Autumn Care Of Chesapeake

Based on observation, Resident and staff interviews, and facility documentation review, the facility staff failed to maintain a Resident call system for Residents to call for staff assistance, on three of four nursing units.
The findings included:
On three of four nursing units, the facility staff failed to ensure that there was a Resident call system in the bathrooms and showers to allow Residents to call for staff assistance, if needed.
On 12/5/23, during an initial tour of the facility it was noted that on three of the Resident care units, there was not a functional call bell system. The Residents were noted to have hand bells and/or tap bells at the bedside. There was no device noted in the Resident bathrooms, many of which also contained showers.
During Resident interviews conducted 12/5/23-12/6/23, Resident #54 reported that the toileted and showered in his room's bathroom independently without any supervision or assistance from staff. When asked how he would call for assistance if he needed help, Resident #54 said, I have no way to call other than yell, the system has been broken for months because of lightening.
Resident #77 reported that she toileted without staff assistance. When asked, if she needed help how she would notify the facility staff? The Resident said, I try to leave the door cracked so if I call out, they can hear me.
On 12/6/23 at 10:20 AM, an interview was conducted with LPN #6. LPN #6 confirmed that Resident #54 is very independent and does toilet and shower without any staff assistance. LPN #6 also confirmed that Resident #77 can toilet herself without staff assistance.
On 9/28/23, an inspection was conducted at this facility and at that time the facility reported their call bell system would be functioning withing 8 weeks. During that inspection, the facility provided a document from the VSC Fire & Security Company dated 09/28/23. The read in part: After hours of troubleshooting, we have discovered in multiple places the existing wiring is burned and multiple location with inoperative stations. It is recommended to replace the entire system with a new nurse call system. After contacting (name of company) there is enough materials to get started and can support with on time delivers as this system replacement progresses. The plan is to replace all the existing system including wire and will work on and complete one (1) 20 room/unit pod at a time. The intention is to complete each unit/pod within a two (2) week period or within 8 weeks for the entire facility.
On the afternoon of 12/7/23, an interview was conducted with the facility Administrator. The Administrator reported that the facility had a lightning strike in July 2023, that had disabled their call bell system for the entire facility. They had contracted with an outside company who was in the process of having to re-wire and install a new system. They had completed the installation of the call bell system on one unit, and it was noted to be operational. The administrator reported that due to the facility having a COVID outbreak the contractors didn't work for two weeks in November, which delayed the installation as well as the fact that they prioritized the fire monitoring system before the call bell system.
Review of the facility policy titled, Resident Communication System and Call Light Policy was conducted. The policy read, It is the policy of the facility to provide residents with a means of communicating with staff. A call system is installed in each resident room and toilet/bath areas .
During the interview with the facility Administrator on 12/7/23, the above concerns were shared that the Residents on three nursing units did not have any means to call for assistance in the bathroom and shower if needed. The Administrator confirmed these observations. The administrator shared that each shift the nurses check to ensure that a call bell is in place at the bedside and every hour a staff member is to walk to hallway to identify if any hand bells and/or tap bells are heard. The Administrator further confirmed that this walk through doesn't include physically entering a Resident's room.
On the morning of 12/8/23, the facility Administrator stated that in response to the concerns shared the day prior, they had procured enough tap bells and hand bells to place one in every bathroom as well.
No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to maintain a safe environment, free of accident hazards on one of four Resident care units.
The findings included:
On the one hundred nursing unit, the facility failed to secure medications and chemicals to maintain a safe environment, free of accident hazards.
1a. On [DATE] at approximately 12:00 PM, observations were conducted of the 100 unit. Multiple Residents were noted to have over the counter medications at the bedside. They included:
a. Resident #42 had hair growth pills/supplement at bedside.
b. Resident #54 had Nutririte-800 multivitamins on the bedside table.
c. Resident #77 had refresh lubricating eye drops at the bedside and hemorrhoid cream in the bathroom.
d. Resident #51 had a tube of hydrocolloid cream and a bottle of [NAME] anti-itch cream on the bedside table. The [NAME] lotion had a prescription label, which indicated it belonged to Resident #394. Per the clinical record and an interview with CNA #1, Resident #394 had expired on [DATE].
e. Resident #78 had refresh eye drops with a prescription label and a container of roll-on bio freeze at the bedside. On [DATE], at approximately 1 PM, an additional observation was made of Resident #78's room. The bio freeze was still noted to be at the bedside.
On [DATE] at 02:14 PM, an interview was conducted with LPN #5. LPN #5 stated that all medications must be kept locked in the medication cart or medication room. When asked if medications can be kept in the Resident rooms, LPN #5 said, They should not keep meds in room, but it is based on their BIMS (brief interview for mental status) score. They must score over a certain thing, to even be considered. Being a nursing home though we don't keep medications in the rooms. We have had people where families are non-complaint and go against what we ask, so if we find something we take it and notify the DON (Director of Nursing) and unit manager.
