Waddell Nursing And Rehab Center

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan (CCP) for 1of 24 residents, Resident #9.The findings included. The findings included.The facility staff failed to review and revise Resident #9's CCP when the resident elected to sign a Do Not Resuscitate (DNR) order. The CCP included the focus area of full code. Resident #9's diagnoses included gastro-esophageal reflux disease, anemia, dysphagia, and weakness. Section C (cognitive patterns) of Resident #9's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/17/25 included a brief interview for mental status (BIMS) score of 10 out of a possible 15 points. Per the MDS manual a 10=moderately impaired in cognitive skills for daily decision making. Resident #9's clinical record included the following orders. 1. Full code order dated 08/08/25 and a discontinued order date of 09/03/25.2. DNR order dated 09/03/25. Resident #9's current CCP included the problem area Advanced Directives/Code Status resident has chosen to be a full code. Interventions included if resident/responsible party chooses to change code status, necessary items will be completed, new order, update documentation/care plan, face sheet. The face sheet in the clinical record included the information DNR. On 10/01/2025 at 10:10 a.m., the surveyor notified the Social Worker that Resident #9's CCP included the problem area of full code when they had a DNR order in place. The facility staff provided the surveyor with a copy of a signed Durable Do Not Resuscitate Order from the Virginia Department of Health dated 09/13/25. During an end of the day meeting on 11/18/25 at 5:10 p.m., with the Administrator, Director of Nursing, Assistant Director of Nursing, and Regional Nurse the issue with Resident #9's CCP not being reviewed and revised to reflect their current DNR status was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference on 11/19/25.

Based on staff interview, clinical record review, and facility document review the facility staff failed to administer a medication per the providers orders for 1 of 24 residents Resident #59 and failed to follow a medical provider order for notification of elevated Blood Sugars for 1 of 24 residents, Resident #21. The findings included: 1. For Resident #59, the facility staff failed to ensure they had a prescription for the medication Gabapentin. Resulting in Resident #59 missing 7 doses of this medication. Gabapentin is a controlled medication and requires an updated prescription to be dispensed.
Resident #59's diagnoses included low back pain, muscle weakness, migraine, and dementia.
Section C (cognitive patterns) of Resident #59's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/06/25 was coded 1/1/3 to indicate Resident #59 had problems with long-and short-term memory and was severely impaired in cognitive skills for daily decision making.
Resident #59's comprehensive care plan (CCP) included the problem area of pain. Approaches included Medications as ordered.
Resident #59's clinical record included a provider order for Gabapentin 100 mg twice a day. Date of order 10/16/24.
The clinical record included a progress note documented on 10/20/25 that read in part. Resident out of prescription gabapentin 100mg. On-call provider.notified; however, unable to refill prescription at this time as the medication requires MD setup due to an alert in the system. On-call provider gave new order to hold HS [bedtime] dose of gabapentin tonight. Pharmacy notified; representative stated they will continue to search for a script but confirmed they did not receive a new script from today.
A review of Resident #59's electronic medication administration record (eMAR) revealed that the nursing staff had documented the following.
10/17/25 9:00 p.m. Not administered, unavailable, Pharmacy and MD notified awaiting script.
10/18/25 5:00 p.m. Not administered, waiting for script from MD.
10/18/25 9:00 p.m., Not administered drug/item unavailable waiting on script.
10/19/25 5:00 p.m., Not administered drug/item unavailable waiting on new script.
10/19/25 9:00 pm., Not administered drug/item unavailable waiting script MD aware.
10/20/25 5:00 p.m., Not administered drug/item unavailable. Provider to send script to pharmacy-delayed due to internet connection issues today.
10/20/25 9:00 p.m., Not administered: On hold.
A review of the Omnicell list (backup supply of medication) revealed this medication was available for administration.
On 11/18/25 at 5:10 p.m., during an end of the day meeting with the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Regional Nurse the issue with Resident #59 not receiving their medication per the providers orders was reviewed.
No further information regarding this issue was provided to the survey team prior to the exit conference.
