings after it is applied. Order received to dc (discontinue) Lac-Hydrin and start triamcinolone ointment q (every) shift x 7 days. Patient has appointment scheduled with dermatologist for Monday 5/13/19. During interview with Licensed Practical Nurse (LPN) Treatment Nurse GG on 5/9/19 at 9:48 a.m., she stated that R#66 had a dermatology appointment scheduled in the past, but the family was unable to accompany him so it had to be canceled. She further stated that weekly skin assessments were done by the shower team CNAs, and were recorded on a paper form and kept in the Unit Manager's office. During interview with R#66 at this time, he stated that he did not sleep at all last night due to the burning from the lotion that had been applied to his skin yesterday. Interview with LPN Treatment Nurse GG at this time, she stated she would call the physician today to see if she wanted to change the order. Observation of R#66's skin at this time by LPN GG revealed that he had a scattered rash and/or small scabbed areas on his legs, especially the left posterior upper leg, his abdomen, and chest. When LPN GG removed R#66's incontinent brief, his buttocks were observed to be extremely red and excoriated in appearance, with bright red blood noted from weeping areas of skin on the brief and bed linen. Interview with LPN GG at this time, she stated that she was aware of the area, that it was blanchable, and that she had put some barrier cream on it that morning. Review of R#66's Skin Assessments from 3/22/19 to present revealed the following shower team CNA documentation: 3/22/19: No issues noted. 3/25/19: No issues noted. 3/29/19: Scars, bruises, and red rashes were noted by the CNA. After reviewing the assessment, LPN GG documented no rash, only dry skin. 4/1/19: Resident has been scratching bottom, drawing blood. Cream applied. (there was nothing seen in response to this from the treatment nurse). 4/5/19: Scratches documented on bilateral shoulders, a scab left anterior lower leg, and scratches on upper back and buttocks. 4/8/19: No skin issues noted. 4/10/19: Sores/scabs noted by CNA on right posterior back. The treatment nurse documented no sores, scabs, pt (patient) scratches. 4/14/19: Multiple scars/bruises documented anterior and posterior body. 4/17/19: Bruises on arms, legs, hands, and back. 4/22/19: Bruises and cuts all over body documented by CNA. The treatment nurse documented no cuts, pt scratches. 4/29/19: Multiple bruises anterior and posterior body, bleeding to left lower anterior leg. 5/1/19: Treatment area left lower anterior leg. The CNA documented redness to bottom, the treatment nurse made a notation that it blanches. 5/3/19: Bruises/scars anterior and posterior body. 5/8/19: Scratch right anterior shoulder area, scratches left anterior thigh, scratches back, right and left buttocks. (there was no indication on this skin assessment of excoriation to the buttocks). During interview with LPN Treatment Nurse GG on 5/9/19 at 9:55 a.m., she stated that it was possible that the skin on R#66's buttocks could have become that excoriated-looking between the time the skin assessment was done on 5/8/19, and this morning's observation. During interview with the LPN Unit Manager AA at this time, she stated that the facility policy was for skin assessments to be done weekly by the shower team, but the shower team CNAs may do it more often. During interview with CNA HH on 5/9/19 at 10:28 a.m., she stated that R#66 was always scratching his skin, and that when she came on duty in the morning there was always blood on his clothes and the sheets from him scratching his bottom, and she had to change him. She stated during further interview that she had told the treatment nurse about this. During interview with LPN II on 5/9/19 at 12:30 p.m., she stated that R#66 scratches himself, and has had rashes for a long time. She stated during further interview that she was not aware of the appearance of the excoriated skin on his bottom, because it would have been reported to the treatment nurse, as she had more expertise with skin conditions. Review of the facility policy Skin Assessment review/revision 9/01 revealed: Residents will be examined weekly by the CNA or nurse during their shower/bath for skin breakdown. Identified problems will be reported to the DON (Director of Nursing) or designee for review and assessment. Appropriate measures will be implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and resident interviews, the facility failed to ensure that one of one resident (R) (R#193) reviewed for vision receive proper treatment and assistive devices to maintain vision. The sample size was 24 residents. Findings include: Resident #193 was admitted to the facility on [DATE] with diagnoses including but not limited to; sepsis, end stage renal