Following the above interview with LPN #5, LPN #5 accompanied the surveyors to Resident #78 and #77's room. LPN #5 confirmed the observations and removed the eye drops and hemorrhoid cream from Resident #77's room. LPN #5 also removed the eye drops from Resident #78's room but left the bio freeze. LPN #5 went on to say that they have difficulty with Resident #78 and her family with bringing items in. The surveyor explained that the items were easily identified upon observation and did not require that the Resident's personal items be inspected to locate the items. LPN #5 agreed that the items were easily identified and should have been removed by facility staff.
The facility provided an undated document titled, Medication Storage. Excerpts from this document read, Proper medication storage is a standard of practice . Medication Carts: . Medication carts and cabinets should be locked when unattended .
1b. On [DATE] at approximately 12:30 PM, the following was observed on the 100 unit.
Resident #85 had a bottle of Lysol spray at her bedside. In Resident #17's bathroom, which was in her room, there was a spray bottle of cleaning chemical that was green in color. The bottle had no label.
On [DATE] at 02:10 PM, an interview was conducted with Other Employee #2, who was a housekeeper. The housekeeper explained that all chemicals are to be kept in the locked portion of the housekeeping cart. Other Employee #2, then proceeded to show the two surveyors that the cart lock was broken so she was not able to lock it. When asked why chemicals must be locked, the employee said, because patients can get to them, and it can be dangerous.
On [DATE] at 3:40 PM, an interview was conducted with the Maintenance/Housekeeping Director (Other Employee #3). The unlabeled bottle with the cleaning chemicals was noted to be in his office. When asked if it is ok to leave chemicals in the Resident's room, he said, 100 percent no. When asked if the bottle was to have a label, he said, Yes that is an OSHA issue, that's not normal for us.
On [DATE] at 02:54 PM, an interview was conducted with CNA #2. CNA #2 confirmed that on the 100 unit they have 3 Residents who wander and self-propel in their wheelchairs. When asked if they go into other Resident rooms, CNA #2 said yes.
A review was conducted of the facility policy titled, Hazard Communication Program Policy. Excerpts from the policy read, .making sure that hazardous chemicals and substances have an HMIS type label on it before it is used in the workplace. Applying a HIMS label (if necessary) to containers . The Employee is responsible for: . following safe work methods and safety rules .
On [DATE], in the late afternoon, the facility Administrator was made aware of the above findings.
No further information was provided.

Based on review of the Payroll Based Journal (PBJ) Staffing Data Report, review of the actual working schedules for nurse staff, and staff interviews, the facility staff failed to ensure they had a Registered Nurse (RN) providing services at least eight consecutive hours within each twenty-four hour period, 7 days a week.
The findings included:
The Fiscal Year Quarter 4 2023 (July 1 - September 30) PBJ Staffing Data Report triggered for four or more days within the quarter with no RN hours. A review of eleven months of actual nurse staffing from January 2023 through November 2023 revealed the facility was without an RN on duty eight consecutive hours on 2/12/23, 2/18/23 2/19/23, 3/4/23, 3/11/23, 3/19/23, 4/29/23, 7/9/23, 7/22/23, 7/23/23, 9/3/23, 9/9/23, 9/16/23, 9/30/23, 10/1/23, 10/14/23, 10/15/23, 11/23/23.
On 12/7/23 at approximately 4:45 PM an interview was conducted with Licensed Practical Nurse (LPN) #11. LPN #11 stated a great deal of effort is expended to obtain RN coverage for the weekends and holidays but it is very challenging and occasionally they are not successful in meeting the requirement to have an RN on duty for eight consecutive hours every twenty-four hours. LPN #11 also stated many times the RN is scheduled, but calls out therefore the facility is without the supervision of the RN. The review also identified that many days in which RN coverage was not available it was because an RN had not been scheduled to work for eight consecutive hours within each twenty-four hour period
Since a lack of RN coverage was identified for four or more days in quarters two and four, and already for quarter one which will end 1/1/2024, random days without RN coverage were reviewed for the potential for more than minimal harm due to the facility's RN staffing failure. The review failured to identify specific services could not be provided when an RN was not available for eight consecutive hours within each twenty-four hour period.
On 8/21/23 at approximately 3:20 p.m., a final interview was conducted with the Administrator, Director of Nursing and two Corporate Consultants. The DON acknowledged the noncompliance but offered no additional information regarding a strategy to become compliant with RN staffing and the facility's team voiced no concerns regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a medication pass observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure medications were available for administration to three (3) of 55 residents in the survey sample (Resident #69, #26, #85) and during a medication pass on one of four units (100 unit).
