GREENVILLE HEALTH CARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to contact the physician for the
need to alter treatment due to significant change for two Residents (#31 and #32) of 14
sampled residents. The facility’s census was 52.
1. Record review of Resident #31’s Admission Minimum Data Set (MDS) (a federally mandated
assessment instrument completed by facility staff), dated 9/29/18, showed [DIAGNOSES
REDACTED].
Record review of the resident’s Face Sheet showed a [DIAGNOSES REDACTED].
Record review of the Treatment Administration Record (TAR), dated 11/1/18, showed the
resident had not worn his/her Bi-level Positive Airway Pressure ([MEDICAL CONDITION]) (a
positive air pressure device that helps with breathing) for15 nights.
During an interview on 11/16/18 at 8:47 A.M., the resident said his/her [MEDICAL
CONDITION] mask does not fit properly and blows air out of the bottom of it. He/she
refuses to wear it because it doesn’t fit.
Record review showed the facility failed to notify the physician of the poor fitting mask
and the [MEDICAL CONDITION] not worn as ordered.
During an interview on 11/19/18 at 4:00 P.M., the Director of Nursing (DON) said she would
expect the charge nurse to notify the physician of any problem with the [MEDICAL
CONDITION] mask.
2. Record review of Resident #32’s monthly weight record showed:
– Admission weight on 3/21/18 of 167.2 pounds (lbs);
– (MONTH) (YEAR) weight of 153.4 lbs (9.02% loss in three months);
– (MONTH) (YEAR) weight of 151.4 lbs;
– (MONTH) (YEAR) weight of 149.0 lbs;
– (MONTH) (YEAR) weight of 154.2 lbs;
– (MONTH) (YEAR) weight of 147.6 lbs (4.28% loss in one month);
– (MONTH) (YEAR) weight of 154.6 lbs;
– (MONTH) (YEAR) weight of 147 then re-weight on 11/15/18 of 152.4 lbs.
Record review of the resident’s Nutrition Progress Notes showed:
– On 5/16/18, noted weight loss, will add Med Pass (dietary supplement to increase
calorie intake) at 60 milliliters (ml) three times daily (TID) with medications;
– On 6/20/18, Registered Dietician (RD) discussed weight loss via telephone with Dietary
Manager (DM);
– On 6/13/18, Pro Shake (a nutritional shake with added calories) added with meals twice
daily;
– On 9/12/18 weight of 147.6 lbs, noted 6.8 % weight loss in past month. Will suggest Med
Pass TID;
– On 11/14/18 weight of 147 lbs, weight fluxes, receiving Med Pass TID, preferences
provided and encouraged. No further dietary changes to recommend.
Record review of the resident’s medical record showed a Nutritional Care Form with a list
of residents with dietary issues. The form had faxed to physician on 9/14/18 and had
dietary recommendations related to weight loss for the resident. The form did not show a
follow up response noted. The facility failed to obtain a response or follow up on the
faxed message.
During an interview on 11/16/18 at 2:00 P.M., the Administrator said the physician had
been faxed a recommendation on 9/14/18. There wasn’t any record of physician response and
she will notify the physician today.

Based on interview and record review, the facility failed to issue a Notice of Medicare
Non-Coverage (NOMNC) (a required notice to beneficiaries of covered skilled services
ending) when benefits were not exhausted and the resident discharged to home for three
residents (Resident #149, #150, and #151) out of three sampled residents. The facility’s
census was 52.
Record review of Resident #149’s medical record showed:
– Medicare Part A skilled services start date of 6/15/18 and end date of 8/13/18;
– The facility initiated a discharge on 8/8/18 from Medicare Part A Services when benefit
days were not exhausted;
– There was no NOMNC form issued.
Record review of Resident #150’s medical record showed:
– Medicare Part A skilled services start date of 5/10/18 and end date of 6/8/18;
– The facility initiated a discharge on 6/9/18 from Medicare Part A Services when benefit
days were not exhausted;
– There was no NOMNC form issued.