disease, diabetes mellitus type 2, peripheral artery disease, cerebrovascular attack and hypertension, The resident's medication included but not limited to; brimonidine 0.2% ( eye drops for Glaucoma) 1 drop 2x daily , apresoline tab ( blood pressure) 25mg 3x day, Norco (pain medication) 5-325 mg tab x1 x6 hrs prn, Novolog (insulin) 100 units /ml 7 units 3x daily, Levemir (insulin) 7 units nightly, lopressor tab(for blood pressure) 37.5 mg x2, timolol (for Glaucoma) 0.5% 2x daily, Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section B: 1000. Vision - Impaired -B. 1200 Corrective Lens- NO /Section C: Brief Interview for Mental Status (BIMS) score 15 out of 15 which indicates no cognitive impairment. Review of R#193's care plan dated 4/29/19 revealed (Impaired Vision), Revealed R #193 reports impaired vision. He is not able to read small print. Review of record: dated 4/15/19 revealed R#193 not involved in Care Plan meeting. Request an order for an eye exam and consult. Certified Nursing Assistant CNA will remind the resident to wear glasses and keep them clean Goal: R's will have optimal vision capabilities as evidenced by feeling safe in a familiar environment and large print material through next review period. During an interview on 5/9/19 at 9:10 a.m. with R#193 he stated that the Ophthalmologist could not accommodate him during his recent visit because he was on a stretcher and needed to be seated upright in order to perform the vision exam. R#193 stated he has blurry vision with headaches when reading or watching television and prefers not to use his outdated prescription glasses. He stated the room often appears very dark and it becomes difficult to see things. During an observation on 5/7/19 at 11:30 a.m. of R#193 revealed his room to have adequate lighting. His prescription glasses on the bedside table were observed to be dirty with fingerprints on the lens. During an interview on 5/7/19 at 4:42 p.m. with Licensed Practical Nurse (LPN) NN she stated she wasn't aware of the issues surrounding R#193's recent vision exam and stated she would reschedule his appointment immediately. She stated R#193 currently receives eye drops for complaints of headaches related to dialysis and pressure changes in his eye. During the interview LPN NN revealed R#193 returned from dialysis a month ago he appeared incoherent, complaining of an acute headache and eye pain. States when she called the attending physician, she was instructed to contact 911. On 5/7/19 at 6:00 p.m. an interview R#193 revealed R#193 entered the facility with his outdated prescription glasses, but never uses them and leaves the old glasses on his bedside table. States he reported his concerns about blurry vision and room darkness to several staff members on numerous occasions without changes. States he had surgery in the past on both eyes for cataracts and the medical doctor (MD) at the most recent emergency room visit told him he has glaucoma. Reports MD prescribed him eye drops to relief pressure, stop pain and redness. The follow up appointment was canceled due to his stroke. Also, states he's not 100% sure if the facility was aware of the canceled Ophthalmologist appointment because of they weren't able to accommodate him. On 5/9/19 at 8:20 a.m. Registered Nurse QQ reported that R#193 was admitted into emergency room last night upon his request with complaints of headaches and eye pain. RN QQ states they have an eye doctor on staff at the facility and isn't sure why R#193 wasn't examined. RN QQ stated that all referrals, transportation and specialist appointments are made by unit secretary and kept on file. The exam follow-up communication is passed on to himself or LPN NN for review then returned to medical records to be scanned into the medical record. RN QQ states he was unaware of the issues surrounding R#193 appointment on 4/22/19. The follow-up documentation wasn't found in electronic medical record. On 5/9/19 Nurse RN QQ requested the documentation from medical record which revealed, Patient had an appt. for 4/22/19 at 3pm. He was on a stretcher and was unable to be removed from it and it seemed like he was in a lot of pain. Patient left and said he would call back to reschedule. On 5/9/19 at 10:49 a.m. an interview with Director of Nursing (DON) revealed that no follow up was done with R #193 4/22/19 vision appointment. States when she contacted the office today for the follow- up documentation they informed her R#193 refused to be seen on 4/22/19. States she's aware the follow-up communication doesn't reflect those claims. The DON acknowledged that her staff drop the ball in this situation. In a normal process the Unit Manager or LPN NN would contact the doctor's office for new orders and send the information to medical records to be scanned into electronic record.

