Pines Retirement Center of Baton Rouge

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility failed to ensure:1. The can opener was free of a dried, black substance and metal shavings;2. Ceiling vents in the kitchen were properly cleaned and free of black and brown substances; 3. Ceiling tiles above the steam table were secured and free of a gray fluffy substance;4. The Steamer drip pan was not overflowing a white, liquid substance onto the table and floor; and5. Milk was held at a safe temperature for consumption of 41 degrees Fahrenheit or below prior to being served to residents. This deficient practice had the potential to affect the 57 residents who were served food from the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure:1. Nursing staff followed physician's orders and obtained a resident's heart rate prior to medication administration for 1 (#33) of 3 (#19, #33, and #53) residents reviewed for medication administration; 2. Nursing staff followed manufacturer instructions for use of an inhaler to prevent side effects of the medication for 1 (#53) of 3 (#19, #33, and #53) residents reviewed for medication administration; and 3. Nursing staff primed insulin pen needles prior to administering insulin for 1 of 1 (#19) residents reviewed for insulin administration.

Inspectors wroteBased on observations and interviews, the facility failed to ensure garbage and waste were properly contained in the outdoor trash dumpsters.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide services with reasonable accommodation of needs by failing to ensure a resident's call light was within reach for 1 (#5) of 16 residents reviewed in the final sample. Review of the facility's undated policy titled, Call Light, Answering, revealed the following, in part:Purpose: The purpose of this procedure is to respond to the resident's requests and needs. Key Procedural Points:5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Steps in the Procedure:9. Position the call light within easy reach of the resident. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents with an identified mental health diagnosis were referred for a Pre-admission Screening and Resident Review (PASARR) Level II evaluation as required for 1 of 1 (#4) resident reviewed for PASARR.Review of Resident #4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus. Further review revealed an additional medical diagnosis of Schizoaffective Disorder, Bipolar Type with an onset date of 10/01/2020. Review of Resident #4's PASARR Level I dated 05/06/2013 revealed no mental health diagnoses were selected. Further review revealed no review for a Level II evaluation and determination had been submitted for Resident #4 following his diagnosis of Schizoaffective Disorder, Bipolar Type. An interview was conducted on 09/09/2025 at 11:45 a.m. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop a Comprehensive Person-Centered Care Plan for 1 of 1 (#53) residents reviewed for activities of daily living (ADL). Review of Resident #53's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Displaced Intertrochanteric Fracture of Left Femur. Review of Resident #53's current Care Plan revealed the following:Focus: The resident has an ADL self-care performance deficit related to activity intolerance. Interventions: Bed Mobility: The resident requires (specify what assistance) by (X) staff to turn and reposition in bed (specify frequency) and as necessary. Dressing: The resident requires (specify what assistance) by (X) staff to dress. Eating: The resident is able to: (specify). Personal hygiene/oral care: The resident is able to: (specify). Transfer: [...]

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding by failing to ensure tube feeding formula, tubing, and free water bags were changed in appropriate timeframe for 1 (#8) of 3 (#6, #8, and #43) residents reviewed for tube feedings. Review of the facility's undated policy titled, Enteral Feedings-Safety Precautions revealed in part, the following:2. The facility will follow accepted best practices in enteral nutrition.5. Hang times:c. Closed-system enteral formulas have a hang time of 24-48 hours, per manufacturer's instructions. Review of the Clinical Record for Resident #8 revealed she was admitted to the facility on [DATE] with diagnoses, which included Dysphagia Following Cerebral Infarction. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure medication carts were free of loose pills for 1 of 1 (Cart A) medication carts reviewed.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents' Medication Administration Records (MAR) were accurately documented for 1 (#8) of 3 (#6, #8, and #43) residents reviewed for tube feedings. Review of the facility's undated policy titled, Documentation revealed in part, the following:12. Personnel will be expected to document timely, accurately, and completely. Review of the Clinical Record for Resident #8 revealed she was admitted to the facility on [DATE] with diagnoses, which included Dysphagia Following Cerebral Infarction. Further review revealed a diagnosis of Gastrostomy Status on [DATE]. Review of the current Physician Orders for Resident #8 revealed in part, the following:Change gastrostomy feeding bag every 24 hours. Review of the [DATE] MAR for Resident #8 revealed in part, the following:Change peg feeding bag every 24 hours. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure posted nurse staffing data included the total number and the actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice had the potential to affect any of the 60 residents residing in the facility.