Record review of Resident #151’s medical record showed:
– Medicare Part A skilled services start date of 6/8/18 and end date of 9/23/18;
– The facility initiated a discharge on 9/17/18 from Medicare Part A Services when benefit
days were not exhausted;
– There was no NOMNC form issued.
During an interview on 11/16/18 at 2:33 P.M., the Social Services Director said she was
not aware that this form should be completed when a resident’s benefits have not been
exhausted.
During an interview on 11/19/18 at 3:00 P.M., the Administrator said she wasn’t aware the
correct form wasn’t being utilized, but would make sure it is in the future.
The facility did not provide a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure discharge/transfer
documentation was completed to include reasons for the discharge/transfer, discharge plan
and notification of the resident’s responsible party for one sampled resident (Resident
#48), who was discharged to the hospital, out of three sampled closed records and 14

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify in writing the
resident and/or family or legal representative of a facility-initiated transfer to the
hospital for five residents (Resident #2, #37, #42, #44, and #45) out of 14 sampled
residents and one closed record for Resident #48. The facility’s census was 52.
1. Record review of the facility’s policy titled Resident Transfer/Discharge, Immediate
Discharge, and Therapeutic Leave Policy, dated 5/28/18, showed before any resident is
transferred or discharged under a facility-initiated transfer or discharge, the facility
must notify the resident and the resident representative the reason for the transfer or
discharge in writing in a manner they understand.
2. Record review of Resident #2’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the resident’s transfer to the hospital.
3. Record review of Resident #37’s medical record showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to prepare and orientate one
resident (Resident #48) for a discharge to the hospital, out of three sampled closed
records and 14 sampled residents. The facility’s census was 52.
Record review of Resident #48’s Physician’s Order Sheet, dated 9/5/18, showed:
– admitted on [DATE];
– [DIAGNOSES REDACTED].
– admitted for rehab to home.
Record review of the resident’s Initial Admission Note, dated 9/9/18, showed Add note:
Resident was dcd (discharged ) today to the hospital.
Record review of the resident’s nurse’s notes, dated 9/5/18 through 9/9/18, showed no
documentation of reason for hospital transfer, transfer/discharge teaching, hospital
transfer notice, or bed hold policy.
During an interview on 11/28/18 at 3:35 P.M., the Administrator said:
– The resident had an infection and the family wanted the resident to be transferred to
the hospital;
– The family chose to take the resident home rather than return to the facility upon
hospital discharge.
Record review of the facility policy titled, Resident Transfer/Discharge, Immediate
Discharge, and Therapeutic Leave Policy, dated 5/28/18, showed:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform the resident and
family or legal representative of their bed hold policy at the time of transfer to the
hospital for five residents (Resident #2, #37, #42, #44, and #45) out of 14 sampled
residents and one closed record for Resident #48. The facility’s census was 52.
1. Record review of Resident #2’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
2. Record review of Resident #37’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE], and again
on 9/24/18 and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
3. Record review of Resident #42’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
4. Record review of Resident #44’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
5. Record review of Resident #45’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE], again on
9/19/18 and readmitted on [DATE], and again on 10/5/18 and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
6. Record review of Resident #48’s closed record showed:
– Resident was transferred to the hospital on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
7. During an interview via email on 11/15/18, the Administrator said they give the bed
hold policy on admission, not with each hospitalization .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop and implement a
baseline care plan (plan for immediate needs) within 48 hours of admission which included
the minimum healthcare information necessary to properly care for the immediate needs of
one residents (Resident #31) out of 14 sampled residents. The facility’s census was 52.
Record review of Resident #31’s Admission Minimum Data Set (MDS) (a federally mandated
assessment instrument required to be completed by facility staff), dated 9/29/18, showed
[DIAGNOSES REDACTED].
Record review of the resident’s Face Sheet showed a [DIAGNOSES REDACTED].
Record review of the Treatment Administration Record, showed Bi-level Positive Airway
Pressure ([MEDICAL CONDITION]) (a positive air pressure device which helps with breathing)
to be worn at bedtime with a start date of 9/18/18.