2. For Resident #21, the facility staff failed to follow a medical provider orders for notification of blood sugar levels greater than 400 (four hundred).
Resident #21's diagnosis list indicated diagnoses, which included, but not limited to, Type 2 Diabetes Mellitus, Vascular Dementia, Atrial Fibrillation, and Atherosclerotic Heart Disease.
The most recent minimum data set (MDS) with an assessment reference date (ARD) of 10/16/25, coded the resident in Section C (Cognitive Patterns) as rarely/never understood with short and long-term memory problems and severe impairment in cognitive skills for daily decision making.
A review of a medical provider orders with a start date of 8/20/25 read in part, .insulin lispro.special instructions.blood sugar.Call provider if over 400. This order had a discontinued date of 9/7/25.
A review of a medical provider orders with a start date of 9/11/25 read in part, .insulin lispro.special instructions.Call MD (medical doctor) if <400 (greater than 400). This order had a discontinued date of 10/16/25.
This surveyor reviewed Resident #21's August 2025 and October 2025 MARs (medication administration records) and observed documentation of the resident's BS (blood sugar) being elevated over 400 on (2) two occasions. No evidence could be located in the clinical record that a medical provider was notified as indicated in the medical provider orders on the following dates:
8/29/25-BS 402
10/1/25-BS 532
A review of the comprehensive person-centered care plan disclosed a focus and intervention which read in part, .The resident has Diabetes Mellitus with CKD (chronic kidney disease).Assess/document/report to MD.for.hyperglycemia (high blood sugar-a condition where there is an abnormally high level of glucose in the bloodstream).
This surveyor requested evidence that the medical provider was notified of Resident #21's elevated blood sugars on 8/29/25 and 10/1/25.
On 11/18/25 at 11:00 AM, the director of nursing (DON) provided this surveyor with a copy of a page from a medical provider communication book which read in part, .8-29-25.(Resident #21).FBS (fasting blood sugar)-402 this AM (morning). The NP (nurse practitioner) had initialed the concern as acknowledged.
On 11/18/25 at 1:20 PM, the DON agreed her expectation would be for the nurse to call the provider as ordered at the time the blood sugar was taken.
This concern was discussed on 11/18/25 at 5:10 PM at the end of day meeting with the administrator, director of nursing, assistant director of nursing, and regional nurse consultant.
No further information regarding this concern was presented to the survey team prior to the exit conference on 11/19/25.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide necessary respiratory services in accordance with professional standards of practice for 1 of 4 closed record reviews, Resident #133. For Resident #133, the facility staff failed to ensure supplemental oxygen was available continuously via nasal cannula to the resident as ordered by a medical provider during transportation to a medical appointment on 12/20/23. Resident #133's diagnosis list indicated diagnoses that included, but were not limited to, COPD (chronic obstructive pulmonary disease), Chronic Respiratory Failure with Hypoxia, Anxiety, and Cerebral Infarction affecting Left Nondominant Side. The most recent complete quarterly minimum data set (MDS) with an assessment reference date (ARD) of 7/22/23, assigned the resident a brief interview for mental status (BIMS) summary score of 14 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of the clinical record disclosed the following documentation: A medical provider orders with a start date of 4/15/23 which read in part, .OXYGEN: O2 @ (at) 3 LPM (three liters per minute) via n/c (nasal cannula- a medical device that delivers supplemental oxygen through a lightweight tube with two prongs that are placed in the nostrils) every shift for COPD w/Chronic hypoxic resp (with/respiratory) failure. A progress note dated 12/20/2023 at 11:51(11:51 AM) read in part, .Note.Reason for Departure: Appointment.LOA (leave of absence) with outside transportation. A progress note dated 12/20/2023 at 18:30 (6:30 PM) read in part, .Note.Time of return: 12/20/2023 6:30 PM. A review of the comprehensive person-centered care plan disclosed a focus, goal, and intervention which read in part, .At risk for altered.resp (respiratory) status r/t (related to).copd, chronic resp. failure.Resident will have no preventable crisis thru {sic} next review.O2 as ordered.Date Initiated: 03/29/2023. On 11/17/25, the administrator provided this surveyor with (3) three witness statements regarding Resident #133's transportation to a medical appointment on 12/20/23. A review of the witness statements disclosed a