**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, manufacturer's directions for use, and staff interview, the facility failed to discard a vial of insulin after 28 days per the manufacturer's directions for use and drew up insulin for administration for 1 of 2 residents sampled (Resident #27). The facility identified a census of 37 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive loss. The MDS documented Resident #27 received insulin injections for a diagnosis of diabetes mellitus. The Order Listing Report signed by the Provider on 6/06/23 showed the following order for insulin aspart solution (a short-acting, manmade version of human insulin): Insulin aspart solution 100 units/milliliter inject as per sliding scale: if 70 - 149 = 6 units. Notify the provider if blood sugar is below 70. 150 - 200 = 7 units 201 - 250 = 8 units 251 - 300 = 9 units 301 - 500 = 10 units. Notify the provider if the blood sugar is greater than 300, subcutaneously before meals related to type 2 diabetes mellitus with ketoacidosis (a serious complication of diabetes where the body cannot produce enough insulin) without coma (state of prolonged loss of consciousness). If the blood sugar is below 90, administer the insulin after meals. Start date 3/07/23. During an observation on 6/13/23 at 11:50 a.m. Staff A Registered Nurse (RN) performed a blood sugar with a result of 226 milligrams/deciliter. On 6/13/23 at 11:52 a.m. Resident #27 reported she didn't know why her blood sugar would be that high. She had eaten eggs, toast, and orange juice for breakfast. She had not asked for more orange juice at breakfast. During an observation on 6/13/23 at 11:53 a.m. Staff A returned to the medication cart and checked Resident #27's physician orders for sliding scale insulin. Staff A opened the medication cart and removed a plastic bag containing Resident #27 box of insulin aspart vial. At 11:54 a.m. Staff A reported the vial of insulin had been opened on 5/12/23 and pointed to the plastic bag that had opened 5/12/23 written on the outside of the bag. Staff A drew up 8 units of insulin aspart per the physician order, locked the medication cart and verbally confirmed she was ready to administer the sliding scale insulin to Resident #27. The Surveyor stopped Staff A from administering the insulin to Resident #27. On 6/13/23 at 11:56 a.m. Staff A reviewed the open date for the insulin vial and then pulled the insulin aspart box from the medication cart. She reviewed the side panel of the box that directed to discard the insulin after 28 days. Staff A opened the electronic calendar on her laptop screen and counted the number of days from 5/12/23. She reported the 28th day would have been 6/10/23 and the insulin should not be given. On 6/13/23 at 11:56 a.m. the Regional Nurse Consultant who observed the insulin preparation reported the insulin should not be administered. On 6/13/23 a review of the pharmacy label on the plastic bag that contained the box of insulin directed to discard the vial at 28 days. A Review of the June 2023 Medication Administration Record (MAR) on 6/14/23 revealed the insulin aspart had been administered on the following dates after 6/08/23 (day 28): a. 6/09/23 at 7:30 a.m. 9 units b. 6/09/23 at 11:30 a.m. 1 unit c. 6/09/23 at 5:30 p.m. 1 unit d. 6/10/23 at 7:30 a.m. 6 units e. 6/10/23 at 11:30 a.m. 7 units f. 6/10/23 at 5:30 p.m. 7 units g. 6/11/23 at 7:30 a.m. 9 units. h. 6/11/23 at 11:30 a.m. 9 units. i. 6/11/23 at 5:30 p.m. 8 units. j. 6/12/23 at 7:30 a.m. 6 units k. 6/12/23 at 11:30 a.m. 9 units l. 6/12/23 at 5:30 p.m. 10 units m. 6/13/23 at 7:30 a.m. 6 units During an interview on 6/14/23 at 1:45 p.m. the Director of Nursing reported she expected the nurses to follow the manufacturer's directions for use. The Medication Administration Policy, revised 4/01/23, provided by the facility, directed the nurse/oral medication technician to check labels (on the medication) with the medication administration record. The Policy lacked direction to follow manufacturer's directions for medication use. The Insulin Aspart box side panel directed to discard the product after 28 days. The Manufacturer's Patient Information insert instructed to throw away all Novolog (Insulin Aspart) after 28 days, even if the vial still had insulin left in it.