Record review of the resident’s Initial Care Plan, dated 9/18/18, showed [MEDICAL
CONDITION] not marked as an area of concern.
During an interview on 11/19/18 at 5:15 P.M., the MDS Coordinator said she would expect
the baseline care plan to include [MEDICAL CONDITION] and oxygen therapy if the nurse knew
about it on admission.
The facility did not provide a policy for Baseline Care Plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop and implement a care
plan with specific interventions for eleven residents (Resident #2, #11, #24, #26, #30,
#31, #32, #37, #43, #44, and #45) out of 14 sampled residents. The facility’s census was
52.
1. Record review of the facility’s policy titled Comprehensive Care Plans, dated 4/6/17,
showed:
– The Facility must develop a comprehensive care plan for each resident that includes
measurable objectives and timetables to meet a resident’s medical, nursing, and mental and
psychosocial needs that are identified in the comprehensive assessment;
– The care plan will be oriented toward:
– Preventing avoidable declines in functioning or functional levels;
– Managing risk factors;
– Addressing residents strengths;
– Using current standards of practice in the care setting;
– Evaluating treatment objectives and outcomes of care;
– Respecting the resident’s right to refuse treatment;
– Offering alternative treatments;
– Using an interdisciplinary team approach to care plan development to improve the
resident’s functional status;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to revise and
update comprehensive care plans with specific interventions to meet the individual needs
of one resident (Resident #44) out of 14 sampled residents. The facility’s census was 52.
Record review of Resident #44’s (MONTH) (YEAR) physician’s orders [REDACTED].
– Weekly weights;
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s Registered Dietician’s (RD) Nutrition Progress Notes
showed:
– On /17/18, noted weight loss in resident. Will put on weekly weights;
– On 9/2/18, noted six pound (lb) weight loss in resident over the past month. Med pass

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to follow physician’s orders for
four residents (Resident #17, #30, #31, and #44) out of 14 sampled residents. The
facility’s census was 52.
1. Record review of Resident #17’s (MONTH) (YEAR) Physician’s Order Sheet (POS), showed:
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].= 3 u; BS 201-250 = 6 u; 251-300 = 9 u; 301-350 = 12 u;
350-400 = 15 u; greater than 400 = call physician) as directed.
Observation on 11/14/18 at 12:30 P.M. showed the resident eating lunch.
Observation on 11/14/18 at 1:43 P.M., showed Certified Medication Technician (CMT) D
performed a finger stick blood sugar test, then administered 7 u of [MEDICATION NAME].
Record review of the Medication Administration Record [REDACTED]
– ProAir three doses missed on 11/14/18 and three doses on 11/15/18, one morning dose
missed on 11/16/18;
– Three doses of [MEDICATION NAME] missed on 11/14/18.
During an interview on 11/14/18 at 1:45 P.M., CMT D said:
– They have a one hour window of time to give medication, so he/she does not think it is a
problem to check a resident’s blood sugar after meals instead of before because they still
get their insulin on time;
– The resident’s inhaler is not available. He/she ordered it from the pharmacy on 11/13/18
but it has not arrived to the facility;
– He/she administered the last available dose of [MEDICATION NAME] during the morning

Based on observation, interview and record review, the facility failed to provide an
ongoing program of activities designed to meet the interests of each resident. This
practice affected six residents (Resident #11, #26, #30, #31, #42, and #43) out of 14
sampled residents and one resident (Resident #28) outside the sample and had potential to
affect all the residents in the facility. The facility’s census was 52.