statement from the interim administrator dated 12/27/23, which read in part, .was notified by our van transport scheduler.that the.transport company came to pick up (Resident #133) to take her to the Neurology clinic.I was told this was a longer than normal trip, so our Charge nurse offered for the driver to take an extra O2 tank. The driver called in to his supervisor of which stated for him not to. The charge nurse made sure the resident had a full tank upon leaving which should have been enough to get to the appointment and return. We received a call from an OBGYN (obstetrics and gynecology) clinic and found out the driver actually took the resident to the wrong location and dropped her off.We asked the OBGYN office if we could use one of their O2 tanks being the time was getting more critical. They were fine with it. The transport company was finally notified and they sent someone else to transport the resident to the right office and bring her back. We were later notified the new driver had to contact EMS (emergency medical services) before making it back to our facility due to the second tank running out of 02. A second witness statement dated 12/27/23 written by licensed practical nurse #3 (LPN#3) read in part, .Transportation arrived.for an appointment.in Roanoke, VA.Making sure resident had enough O2 for her departure and return trip to appt (appointment), her portable O2 tank was changed. This nurse asked if another tank could be sent with her in case she needed it, transportation aide stated it was only his 3rd day on the job and he didn't know how to change it, that he would call his supervisor to see if he could take it in the van, after talking with his supervisor, we were notified that the van had nowhere to store a O2 cylinder. Resident left with a full tank O2 cylinder to her appt. Notified by Neurology Clinic that resident was late for her appointment, that the transportation aide dropped her off a the OB dept. (department) and left.In route back to the facility, resident had been picked up by another transportation aide who had stated that resident ran out of O2 on her way back to facility, so she had to pull over on the side of the highway and call EMS for O2, stated that [name of clinic omitted] did not supply her with a full tank as they said they would do. A third witness statement dated 12/27/23 written by licensed practical nurse #4 (LPN#4)-unit manager, read in part, .Resident.was scheduled with transport to neurology, pick up set for 11:40 AM.driver arrived.driver noted that she (Resident #133) had O2 and was afraid she would run out & was uncomfortable taking her. The Charge Nurse.offered to send another E-cylinder with him, he stated that is was his 3rd day on the job and he didn't know how to change it out.called his supervisor who also said he could not take an extra tank. Staff got a new tank and hooked resident up at that time. Resident should have enough O2 for appointment and return to facility.Later in the day, the neurology office called & notified the facility.(Resident #133) had been taken to the wrong office (OB/GYN) and was so late arriving that she missed her appointment and was now running low on O2 and would not have enough to make the return trip. They also stated the driver had not left a call back # (number) for him to be reached.Staff contacted the office to try to secure a e-cylinder for.return trip.contacted her (Resident #133) insurance.to reach out to transport agency.I was on the phone for over 1 1/2 hours while they were trying to reach the driver to establish an ETA (estimated time of arrival). On 11/17/25 at 12:41 PM, this surveyor interviewed other staff #5 (OS#5) and she remembered that transport took Resident #133 to the wrong appointment and then took her to correct appointment. The family called the facility and informed them the resident had run out of oxygen. On 11/17/25 at 3:45 PM, this surveyor interviewed other staff #6 (OS#6) and she stated she set-up transport for the appointment and the resident was scheduled to go to the neurologist in Roanoke. She recalled neurology called the facility and informed them Resident #133 needed to be picked up from the appointment. OS#6 stated it took the transport driver a while to get there and the resident ran out of oxygen, so the driver called 911. OS#6 denied Resident #133 was accidentally taken to the ob-gyn office that day by mistake. OS#6 provided this surveyor with a copy of the appointment page depicting Resident #133's appointments. Resident #133's neurology appointment on 12/20/23 was scheduled for 1:45 PM. On 11/17/25 at 3:52 PM, this surveyor interviewed other staff #10 (OS#10) and she informed surveyor she took the call from neurology on 12/20/23 and stated neurology called to let the facility