Inspectors wroteBased on record reviews, observation, and interviews, the facility failed to ensure services provided by the facility met professional standard of quality by failing to ensure nursing staff did not borrow medications from one resident to administer to another resident for 1 (#R2) of 7 (#1, #2, #3, #4, #R1, #R2 and #R3) residents reviewed for pharmaceutical services. Review of the facility's undated policy titled, Medications - Administering revealed the following, in part:Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation:7. The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.19. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure it was free of significant medication errors for 1 (#R2) of 2 (#R1 and #R2) residents reviewed for medications. The deficient practice had the potential to affect the 56 residents residing in the facility who received medications. Review of the facility's undated policy titled, Medications - Administering revealed the following, in part:Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation:7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#R4) of 8 (#1, #2, #3, #4, #R1, #R2, #R3, and #R4) residents observed for infection control practices. The facility failed to ensure:1. Staff used proper personal protective equipment when emptying Resident #R4's urinal; and2. Staff transported linens in a manner to prevent spread of infection. Review of the facility's policy, dated January 2025, titled, Infection Prevention and Control Program revealed the following, in part:Policy: [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure a resident's comprehensive plan of care was developed and implemented for 2 (#1 and #3) of 3 (#1, #2 and #3) residents reviewed for care plans. The facility failed to ensure: 1. Resident #1's care plan was revised for the use of a geri chair; 2. Resident #3's care plan was implemented for neurological assessments after two unwitnessed falls; and 3. Resident #3's care plan was revised for a fall on 12/07/2024.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all alleged violations of abuse were reported to the state survey agency. The facility failed to: 1. Ensure allegations of verbal and physical abuse were reported to the State Survey Agency, immediately but not later than 2 hours after the allegation was made for 5 (#35, #42, #46, #51, and #52) of 19 sampled residents reviewed for abuse; and 2. Report the results of the investigations within 5 working days with appropriate corrective actions implemented for 5 (#35, #42, #46, #51, and #52) of 19 sampled residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 09/04/2024 when multiple staff witnessed S4CNA and S5CNA curse, yell, and point in Resident #52's face. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure it was administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to have an effective system in place to: 1. Ensure residents remained free from verbal and mental abuse for 3 (#42, #46, and #52) of 7 (#18, #26, #42, #46, #51, #52, and #111) residents reviewed for abuse; and 2. Ensure allegations of verbal and physical abuse were reported to the State Survey Agency, immediately but not later than 2 hours after the allegation was made for 5 (#35, #42, #46, #51, and #52) of 19 sampled residents reviewed for abuse; and 3. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident remained free from verbal and mental abuse for 3 (#42, #46, and #52) of 7 (#18, #26, #42, #46, #51, #52, and #111) residents reviewed for abuse. The facility failed to prevent: 1. S4CNA and S5CNA from yelling, cursing, and pointing at Resident #52 while surrounding the wheelchair and preventing the resident from getting away; and 2. S6CNA from yelling and cursing at Resident #52 in the hall; and 3. S13LPN from intimidating and threatening Resident #42; and 4. S6CNA from following and verbally threatened Resident #46 in her room. This deficient practice resulted in an Immediate Jeopardy situation for Resident #52 on 09/04/2024, when multiple staff witnessed S4CNA and S5CNA curse, yell, and point in Resident #52's face. Resident #52 reported he no longer felt safe in the facility. [...]

Inspectors wroteBased on record reviews and interview, the facility failed to notify the physician when a resident had aggressive behaviors toward staff and other residents for 1(#52) of 6 (#18, #26, #42, #51, #52, and #111) residents reviewed for behaviors.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the resident's care plan was reviewed and revised for 2 (#5 and #52) of 19 sampled residents reviewed for care plans. The facility failed to ensure: 1. Resident #5's transfer status was documented on his care plan; and 2. Resident #52's care plan was reviewed and revised for behaviors.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (#28) of 19 residents reviewed in the final sample. The facility failed to ensure Resident #28 received her required HIV medication.

Inspectors wroteBased on interviews and record review the facility failed to ensure direct care staff had appropriate competencies and skills to assure resident safety and maintain the highest practicable physical, mental, and psychological well-being of each resident. The facility failed to ensure all direct care staff had competency training in crisis prevention interventions (CPI) for a resident (Resident #52) who displayed aggressive threatening behaviors. The deficient practice had the potential to effect all 59 residents that resided in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff. This deficient practice had the potential to affect the 56 residents who consumed food from the kitchen.

Inspectors wroteBased on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 56 residents who consumed food from the kitchen.