1. Record review of the facility’s (MONTH) (YEAR) Activity Calendar showed:
– On 11/14/18, The Main Unit-at 8:45 A.M., Concerns; 9:30 A.M., Bingo; 10:30 A.M. Exercise
and Fitness; 3:00 P.M., Bible Study; 7:00 P.M. Greenville Baptist;
– On 11/14/18, The Behavioral Unit-8:45 A.M., Concerns; 9:30 P.M., Bingo; 11:00 A.M.,
Exercise and Fitness; 2:00 P.M., World Day of Diabetes Day Update; 7:00 P.M., Greenville
Baptist;
– On 11/16/18, The Main Unit-8:45 A.M., Concerns; 9:30 A.M., Bingo; 3:00 to 6:00 P.M.,
Setting Up For Dinner; 6:00 to 8:00 P.M., Thanksgiving Dinner;
– On 11/16/18, The Behavoral Unit-8:45 A.M., Concerns; 9:30 A.M., Bingo; 11:00 A.M.,
Stress Management and Lower Back Pain; 2:00 P.M., WOF Safety and Security; 3:00 to 6:00
P.M., Preparing For Dinner; 6:00 to 8:00 P.M., Thanksgiving Dinner;
– On 11/19/18, The Main Unit-8:45 A.M., Concerns; 9:30 A.M., Bingo; 11:00 A.M.,
Alzheimer’s Awareness; 2:00 P.M., Crafts; 3:00 P.M., Bean Quiz;
– On 11/19/18, The Behavioral Unit-8:45 A.M., Concerns; 11:00 A.M., Dressing For The Job;
2:00 P.M., Alzheimer’s Awareness; 3:00 P.M., Bean Quiz.
During an interview on 11/14/18 at 10:39 A.M., Resident #26 said they don’t do too much,
sometimes on Sundays they have church and they played bingo today. He/she would like to do
more.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure that a
resident received care to prevent and promote healing of pressure ulcers for one resident
(Resident #24) out of 14 sampled residents. The facility’s census was 52.
Record review of Resident #45’s significant change Minimum Data Set (MDS) (a federally
mandated comprehensive assessment tool completed by the facility staff), dated 8/26/18,
showed:
– At risk of pressure ulcer;
– Urinary catheter;
– Always incontinent of bowel;
– One Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow
open ulcer with a red pink wound bed).
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Observation on 11/16/18 12:10 P.M., showed a wound to coccyx approximately 2 to 3
centimeters (cm), round, open red area, without a dressing.
During an interview on 11/16/18 at 12:15 P.M., Licensed Practical Nurse (LPN) G said the
Treatment Administration Record (TAR) showed wound healed, no wound care. She said she
would fax an order to the physician to tell him it was not healed and to get orders.
Record review of the resident’s Nutrition Progress Note, dated 10/18/18, showed resident
has a decub to coccyx that is treated per nursing and healing. No dietary change to
recommend at this time.
Record review of the TAR, dated (MONTH) (YEAR), showed the wound to be healed on (MONTH)
28, (YEAR).
Record review of the resident’s nurse progress notes, dated 10/28/18 through 11/3/18,
showed no notes regarding the wound.
Record review of the resident’s Comprehensive Care Plan, updated 11/3/18, showed the care
plan not updated for healed or Stage II pressure ulcer.
Record review of the resident’s nurse progress notes, dated 11/7/18, 11/8/18, and
11/14/18, showed dressing dry and intact to coccyx. Note dated 11/7/18 showed complaints
of pain to coccyx.
Record review of the resident’s skin assessments, dated 10/23/18 through 11/13/18, showed
a wound to the coccyx 2 cm in length and 1 cm in width with granulation (pink tissue
beginning to heal), treated with [MEDICATION NAME] (a product used to manage wounds),
cover with island dressing (an absorbent pad).
Record review showed physician order [REDACTED].
During an interview on 11/19/18 at 10:25 A.M., LPN I said he/she marked the wound as
healed on 10/28/18 because it was no longer open, it was superficial so they began putting
[MEDICATION NAME] ointment on it. He/she did not notify the physician because they had the
order for [MEDICATION NAME] as needed. He/she said it was not opened the last time he/she
worked and looked at it, it doesn’t look any different than it did when he/she marked it
healed but he/she hasn’t worked for days. He/she has worked in (MONTH) and did not note
any change in the wound. The resident is supposed to be turned every 2 hours, but he/she
will not say that he is turned every 2 hours. The resident likes to be up most of the
time. There is a pressure relieving pillow on his/her wheelchair.
