Based on observation, interview, and record review it was determined the facility failed to ensure supplies available for use were not expired in one (1) of three (3) medication rooms. Observation of the Seasons Unit's medication room on 08/01/19, revealed sixty (60) blue top serum vacutainer vials with the expiration date of 04/10/19 available for resident use. The findings include: Interview with the Director of Nursing (DON) on 08/01/19 at 4:15 PM, revealed the facility did not have a policy related to the storage of laboratory supplies. Observation of the Seasons Unit's medication room on 08/01/19 at 12:57 PM, revealed a bin sitting on the counter, which contained sixty (60) blue top vacutainer vials utilized for blood collection with an expiration date of 04/10/19. Review of a Medication Room Audit tool, dated 2018 and 2019, revealed audits were performed in March and September of each year. Further review of the audit tool revealed the March 2019 audit had comments that all discontinued and expired medications and supplies were discarded. Interview with Licensed Practical Nurse (LPN) #1 on 08/01/19 at 1:10 PM, revealed the vacutainer vials were used when the facility had to obtain a laboratory specimen. She further stated she could not remember the last time the facility had to perform a venipuncture to obtain a blood specimen. She added the facility's contract laboratory utilizes their own vials and does not use the facility's. The LPN then stated she was not sure who was responsible to audit the medication room for expired supplies. Interview with Registered Nurse (RN) #1, the Seasons Unit Manager, on 08/01/19 at 3:48 PM, revealed the medication room was audited two (2) times per year for expired/damaged items. She stated this usually occurred in the spring and fall of the year. She then added the expired laboratory vacutainer vials should have been discarded due to the possibility of incorrect results if an expired vacutainer was used. Interview with the DON on 08/01/19 at 4:15 PM, revealed that two (2) times a year a big cleaning and audit for expired supplies occurred. She further stated it was the responsibility of the staff to check before using any supply to ensure it was not expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of twenty-three sampled (23) residents (Resident #68 and Resident #92) received the necessary care and services to maintain grooming and hygiene. Observation of incontinence care for Resident #68 on 05/23/18, revealed staff failed to provide the resident with incontinence care every two (2) hours as required. In addition, after providing Resident #68 with incontinence care, staff were observed to place the resident back onto the urine-soiled mattress without cleaning the mattress. Observation of Resident #92 on 05/23/18, revealed the resident was in bed and observed to have soiled feet; however, the resident had been provided a bed bath approximately 20 minutes earlier. The findings include: 1. Review of the facility's policy titled, Perineal Care Male or Female, with a revision date of 12/03/15, revealed the policy did not address how often incontinence care should be provided, or the cleaning of the mattress if it has been soiled during an incontinence episode. Review of the medical record for Resident #68 revealed the facility admitted the resident on 11/21/17, with diagnoses that included Unstageable Area to Right Buttock, Alzheimer's Dementia, and Osteomyelitis of the Left Foot. Review of a significant change Minimum Data Set (MDS) assessment completed by the facility for Resident #68 dated 04/06/18, revealed the resident had been assessed to have a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident had severe cognitive impairment. The MDS also revealed the resident was incontinent of bowel and bladder. Review of Resident #68's comprehensive care plan dated 05/10/18, revealed interventions to provide incontinence care every two (2) hours and as needed, and to keep the resident's skin clean and dry. Observation of incontinence care for Resident #68 on 05/23/18 at 9:30 AM, revealed State Registered Nursing Assistant (SRNA) #3 and SRNA #4 washed/sanitized their hands and donned gloves. SRNA #3 then removed the resident's brief, which was observed to be saturated with urine. The resident's gown, drawsheet, and mattress were also observed to be saturated with urine. Continued observation revealed SRNA #3 provided incontinence care for Resident #68, applied a clean brief and gown to the resident, and changed the drawsheet on the bed. However, the SRNAs failed to clean or dry the mattress, and Resident #68 was placed onto the urine-soaked mattress. Interview conducted with SRNA #3 and SRNA #4 on 05/23/18 at 9:40 AM, revealed Resident #68 had not been provided incontinence care since approximately 6:00 AM. The SRNAs stated they had been busy and had not had time to change the resident within the two-hour timeframe the resident was assessed to require. The SRNAs stated they should have also cleaned and dried the mattress prior to placing Resident #68 back onto it. Interview conducted with License Practical Nurse (LPN) #2 on 05/24/18 at 3:44 PM, revealed she made rounds every two (2) hours to ensure residents received the care they required. The LPN stated that Resident #68 was to receive incontinence care every two (2) hours and as needed, and that staff should not have placed the resident onto the mattress until it had been cleaned and dried. Interview conducted with the Director of Nursing (DON) on 05/24/18 at 4:15 PM, revealed she made rounds daily and provided random spot checks to ensure care was being provided as required. The DON stated she had not identified any concerns related to residents not receiving timely incontinence care, or staff not properly cleaning/drying mattresses that become soiled. 2. Review of the facility's policy titled, Shower/Tub bath Competency, with a revision date of 08/24/17, revealed staff were required to assist residents into the shower and to provide assistance as needed to complete the bath or shower. Review of the medical record for Resident #92 revealed the facility admitted the resident on 07/15/15, with diagnoses including Mental Retardation, Cellulitis of Lower Extremities, Dementia, and Peripheral Vascular Disease. Review of a significant change MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of three (3) which indicated the resident was severely cognitively impaired. The MDS also revealed the resident required extensive assistance of two (2) persons for personal hygiene and bathing. Observation of Resident #92 on 05/23/18, at 11:54 AM, revealed the resident was observed to be in bed with his/her feet uncovered with a dark buildup of dirt on the soles of his/her feet. However, review of Resident #92's bathing sheet dated 05/23/18, and interview with SRNA #1 on 05/24/18 at 8:30 AM revealed Resident #92 had been given a bed bath on 05/23/18 at approximately 11:30 AM. Continued interview with SRNA #1 on 05/24/18 at 8:30 AM, revealed she always washed Resident #92's feet when providing the resident with a bed bath. However, she had not been aware that Resident #92's feet remained soiled after having provided the bed bath to the resident on 05/23/18. Interview conducted with LPN #2 on 05/24/18 at 3:44 PM, revealed she made rounds every two (2) hours to ensure residents were receiving the care they had been assessed to require. LPN #2 stated she had identified no concerns with residents not receiving appropriate care during bathing. Interview conducted with the Director of Nursing (DON) on 05/24/18 at 4:15 PM, revealed she made rounds daily and provided random spot checks to ensure care was being provided as required by the resident. The DON stated the SRNAs were required to check the care plan daily and as needed to obtain the care required by the residents. The DON stated Resident #92's feet should not have remained soiled on 05/23/18 after receiving a bed bath.