Inspectors wroteBased on interviews and record reviews, the facility failed to promote and facilitate residents' self-determination through support of the residents' choice about aspects of his or her life in the facility which were significant to the resident for 3 (#42, #48, and #52) of 24 residents reviewed in the initial pool. The facility failed to ensure residents had rights as evidenced by: 1. Staff did not allow Resident #42 to visit Resident #48; 2. Staff did not allow Resident #48 out of his room; and 3. Staff did not wear gloves at Resident #52's request.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's assessment accurately reflected the Discharge Status for 1 (#62) of 24 residents reviewed in the final sample.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents remained free of accidents by failing to ensure residents were transferred with proper transfer assistance and devices for 1 (#5) of 19 sampled residents reviewed for accidents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to ensure resident safety, as determined by resident assessments and individual plans of care. The facility failed to ensure: 1. All nursing staff were competent to implement a resident's assessed transfer needs for 1 (#5) of 19 sampled residents reviewed for transfer status. This deficient practice had the potential to affect 14 residents residing in the facility who required mechanical lift transfers.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure S8LPN disinfected the glucometer between resident use for 1 (#1) of 3 (#1, #26, and #55) residents observed during blood glucose monitoring.

Inspectors wroteBased on interviews and observations, the facility failed to ensure that residents had a clean and safe environment for 1 (#7) of 7 (#1,#3,#7, #8,#9,#10, and #11) residents reviewed for environment. The facility failed to ensure the following: 1. Resident #7's blanket and floor mattress were clean and free of debris. 2. Hall A and Hall C were clean and free of debris. Findings On 08/28/2024, review of the facility's undated policy titled Homelike Environment, revealed, in part: In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment. 3. The facility will maintain a clean environment. 1. On 08/26/2024 at 11:50 a.m., an observation was made of Resident #7 in his room. Multiple areas of dried tube feeding were observed on a soiled, uncovered mattress on the floor beside Resident #7's bed. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed implement a resident's comprehensive person-centered care plan by failing to implement Physician's Orders for 2 (#6 and #10) of 12 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) residents reviewed for comprehensive care plans. The facility failed to ensure the following: 1. MRI orders were implement per Physician's Orders for Resident #6, and 2. Oxygen orders were implemented per Physician's Orders for Resident #10.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure services provided by the facility met professional standards of quality by failing to ensure nursing staff did not borrow medications from one resident to administer to another resident for 1 (#R4) of 7 (#5, #6, #7, #R1, #R2, #R3, and #R4) residents reviewed for pharmaceutical services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each for 2 (#6 and #R4) of 7 (#5, #6, #7, #R1, #R2, #R3, and #R4) residents reviewed for pharmaceutical services. The facility failed to ensure Resident #6 and #R4's prescribed medications were available for administration.

Inspectors wroteBased on a record review, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) for 1(#8) of 2 (#7 and #8) residents who were on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pest and insects. The deficient practice had the potential to affect 67 residents who resided in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's physician was notified after a change in physical and mental status occurred for 1 (#2) of 4 (#1, #2, #11, and #12) residents reviewed for notification of change.

Inspectors wroteBased on interview and record review, the facility failed to document the reason for transfer in the resident's Medical Record for 1 (#2) of 3 (#1, #2, and #10) residents reviewed with hospital transfers.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (#7) of 2 (#7, and #8) residents reviewed for enteral feedings. The facility failed to ensure: 1. Enteral feeding solution bags were changed every 24 hours; and 2. Opened enteral feeding solution was labeled with the date and time.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented for 1 (#8) of 12 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) sampled residents reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#1) of 2 (#1 and #2) residents reviewed for medical appointments. The facility failed to ensure Resident #1 attended their follow up outpatient wound clinic appointment as scheduled.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comfortable environment. The facility failed to ensure: 1. Room A was clean and free of debris. This had the potential to affect any of the 60 residents residing in the facility who used Room A, and; 2. The ceiling tiles were clean and free of stains for 1 (Room B) of 20 rooms observed on Hall A.

Inspectors wroteBased on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect all residents who were served from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 (#5) of 8 (#1, #2, #3, #4, #5, #6, #7, and #8) residents reviewed for abuse. The facility failed to ensure Resident #5 was free from physical abuse by Resident #4.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure new interventions were implemented following an allegation of physical abuse for 1 (#5) of 3 (#1, #4, and #5) sampled residents reviewed for abuse.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure new interventions were implemented following a resident's fall to prevent future falls for 1(#8) of 3 (#1, #7, and #8) sampled residents reviewed for falls.

Inspectors wroteBased on observation and interview, the facility failed to post the required nurse staffing information on a daily basis.

Inspectors wroteBased on interviews and record review, the facility failed to acquire and ensure medications were available for administration as ordered by the physician for 1 (#6) of 3 (#1, #6, and #7) sampled residents reviewed for discharges.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's fall was documented in the nurse's notes for 1 (#7) of 3 (#1, #6, and #7) sampled residents reviewed for discharges.