During observation on 11/19/18 at 4:04 P.M., the resident lay on his/her back in bed,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to discontinue an
indwelling urinary catheter (a tube inserted in the bladder to drain urine) as soon as
clinically warranted for one resident (Resident #2) out of 14 sampled residents. The
facility’s census was 52.
Record review of Resident #2’s (MONTH) (YEAR) physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– Catheter Care every shift starting on 10/26/18;
– an order written [REDACTED].
Record review of the resident’s nurse progress notes showed:
– Dated 10/31/18, showed an order for [REDACTED].>- Dated 11/5/18, showed physician
made rounds with new orders written;
– No notes documented after 11/5/18.
Observation on 11/14/18 at 10:30 A.M., showed the resident to have an urinary catheter
which drained to a bag.
During an interview on 11/16/18 at 9:25 A.M., the Director of Nursing (DON) said the
resident does have a catheter and she would find out why it had not been removed.
Observation on 11/19/18 at 4:37 P.M., showed the resident sat in a wheelchair in the
hallway without a catheter.
During interview on 11/19/18 at 4:38 P.M., Licensed Practical Nurse (LPN) I said he/she
removed the catheter on 11/14/18 and the resident is voiding without difficulty.
Record review of the facility’s Nurse Schedule showed LPN I was not scheduled to work on
11/14/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure the
pharmacy delivered one resident’s (Resident #17) ProAir Inhaler (a medication that relaxes
muscles in the airways and increases air flow to the lungs) and [MEDICATION NAME] (a
medication used to reduce blood ammonia levels) to the facility out of 14 sampled
residents. The facility’s census was 52.
Record review of Resident #17’s (MONTH) (YEAR) Physicians Order Sheet (POS), showed:
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s Medication Administration Record [REDACTED]
– Three ProAir doses missed on 11/14/18 and three doses on 11/15/18, one morning dose
missed on 11/16/18;
– Three doses of [MEDICATION NAME] missed on 11/14/18.
During an interview on 11/14/18 at 1:45 P.M., Certified Medication Technician (CMT) D
said:
– The resident’s inhaler is not available, he/she ordered it from the pharmacy on
11/13/18, but it has not arrived to the facility;
– He/she administered the last available dose of [MEDICATION NAME] during the morning
medication pass, there isn’t any available.
During an interview on 11/16/18 at 7:54 A.M., the Administrator said she would expect to
be notified if a resident is out of a medication so that there are no missed doses. The
[MEDICATION NAME] is in the facility now and she will notify the pharmacy today to get the
ProAir.
During an interview on 11/16/18 8:24 A.M., the Administrator said she talked with the
pharmacy and Resident #17’s insurance no longer covers ProAir but they will cover
[MEDICATION NAME] (a substitute medication for ProAir). The pharmacy claims they notified
the facility but the Administrator said they did not. The [MEDICATION NAME] will be in the
building today.
Record review of the facility’s policy titled Medication Administration and Monitoring,
dated 4/6/17, showed:
– Medications are to be given per doctors’ orders;
– The nurse or CMT should note if the medication is refused or not available;
– The Director of Nursing (DON) or Registered Nurse (RN) designee will be notified
immediately regarding the resident not receiving the medication;
– It will then become the DON or RN responsibility to ensure that the medication is
received and that the Licensed Practical Nurse (LPN) or CMT distributes the medication to
the resident;
– The back-up pharmacy or primary pharmacy will be notified and medication will be
received;
– The physician will be notified if medication is given late and the nurse’s notes will

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to maintain an
error rate of less than five percent (%) when medications were given. There were 27
opportunities with two errors made, for an error rate of 7.41%. This affected one resident
(Resident #17) and had the potential to affect all residents. The facility’s census was
52.