Based on observation, record review, and staff interview, the facility failed to ensure that two opened multi-dose vials of PPD (Purified Protein Derivative) were labeled with an open date to be able to determine when to discard the vial in one of two medication room refrigerators observed at Facility A, and failed to ensure that two medications were not used past their expiration date (one bottle of floorstock aspirin currently used for two residents (R)(R#22 and R#216), and one bottle of Aloe Vera capsules used for one resident (R#24)) on one of two medication carts observed at Facility A. There was a total of five medication storage rooms and nine medication carts in Facility A and Facility B combined. The sample size was 29 residents. Findings include: 1. Observation in the medication refrigerator located in the medication room on Unit 3 in Facility A on 5/7/19 at 12:27 p.m. revealed that there were two opened multi-dose vials of PPD (Tuberculin, Purified Protein Derivative, Diluted Aplisol), which contained ten 0.1-mL (milliliter) PPD tests when full. Further observation revealed that both bottles had manufacturer's expiration dates of 9/20 (September 2020), but neither the bottles or box they came in were labeled with the date they were opened. Continued observation revealed that one vial was approximately half-full, and the other vial approximately two-thirds full. This observation was verified by Licensed Practical Nurse (LPN) JJ at this time, who stated during interview that whenever a multi-dose vial was opened, it should be labeled with the open date. LPN JJ stated during continued interview that she did not know how long PPD vials were good for once they were opened. 2. On 5/8/19 at 10:25 a.m., the Unit 1 North medication cart in Facility A was checked with LPN KK. One floorstock bottle of aspirin 325 mg (milligram) tablets was observed to have an expiration date of 04/19 (April 2019). Continued observation revealed a 90-capsule bottle of Aloe Vera 500 mg capsules, with an expiration date of 7-2018 (July 2018). This was verified during interview with LPN KK at this time, who stated the Aloe Vera capsules were most likely brought in by family for R#24, as the bottle was labeled with her name handwritten in black ink. During continued interview, LPN KK stated that it was the night shift nurse's responsibility to check the medication cart for expired meds, and that both of these medications were currently in use for residents. During observation in the Unit 1 medication room at this time, all of the floorstock bottles of aspirin were noted to have dates on the bottles later than 04/19, and LPN KK stated that she would replace the aspirin bottle on the medication cart labeled 04/19 with a bottle that was not expired. Review of R#24's Active Order Sets revealed an order for Aloe Vera, one capsule two times daily PRN (as needed). Review of R#216's Active Order Sets revealed an order for aspirin 325 mg tablet two times daily. Review of R#22's Active Order Sets revealed an order for aspirin 325 mg tablet daily. Review of R#24's electronic medication administration record (e-MAR) revealed that she most recently received PRN doses of the Aloe Vera on 4/14/19 at 4:28 p.m.; 4/28/19 at 6:08 p.m.; and 5/6/19 at 8:03 a.m. Review of R#216's e-MAR revealed that he received two doses of the aspirin daily from 5/1/19 through 5/7/19, and had received the first scheduled dose on 5/8/19. Review of R#22's e-MAR revealed that he received the aspirin once daily from 5/1/19 through 5/8/19. During interview with the Director of Nursing (DON) on 5/8/19 at 12:40 p.m., she stated that the nurses and Unit Managers were responsible for checking for expired medications on the medication carts. She stated during continued interview that whenever a multi-dose vial was opened, it should be labeled with the open date. The DON further stated that a vial of PPD was good for 30 days after it was opened. Review of the manufacturer's insert for Aplisol (PPD) revealed: Vials in use for more than 30 days should be discarded. Review of the facility policy Multi-Dose Vials-Patient Care (undated) revealed: All multi-dose vials are labeled with an expiration date of 28 days from the date the vial is first opened. Labeling with only the date opened is not acceptable. All multi-dose vials with the exception of insulin and reconstituted injectable medications should be discarded when empty, when suspected or visible contamination occurs, or when the manufacturer's stated expiration date is reached.