know Resident #133 was ready to be picked up. OS#10 denied Resident #133 was accidentally taken to the ob-gyn clinic by mistake on that day. On 11/17/25 at 3:56 PM, this surveyor interviewed LPN#4 and she informed surveyor Resident #133 was on oxygen and had a full tank when she left the facility for the appointment. The transport driver stated he was not allowed to take extra tanks of oxygen on the van. LPN#4 recalled neurology switched the tank to her understanding so the resident could get back to the facility. She recalled there was a delay in transport picking the resident up from neurology and the resident was later coming back. LPN#4 stated she was not working by the time the resident returned to the facility, but it had been discussed that the resident ran out of oxygen on the way back and the driver pulled over and called 911 and they (EMS) gave Resident #133 enough oxygen to get back to the facility. On 11/18/25 at 3:04 PM, this surveyor interviewed LPN#3 and she informed surveyor that she was Resident #133's nurse on 12/20/23. She stated she was going to send another oxygen cylinder with the resident and transport told her they could not take an extra oxygen tank on the van and the driver did not know how to change the oxygen tank. This surveyor inquired the process for ensuring there is an adequate supply of oxygen for appointments that are a greater distance away from the facility and LPN#3 stated she believes in times past that the oxygen tank should have lasted, but she believed the transport driver took Resident #133 to the wrong appointment first or was late getting her to the neurology appointment and that's why the resident ran out of oxygen. LPN#3 did not recall speaking with the ob-gyn office or the neurology office. On 11/18/25 at 3:17 PM, this surveyor and LPN#3 observed the oxygen cylinders at the facility. LPN#4 assisted LPN#3 and this surveyor and found information on the internet and the information stated a fully charged e-tank (tanks the facility utilizes) contains 680 (six-hundred eighty) liters of oxygen. The survey team reviewed an internet site at https://pipingtechs.com/oxygen-tank-size-chart-calculating-oxygen-tank-duration/ that calculated a fully charged e-tank at 680 liters divided by the flow rate of 3 liters per minute x 60 = 3.78 hours of supplemental oxygen. Resident #133 departed the facility at approximately 11:40 AM and the neurology appointment was scheduled at 1:45 PM at an approximate distance of 97.48 miles with an uninterrupted drive duration of one hour and thirty-nine minutes one-way. Total time for the appointment trip with an uninterrupted drive was calculated at two hours and eighty minutes, excluding the duration of time Resident #133 would have been at the appointment facility. This concern was discussed on 11/18/25 at 5:10 PM, at the end of day meeting with the administrator, director of nursing, assistant director of nursing, and regional director of clinical services. The director of nursing informed this surveyor her expectation would have been to send a CNA (certified nursing assistant) with Resident #133 to the appointment on 12/20/23. Surveyor requested and received a facility policy titled, Oxygen Administration (all routes) Policy with a revision date of 6/23/25 that read in part, .licensed clinicians with demonstrated competence will administer oxygen.as ordered by the provider. No further information regarding this concern was presented to the survey team prior to the exit conference on 11/19/25.

3. For Resident #58, the facility staff failed to follow physician's orders for the administration of Novolog (a rapid-acting insulin) on two separate occasions.
Resident #58's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus without Complications, Essential Primary Hypertension, Presence of Left Artificial Knee Joint, Aftercare following Joint Replacement Surgery, and Pain Unspecified.
The most recent significant change MDS (minimum data set) with an ARD (assessment reference date) of 6/07/21 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, Cognitive Patterns. In section I, Active Diagnoses, Resident #58 was coded for the diagnosis of Diabetes Mellitus.
Resident #58's active physician's orders included an order for Novolog FlexPen Solution Pen-Injector 100 UNIT/ML (Insulin Aspart) Inject 4 unit subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) **Hold for BG (blood glucose) less than 200**.
A review of Resident #58's June 2021 MAR (medication administration record) revealed the resident received Novolog 4 units on 6/15/21 at 5:41 am in the right arm with a documented blood sugar of 104. On 6/16/21 at 5:46 am, the resident received Novolog 4 units in the right lower abdominal quadrant with a documented blood sugar of 117.