Record review of Resident #17’s (MONTH) (YEAR) physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s Medication Administration Record [REDACTED]
– Three ProAir doses missed on 11/14/18 and three doses on 11/15/18, one morning dose
missed on 11/16/18;
– Three doses of [MEDICATION NAME] missed on 11/14/18.
During an interview on 11/14/18 at 1:45 P.M., Certified Medication Technician (CMT) D
said:
– The resident’s inhaler is not available, he/she ordered it from the pharmacy on 11/13/18
but it has not arrived to the facility;
– He/she administered the last available dose of [MEDICATION NAME] during the morning
medication pass, there isn’t any available.
During an interview on 11/16/18 at 7:54 A.M., the Administrator said she would expect to
be notified if a resident is out of a medication so that there are no missed doses. The
[MEDICATION NAME] is in the facility now and she will notify the pharmacy today to get the
ProAir.
During an interview on 11/16/18 8:24 A.M., the Administrator said she talked with the
pharmacy and Resident #17’s insurance no longer covers ProAir but they will cover
[MEDICATION NAME] (a substitute medication for ProAir). The pharmacy claims they notified
the facility but the Administrator said they did not. The [MEDICATION NAME] will be in the
building today.
Record review of the facility’s policy titled Medication Administration and Monitoring,
dated 4/6/17, showed:
– Medications are to be given per doctors’ orders;
– The nurse or CMT should note if the medication is refused or not available;
– The Director of Nursing (DON) or Registered Nurse (RN) designee will be notified
immediately regarding the resident not receiving the medication;
– It will then become the DON or RN responsibility to ensure that the mediation is
received and that the Licensed Practical Nurse (LPN) or CMT distributes the medication to
the resident;
– The back-up pharmacy or primary pharmacy will be notified and medication will be
received;
– The physician will be notified if medication is given late and the nurses notes will

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that two
residents (Resident #17 and #30) out of 14 sampled residents were free from significant
medication errors. The facility’s census was 52.
1. Record review of Resident #17’s (MONTH) (YEAR) physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED]. Insulin works by lowering levels of glucose in the blood)
30 units (u) every morning;
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].= 3 units (u); BS 201-250 = 6 u; 251-300 = 9 u; 301-350 = 12
u; 350-400 = 15 u; greater than 400 = call physician).
Observation on 11/14/18 at 12:30 P.M. showed the resident eating lunch.
Observation on 11/14/18 at 1:43 P.M. showed Certified Medication Technician (CMT) D
performed a finger stick blood sugar test, result 112, and administered 7 u of [MEDICATION
NAME].
During an interview on 11/14/18 at 1:45 P.M., CMT D said:
– They have a one hour window of time to give medication so he/she does not think it is a
problem to check resident’s blood sugar after meals instead of before because they still
get their insulin on time.
2. Record review of Resident 30’s (MONTH) (YEAR) POS, showed:
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].= zero u; 131-240 = 4 u; 241-300 = 10 u; 301-350 = 12 u;
351-400 = 16 u; 401-450 = 25 u; 451-500 = 30 u.
Observation on 11/14/18 at 12:30 P.M. showed the resident eating lunch.
Observation on 11/14/18 at 1:48 P.M. showed CMT D performed a finger stick blood sugar
test, result 170, and administered 4 u of [MEDICATION NAME].
3. During an interview on 11/19/18 at 5:15 P.M., the Director of Nursing (DON) said she
would expect finger stick blood sugar to be checked prior to meals if that is how it is
ordered because it could affect the sliding scale insulin dose.
4. Record review of the facility’s policy titled Blood Glucose Monitoring, dated 4/6/17,
showed:
– The blood sugar monitoring/accucheck orders will be obtained from the physician,
including the recommended time and frequency of the monitoring;
– At the scheduled time, the Licensed Nurse/ Insulin Certified CMT will complete the blood

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain
adequate infection control practices to prevent the spread of infection for seven
residents (Resident #9, #17, #24, #30, #31, #43, and #44) out of 14 sampled residents and
five residents (Resident #1, #14, #16, #19 and #34) outside the sample. The facility’s
census was 52.