Inspectors wroteBased on observations and interviews, the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior by failing to ensure: 1. trash was not overflowing from the facility's dining room trash can; 2. supper meal trays were not left in the facility's dining room or in Room g overnight; 3. the kitchen floor and baseboards were free of any food or debris; 4. the kitchen entry door frame was free of any brown, flaky substances; 5. the baseboard and sheetrock were not separated from the frame of the kitchen door; 6. the black rubber baseboard measuring 4 inches in length was not missing from Room a's bedroom wall next to the in-room bathroom door; 7. the bedroom wall of Room b was free of a baseball-sized brownish yellow stain above the lower third of Resident #12's bed; 8. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure allegations of verbal abuse were reported to the facility administrator immediately, but not later than 2 hours after abuse occurred and/or an allegation was made for 1 (#9) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) residents reviewed for abuse. The facility failed to ensure the following: 1. S13CNA and S4CNA reported an allegation S12CNA verbally abused Resident #9; and 2. S3CNA reported an allegation S4CNA verbally abused Resident #9

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide both facility-sponsored group and individual activities for 3 (#1, #2, and #R1) of 17 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #R1, #R2, #R3 and #R4) sampled residents. The total facility census was 50.

Inspectors wroteBased on interviews, the facility failed to ensure the activities program was directed by a qualified professional. This deficient practice had the potential to affect a census of 50 residents.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 (#7 and #13) of 3 (#7, #12, and #13) residents reviewed for tube feedings. The facility failed to ensure: 1. Enteral feeding solution bags were changed every 24 hours; 2. Enteral feeding solution and free water were infusing at ordered rate.

Inspectors wroteBased on an observation and interview, the facility failed to ensure nurse staffing data, including facility name, current date, resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 50 residents residing in the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to: 1. Ensure a qualified activities professional was hired to direct the facility's Activity Program; and 2. Ensure facility policies and procedures were implemented for an effective Activities Program. This deficient practice had the potential to affect a census of 50 residents. Cross Reference F679, F680.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure low air loss mattresses were functioning correctly for 3 of 3 (#9, #11, and #R2) residents reviewed with air mattresses.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective pest control program to ensure the facility was free of insects. This deficient practice had the potential to affect any of the 50 residents residing in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect the resident's right to be free from verbal abuse by S4CNA for 1 (#9) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) residents reviewed for abuse.

Inspectors wroteBased on record reviews and interviews, the facility failed to implement and monitor appropriate plans of action to correct identified quality deficiencies. The facility failed to ensure staff were monitored for providing and documenting ADL care for 2 (#4 and #5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for ADLs. This failed practice had the potential to effect all 53 residents who currently resided in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comfortable environment. The facility failed to ensure: 1. The bathroom floor tiles and grout between the tiles were free of discoloration and a gray/black substance in Room a; and 2. The shower room, Room b was clean and free of debris. This had the potential to affect any of the 39 residents residing in the facility who used Room b.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident who was unable to carry out activities of daily living without assistance received the necessary services to maintain good grooming and personal hygiene for 2 (#4 and #5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for ADLs.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received mail on Saturdays for 3 (#12, #18, and #26) of 5 (#9, #12, #18, #20, and #26) residents reviewed for mail during resident council. This deficient practice had the potential to affect 49 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure services were provided to meet quality professional standards for 7 (#7, #12, #21, #38, #39, #43, and #46) of 13 (#7, #12, #20, #21, #23, #26, #34, #38, #39, #43 #46, #154, and #155) residents reviewed for medication administration.

Inspectors wroteBased on policy review, observations and interviews, the facility failed to ensure nurse staffing data, including facility name, current date, resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 49 residents residing in the facility.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to provide pharmaceutical services, including procedures that assure the dispensing and administering of all drugs and biologicals, to meet the needs of each resident. The facility failed to ensure: 1. Insulin pen needles were primed prior to administration of insulin for 3 (#26, #34, and #155) of 3 (#26, #34, and #155) residents observed for insulin administration; 2. Physician Orders were verified prior to medication administration for 1 (#23) of 7 (#7, #20, #23, #26, #34, #154, and #155) residents observed during medication pass; and 3. A system was in place for nursing staff to accurately document the amount of insulin administered to each resident for 4 (#13, #26, #39, and #46) of 5 (#13, #26, #31, #39, and #46) residents reviewed for insulin administration. [...]

Inspectors wroteBased on policy review, observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 (Cart B) of 2 (Cart A and Cart B) medication carts observed. The facility failed to ensure: 1. Inhalers, Insulin pens and Insulin vials were labeled with the date opened; 2. Insulin pens were labeled with the resident's name; and 3. Injectable Glucagon was not past the manufacturer's expiration date.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practice for 4 (#13, #26, #39,#46) of 14 sampled residents reviewed for documentation of insulin doses. The facility failed to complete, and accurately document, the insulin dosage administered to residents per the medication administration record.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure an infection prevention and control program was maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure nursing staff sanitized insulin pen stoppers prior to attaching an insulin pen needle for 3 of 3 (#26, #34, and #155) residents reviewed for insulin administration.