On 6/24/21 at 4:00 pm during a meeting with the facility administrative team, surveyor discussed the concern of Resident #58 receiving Novolog on 6/15/21 and 6/16/21 with documented blood sugars below 200.
No further information regarding this issue was presented to the survey team prior to the exit conference on 6/24/21.
4. For Resident #2 the facility staff administered insulin outside the physician ordered parameters.
Resident #2's face sheet listed diagnoses which included, but not limited to type 2 diabetes mellitus, acute respiratory failure, dysphagia, end stage renal disease, and anxiety.
The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 06/17/21 assigned the resident a BIMS (brief interview for mental status) of 14 of 15 in section C, cognitive patterns. This indicated the resident is cognitively intact.
Resident #2's comprehensive care plan was reviewed and contained a care plan for Resident is at risk for hypo/hyperglycemia episodes R/T (related to): dx (diagnosis) IDDM (insulin dependent diabetes mellitus); hypoglycemia with recent ER visit. Interventions for this care plan included medication as ordered; hold as needed per ordered parameters.
Resident #2's clinical record was reviewed and contained a physician's order summary for the month of June 2021, which read in part Humalog Solution (Insulin Lispro). Inject 10 unit subcutaneously before meals for DM (diabetes mellitus). Hold if <180 (less than).
Resident #2's eMARs (electronic medication administration record) for the month of June was reviewed and contained an entry as above. The entry for 06/01/21 at 11:30 am recorded the resident's blood glucose level as 163 and was initialed as insulin given. The notes section of the eMAR indicated the resident had been administered insulin subcutaneously in the right lower abdomen.
The concern of administering insulin outside physician ordered parameters was discussed with the administrative team (administrator, director of nursing, regional nurse consultant, regional vice president of operations, assistant administrator) during a meeting on 06/24/2021 at approximately 4:00 pm
No further information was provided prior to exit.
Based on staff interview and clinical record review, the facility staff failed to ensure 5 of 26 residents were free of significant medication errors involving insulin. Residents #3, #92, #58, #2, and #20.
The findings included:
06/24/2021 the (DON) director of nursing provided the survey team with a copy of a policy titled, Facilities Receiving Pharmacy Products and Services from Pharmacy. This policy read in part, .Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following .Verify each time a medication is administered that it is the correct medication at the correct dose .
1. For Resident #3, the facility staff failed to follow the physician ordered parameters in regards to insulin administration. Resulting in resident #3 not receiving their insulin on 05/07/2021 for a (BS) blood sugar of 180 and receiving insulin on 05/25/2021 for a BS of 159.
Resident #3's facesheet in the (EHR) electronic health record included the diagnoses, diabetes, aphasia, hypertension, and major depressive disorder.
Section C (cognitive patterns) of Resident #3's annual (MDS) minimum data set assessment with an (ARD) assessment reference date of 06/15/2021 included a (BIMS) brief interview for mental status summary score of 8 out of a possible 15 points.
Resident #3's EHR included a physicians order for Novolog insulin inject 12 unit subcutaneously before meals for diabetes. Hold if BS less than 180. The order date was documented as 11/02/2020.
A review of Resident #3's (EMARs) electronic medication administration records revealed the following
05/07/2021 the nursing staff documented a 16. Per the preprinted code on the EMAR a 16=Hold/See Nurses Note. This nurse documented Resident #3's BS as 180 and documented in the medication administration note that the insulin was held. Per the physicians order the insulin should have been administered.
05/25/2021 the nursing staff documented a BS of 159 and that the insulin was administered in the right lower quadrant of Resident #3's abdomen. Per the physicians order the insulin should have been held.
06/23/2021 4:05 p.m., the administrator, DON, regional nurse, regional vice president of operations and assistant administrator/ADON (assistant director of nursing) were made aware of the issue regarding Resident #3's insulin. This issue was again reviewed on 06/24/2021 at 4:00 p.m. with these same staff.
No further information regarding this issue was provided to the survey team prior to the exit conference.