2. On 5/8/19 at 4:00 p.m. The Charge Nurse (EE) was observed performing a glucometer check for one resident R#163. The nurse was observed cleaning the glucometer with Sani-wipes times three - thoroughly wet the machine then placed it on a paper towel on top of the med cart to air dry - stated that she would leave it for three minutes. After the three minutes passed - the Charge Nurse sanitized her hands, gathered her supplies, knocked on resident's door and asked permission to enter - she then explained to the resident what she was going to do. The nurse provided privacy by pulling the privacy curtain - placed glucometer on paper towel and cup with lancet, alcohol wipes and cotton ball on the over-the-bed table - washed her hands, donned gloves and cleaned the resident's tip of the thumb on the left hand with alcohol - wiped with a cotton ball, got another drop of blood and placed on strip - results 289. The nurse then told the resident the results. Then observed the nurse as she picked up the glucometer in one hand and with the other she picked up the lancet and trash - pulled off her gloves and wrapped the lancet it one of the gloves, folded the other glove over the first glove and disposed both gloves in the resident's bathroom trash receptacle. When asked, the nurse verified that she threw the used lancet in the trash can - further stated that she didn't like to take the used lancet out of the room to the needle box on the cart which was in the hallway. On 5/8/19 at 4:35 p.m an interview was conducted with the DON who stated that she would expect the nurse to dispose of the used lancet either in the trash can or in the needle box since they are self-sheathing. Review of the facility form entitled 'Glucose Meter Visual Observation Form' revealed the 'operator' was Charge Nurse (EE) and that she was checked off 9/27/18 on scanning the patient identification (ID) into the glucometer; appropriate cleaning of site, used 2nd drop of blood; opened strip correctly; proper handling & cleaning of meter, results need to be traceable (docked) and further review of the form revealed that it was signed by a 'superuser.' Review of the facility's policy entitled 'Laboratory Services - Glucose Testing Point of Care' with approval date 10/16/17 revealed under Section VII. 'Patient Test Procedure - Arterial, Venous, Capillary or Neonate Blood' pages four and five - with steps A through V outlining the step by step procedure for obtaining the resident's blood for glucose testing with step S. 'Discard lancet in a biohazard sharps container.' Review of the insert which is included in the boxes of lancets (used by the nursing staff) entitled 'BD Microtainer - Contact-Activated Lancet' revealed under Universal Precautions: Handle all biologic samples and blood collection 'sharps' (lancets, needles, leur adapters, and blood collection sets) in accordance with the policies and procedures of your facility. Obtain appropriate medical attention in the event of any exposure to biologic samples (e.g. through a puncture injury) since samples may transmit viral hepatitis, HIV (AIDS), or other infectious diseases. Utilize any built-in used needle protector if the blood collection device provides one. Discard all blood collection 'sharps' in biohazard containers approved for their disposal. Based on observation, record review and staff interview, the facility failed to administer a subcutaneous (SQ) injection in a sanitary manner for one resident (R)(#163) by one of two nurses observed administering SQ injections to two residents in Facility A. In addition, the facility failed to dispose of a lancet after a fingerstick blood sugar (FSBS) for one resident (R#163) per facility policy and manufacturer's guidelines to prevent the potential for bloodborne illness. Three residents total were observed getting a FSBS (two residents in Facility A, and one resident in Facility B) performed by three different nurses. The sample size was 29 residents. Findings include: 1. On 5/8/19 at 9:52 a.m., Licensed Practical Nurse (LPN) EE was observed preparing a scheduled dose of Levemir (a long-acting insulin) for R#163. LPN EE took the prepared syringe with a cap covering the needle to R#163's room, cleaned the resident's right upper arm with an alcohol swab, and removed the cap covering the needle. Further observation revealed that LPN EE dropped the uncapped syringe on the resident's bed sheets, and before the surveyor could intervene the nurse quickly picked up the syringe and gave the injection in the resident's arm. After leaving R#163's room on 5/8/19 at 10:01 a.m., LPN EE was unable to describe how she gave the injection and stated she did not remember dropping the syringe. She stated during further interview that if she had dropped a syringe, she should have disposed of it and prepared another dose with a new syringe. During interview with the Director of Nursing (DON) on 5/8/19 at 12:40 p.m., she stated that if a nurse dropped a syringe with an uncapped needle, that the nurse should discard the needle and syringe and prepare another dose. Review of inservice material Information Zone Training 2018 and 2019 provided by the Infection Control nurse on 5/9/19 at 4:51 p.m. revealed: Infection Prevention & Control - Bloodborne Pathogens Bloodborne pathogens are disease producing organisms that may be transmitted through blood or other body fluids. Bloodborne pathogens are spread in the workplace in the following ways: Sharps, cuts, splashes. Bloodborne pathogens are spread through injuries from contaminated sharps. You should handle sharps carefully. You should never bend, break or recap needles and dispose of used sharps promptly in a sharps container only. Waste Disposal: Place sharps in sharps container. Review of a listing of staff completing the facility's required annual training, that included the infection control education above, revealed that LPN EE completed the training on 10/15/18.