1. Observation on 11/14/18 between 12:52 P.M. and 1:34 P.M. during medication
administration showed Certified Medication Technician (CMT) D failed to sanitize his/her
hands before and after administering medications to Resident #1, Resident #9, Resident
#16, Resident #17, Resident #30, Resident #31, and Resident #34.
During an interview on 11/14/18 at 1:35 P.M., CMT D said he/she should have washed his/her
hands after giving medication and before giving medication to another resident.
2. Manufacturer’s cleaning recommendations for the glucometer showed:
– Professional Disposables International (PDI) wipes (hospital-grade disinfectant wipes)
and/or Clorox (bleach) wipes as approved cleaning agents;
– Glucometers need to be cleaned after each use;
– Keep the glucometer wet with the wipe for at least two minutes.
Observation on 11/14/18 at 1:40 P.M. showed CMT D performed a finger stick blood sugar
(fsbs) test for Resident #16:
– CMT D wore gloves;
– Picked up glucometer (a device use to monitor blood sugar);
– Used a lancet to obtain blood from the resident’s finger;
– Dropped blood onto the glucometer stick and obtained blood sugar results;
– Placed the soiled glucometer on medication cart;
– Sanitized hands and put gloves on;
– Went through insulin medication cart with gloved hands;
– With soiled gloves, prepared the syringe with insulin and administered the injection to
the resident;
– Did not clean the glucometer as per manufacturers instructions after each use.
Observation on 11/14/18 at 1:43 P.M., showed CMT D performed a fsbs test for Resident
#17:
– CMT D put on gloves and picked up soiled glucometer;
– Used a lancet to obtain blood from the resident’s finger;
– Dropped blood onto the glucometer stick and obtained blood sugar results;
– Placed the soiled glucometer on the medication cart;
– Removed gloves and re-gloved;
– Went through insulin medication cart with gloved hands;
– With soiled gloves, prepared the insulin syringe and administered injection to the
resident;
– Removed gloves and wiped the glucometer with an alcohol swab;
– Did not clean the glucometer as per manufacturers instructions after each use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to implement an antibiotic
stewardship program to include an infection surveillance program and antibiotic use
protocols. This deficient practice had the potential to affect all residents in the
facility. The facility’s census was 52.
Record review of the facility’s Infection Prevention and Control Program (IPCP) showed the
facility did not establish an Antibiotic Stewardship Program which includes antibiotic use
protocols and a system to monitor antibiotic use. The facility did not have the following:
– No infection surveillance program;
– No protocols to review clinical signs and symptoms and lab reports to determine if the
antibiotic is indicated or if adjustments to therapy should be made and to identify what
infection assessment tools or management algorithms are used for one or more infections;
– No process for periodic review of antibiotic use by prescribing practitioners;
– No protocols to optimize the treatment of [REDACTED].
– No system for the provision of feedback reports on antibiotic use, antibiotic resistance
patterns based on lab data, and prescribing practices for the prescribing practitioners
and for the Quality Assurance and Assessment (QAA) committee.
Record review of the facility’s Census and Conditions of Residents, dated 11/16/18, showed
seven residents currently receiving antibiotics.
During an interview on 11/19/18 at 2:00 P.M., the Administrator said the facility doesn’t
have an antibiotic stewardship program other than a policy for it.

Based on observation and interview, the facility failed to maintain all areas of the
facility in a safe, functional, sanitary, and comfortable environment for two residents
(Resident #30 and #31) out of 14 sampled residents and two additional residents (Resident
#4 and #20) outside of the sample. The facility’s census was 52.
1. Observation on 11/14/18 at 10:40 A.M., showed Resident #4’s room door had to be lifted
to open or close because it dragged on the floor.
Record review of the resident’s Quarterly Minimum Data Set (MDS) (a federally mandated
assessment instrument required to be completed by facility staff), dated 8/12/18, showed