2. For Resident #92, the facility staff failed to follow the physician ordered parameters in regards to insulin administration. Resulting in resident #92 not receiving their insulin on 06/13/2021 for a (BS) blood sugar of 210.
Resident #92's facesheet in the (EHR) electronic health record included the diagnoses diabetes and cognitive communication deficit.
Section C (cognitive patterns) of the residents quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 06/03/2021 included a (BIMS) brief interview for mental status summary score of 9 out of a possible 15 points.
Resident #92's EHR included a physicians order dated 05/21/2021 for Novolog insulin inject 10 units subcutaneously two times a day for diabetes. Hold for (BG) blood glucose less 180. Give before lunch and supper.
A review of Resident #92's (EMARs) electronic medication administration records revealed that the nursing staff documented a 3 on 06/13/2021 at 5:00 p.m. Per the preprinted code on this form a 3=No insulin required. The blood sugar was documented as 210. Indicating the resident should have received insulin per the physician ordered parameters.
06/23/2021 4:05 p.m., the administrator, DON, regional nurse, regional vice president of operations and assistant administrator/ADON (assistant director of nursing) was made aware of the issue regarding Resident #92's insulin. This issue was again reviewed on 06/24/2021 at 4:00 p.m. with these same staff.
No further information regarding this issue was provided to the survey team prior to the exit conference.
5. For Resident #20 the facility failed to hold the resident's Novolog (insulin) according to the provider's written order.
The resident's electronic clinical record was reviewed and the facesheet listed diagnoses to include but not limited to: Type 2 diabetes mellitus with hyperglycemia, schizoaffective disorder, malignant neoplasm of larynx, and chronic obstructive pulmonary disease. Resident #20's MDS (minimum data set) with an ARD (assessment reference date) of 04/04/2021 noted in Section C (cognitive patterns) the resident had a BIMS (brief interview for mental status) score of 11 out of 15.
One of the resident's medication orders, with a 04/03/2021 start date, read NovoLOG FlexPen Solution Pen-Injector 100 UNIT/ML (Insulin Aspart) Inject 6 unit [sic] subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) Hold for BG [blood glucose] less than 180. Resident #20's MAR (medication administration record) was reviewed and for the month of June 2021, there were three (3) times facility staff documented the medication was administered when the resident's blood glucose was noted less than 180; on 06/01/2021 at 4:30 p.m. the resident's blood glucose was 177, on 06/03/2021 at 4:30 p.m., the resident's blood glucose was 178, and on 06/06/2021 at 6:30 a.m. the resident's blood glucose was 138.
On 06/24/21 at 11:30 a.m. the director of nursing (DON) was interviewed about the facility's staff documenting they administered insulin to Resident #20 when the resident's blood glucose was less than the ordered parameter of 180. The DON acknowledged Resident #20's June 2021 MAR contained evidence the resident received insulin with blood glucose levels less than 180. The DON reported becoming aware of this concern while recently completing an insulin audit and reported discussing the concern with the medical director.
The DON, administrator, assistant administrator, regional director of clinical services, and regional vice president of operations were informed of the medication findings described above on 06/24/2021 at 4:00 p.m.
No further information was provided prior to the exit conference.

Based on observation, staff interview, and facility document review, the facility staff failed to keep a controlled medication in a separately locked, permanently affixed compartment on 1 of 3 units, Unit 2.
The findings included:
The facility staff failed to secure the medication, Gabapentin (a schedule V controlled substance under Virginia state law used to treat seizures and nerve pain) in a separately locked, permanently affixed compartment in the medication cart.
On 6/24/21 at 11:40 am, the surveyor accompanied by LPN (licensed practical nurse) #2, observed two separate bubble pack cards of Gabapentin in an open area of the medication cart drawer beside the separately locked, permanently affixed, metal compartment containing controlled medications. One bubble pack card was labeled Gabapentin 300 mg and contained 13 capsules and had the Controlled Substance Sheet folded around the card, the sheet indicated there were 13 capsules remaining. The second bubble pack card was labeled Gabapentin 300 mg and contained 21 capsules and also had a Controlled Substance Sheet folded around the card, the sheet indicated there were 21 capsules remaining. LPN #2 stated the resident went home yesterday and the unit manager comes around and picks up the medications.
At 11:55 am, LPN #2 stated I just pulled them this morning to prevent an error. The director of nursing was also present and stated they have called the pharmacy to bring a new cart with a single locking door with two compartments for the narcotics drawer.
Surveyor requested and received the facility policy entitled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles which states in part:
Procedure
3. General Storage Procedures:
3.1 Facility should store Schedule II - V Controlled Substances, in a separate compartment within the locked medication carts and should have a different key or access device, i.e.
3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II - V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access
On 6/24/21 at 4:00 pm during a meeting with the facility administrative team, surveyor discussed the concern of the facility staff not properly storing the medication Gabapentin in the Unit 2 medication cart.
No further information regarding this issue was presented to the survey team prior to the exit conference on 6/24/21.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow established infection control procedures during wound care observations for 2 of 26 residents. Residents #74 and #58.
The findings included:
06/24/2021 the (DON) director of nursing provided the survey team with a copy of a policy titled, Hand Hygiene/Handwashing Policy date of revision 01/31/2020. This policy read in part, Hand washing is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing .Perform hand hygiene .Before and after having direct contact with residents .After removing gloves .After contact with body fluids or excretions, mucous membranes, non-intact skin and/or wound dressings .If moving from a contaminated body site to a clean body site during resident care .
1. For Resident #74, the facility staff failed to complete hand hygiene during a wound care observation. Resident #74 had three stage IV pressure ulcers and an excoriated area to their sacrum.
Resident #74's facesheet in the (EHR) electronic health record included the diagnoses, adult failure to thrive, (MS) multiple sclerosis, nutritional deficiency, and major depressive disorder.
Section C (cognitive patterns) of Resident #74's quarterly (MDS) minimum data set assessment with an (ARD) assessment reference date of 05/23/2021 included a (BIMS) brief interview for mental status summary score of 6 out of a possible 15 points. Section G (functional status) was coded (4/3) for bed mobility, transfers, locomotion of unit, dressing, and toilet use to indicate the resident required total assistance of two people for these tasks. Section M (skin conditions) was coded to indicate the resident was at risk for pressure ulcers and had three stage IV pressure ulcers.
Resident #74's (CCP) comprehensive care plan included the focus areas at risk for infection related to history of recurrent infections pneumonia, urinary tract infections, sepsis, and wound. Total assistance for all activities of daily living, quadriplegia. Risk for skin breakdown related to decreased mobility, function and weakness diagnosis MS, skin is fragile, resistive to care such as turning and repositioning, pressure relief positioning and devices actual skin breakdown to right hip right buttocks, left hip, and sacrum.
Resident #74's EHR included physician orders for contact isolation, dakins solution to left hip, right hip and right buttock topically every shift for wound care.
06/23/21 2:00 p.m., wound care observation with (LPN) licensed practical nurse #3 and the (IP) infection preventionist. These staff were observed to wear a protective mask, gown, and gloves due to Resident #74's contact isolation status. LPN #3 was observed to remove the old dressings from the excoriated area and two stage IV pressure ulcers. LPN #3 changed their gloves and then cleaned these three areas with (DWC) dermal wound cleanser, applied skin prep to the sacral area X2 and a protective dressing, opened kerlix, changed gloves, poured the dakins solution onto the kerlix, applied the dakins soaked kerlix to two stage IV pressure ulcers, applied a protective dressing to the left hip wound, and then changed their gloves. LPN #3 was unable to cover wound #2 with a protective dressing due to the residents position. LPN #3 and the IP repositioned Resident #74 to their left side, removed the dakins gauze from wound #2, placed new dakins soaked kerlix into the wound bed, and applied a protective dressing. LPN #3 changed their gloves, cleaned wound #3 with DWC, applied dakins soaked kerlix to the wound bed, and then applied a protective dressing.
06/24/21 10:09 a.m., interview with IP. This nurse stated LPN #3 washed their hands before starting the treatments and after completion of the treatments but did not complete any hand hygiene during wound care. The IP stated LPN #3 should have washed her hands during wound care and they had discussed it after the observation.
06/24/21 4:00 p.m., the administrator, DON, nurse consultant, assistant administrator, and regional vice president of operations were made aware that LPN #3 did not complete hand hygiene during a treatment observation of three stage IV wounds.
No other information regarding this issue was provided to the survey team prior to the exit conference.
2. For Resident #58, the facility staff failed to perform hand hygiene while performing treatments to multiple pressure areas.
Resident #58's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus without Complications, Essential Primary Hypertension, Presence of Left Artificial Knee Joint, Aftercare following Joint Replacement Surgery, and Pain Unspecified.
The most recent significant change MDS (minimum data set) with an ARD (assessment reference date) of 6/07/21 assigned the resident a BIMS (brief interview for mental status) score of 13 out of 15 in section C, Cognitive Patterns. In section M, Skin Conditions, Resident #58 was coded for the presence of two (2) unstageable pressure ulcers with slough and/or eschar and five (5) unstageable pressure areas presenting as deep tissue injury.
Resident #58's active physician's orders included the following current orders for the treatment of pressure ulcers:
1. Apply sure prep to right heel and right 5th metatarsal and cover with bordered gauze every day shift
2. Apply sure prep to left heel, left lateral malleolus, and left mid foot, cover with bordered gauze every day
shift
3. Cleanse wound to left lower extremity lateral aspect with normal saline, apply santyl to wound bed, cover
with bordered gauze every day shift
4. Cleanse wound to right buttock with wound cleanser, apply santyl and calcium AG to wound bed and cover
with bordered gauze, change every day and as needed
On 6/23/21 at 4:58 pm, surveyor entered Resident #58's room to observe wound treatments. LPN (licensed practical nurse) #1 had already prepared the over bed table with dressings, treatment solutions had been poured into clear medication cups and ointment was also placed in a clear medication cup. Surveyor was unable to verify the solutions in each medication cup.
LPN #1, with the assistance of RN (registered nurse) #1 turned the resident on their left side and discovered the resident had recently had a bowel movement. With gloved hands, LPN #1 cleaned the bowel movement from the resident's skin and placed a new pad under the resident and immediately proceeded to treatment the pressure area to the right buttock and apply the clean dressing without removing gloves and performing hand hygiene. LPN #1 removed gloves but did not wash hands or use hand sanitizer and obtained two clean gloves and carried them out of the resident's room. LPN #1 returned to the room with two gloves and a wash cloth in their hands. LPN #1 donned the gloves and cleaned the pressure areas to the resident's right lateral foot, left heel, left mid foot, and applied the treatment to the left mid foot and left lateral malleolus without performing hand hygiene or changing gloves. There was a knock at the resident's door and LPN #1 touched the door handle and opened the door with the same gloved hands. With the same gloved hands, LPN #1 returned to the resident and applied a dressing to right heel. LPN #1 then removed gloves and left the room without performing hand hygiene. LPN #1 returned to the room and donned clean gloves and cleaned the area to the resident's left lower extremity and applied the treatment. With the same gloved hands, LPN #1 pulled an ink pen from their hair and dated a clean dressing and applied it to the left lower extremity. With the same gloved hands, LPN #1 applied a dressing to the right lateral foot.
On 6/24/21 at 10:12 am, surveyor discussed treatment observations with the infection control nurse who stated the nurse should have done hand hygiene and changed gloves during the treatments.
On 6/24/21 at 10:25 am, surveyor spoke with LPN #1 and asked about their hand hygiene during the treatment observation. LPN #1 immediately replied I didn't do it like I was supposed to. LPN #1 further stated that they should have washed their hands and changed gloves after cleaning the resident's bowel movement and between each wound, LPN #1 stated they did use hand sanitizer between one.
On 6/24/21 at 4:00 pm during a meeting with the facility management staff, surveyor discussed the concerns of the lack of hand hygiene identified during the observation of treatment administrations performed by LPN #1.
No further information regarding this issue was presented to the survey team prior to the exit conference on 6/24/21.