The findings include:
1. Resident #69's medication Janumet was not available for administration resulting in five missed doses of the medication.
Resident #69 (R69) was admitted to the facility with diagnoses that included diabetes, cerebral infarction, dysarthria, hypertension, protein-calorie malnutrition and dysphagia. The minimum data set (MDS) dated [DATE] assessed R69 as cognitively intact.
Resident #69's clinical record documented a physician's order dated [DATE] for the medication Janumet 50-1000 mg (milligrams) one tablet by mouth two times per day for type 2 diabetes. A physician's order was documented on [DATE] for Janumet 50-1000 mg two times per day via gastric tube for management of type 2 diabetes.
Resident #69's medication administration record (MAR) documented the 9:00 a.m. dose of Janumet was not administered on [DATE] and the 9:00 a.m. and 5:00 p.m. doses were not administered on [DATE]. The [DATE] MAR documented the Janumet was not administered on [DATE] at 9:00 p.m. and on [DATE] at 9:00 a.m.
A nursing note dated [DATE] documented R69's Janumet was not administered because the drug was not available from the pharmacy. A nurse practitioner's note dated [DATE] documented, .missed Janumet .Per nurse, Janumet not given for 2 days . A nursing note dated [DATE] documented regarding the Janumet, .hold per MD [physician] awaiting pharmacy to deliver . and a note on [DATE] documented, .On hold per MD until received from pharmacy .
On [DATE] at 9:37 a.m., the licensed practical nurse (LPN #1) caring for R69 was interviewed about the missed doses of Janumet. LPN #1 stated she sometimes experienced problems with timely deliveries from the pharmacy. LPN #1 stated she usually ordered refills on medicines when there were five or less doses on the supply card. LPN #1 stated she had reordered medications before and three days later, the medications had not been delivered. LPN #1 stated she was not sure why the Janumet was not available on [DATE], [DATE], [DATE] or [DATE].
On [DATE] at 10:30 a.m., the unit manager (LPN #2) was interviewed about R69's unavailable Janumet. LPN #2 stated the pharmacy usually sent a 14-day supply of the Janumet and at times the pharmacy requested additional information about this prescription because it was expensive. LPN #2 stated the Janumet was most recently reordered on [DATE] so she was not sure why it was not available on [DATE].
On [DATE] at 1:54 p.m., the unit manager (LPN #2) was interviewed again about R69's unavailable Janumet. LPN #2 stated the Janumet was not stocked in the back-up supply, so it had to be delivered from the pharmacy. LPN #2 stated nurses were expected to order medication refills several days in advance of running out.
On [DATE] at 3:04 p.m., the director of nursing (DON) was interviewed about R69's unavailable Janumet. The DON stated regarding the pharmacy deliveries, We have problems at times. The DON stated the Janumet was not part of the back-up inventory. The DON stated nurses entered refill orders from the computer and were expected to reorder medicines at least two days in advance of running out to allow time for delivery.
On [DATE] at 5:55 p.m., the facility's consultant pharmacist (other staff #1) was interviewed about R69's unavailable Janumet doses. The pharmacist stated R69's insurance did not like the medicine. The pharmacist stated sometimes a 14-day supply was provided and other times a 7-day supply was sent to the facility. The pharmacist stated Janumet had not been setup in the back-up inventory, and he was not sure if an alternate medication had been considered since there had been problems with keeping the Janumet in stock at the facility.
The facility's policy titled Medication Storage (undated) documented staff should ensure, .Medication is available for all active resident orders . The facility's training protocol titled Medication Storage and Labeling Critical Element Pathway (CMS for 20089) documented, .Medications should be always available to be administered as ordered by following these steps: -Prompt re-ordering -Prompt receiving of medications - Prompt notification to provider or pharmacy if issue with medication order .
This finding was reviewed with the administrator and director of nursing during a meeting on [DATE] at 9:35 a.m. with no further information provided regarding the unavailable medication.
2. For Resident #26, the facility staff failed to ensure that medications were available for administration.
On [DATE] at 8:16 AM, LPN #6 was observed to prepare and administer medications to Resident #26. LPN #6 administered 4 medications, Coenzyme Q10 Capsule 100 MG, Coreg Tablet 12.5 MG (Carvedilol), Peridex Mouth/Throat Solution 0.12 % (Chlorhexidine Gluconate (Mouth-Throat), and boost (a nutritional supplement).
Following the administration a record review was conducted to reconcile the administration. It was noted that LPN #6 had documented that Lasix Oral Tablet 20 MG (Furosemide) and MiraLAX Packet 17 GM (Polyethylene Glycol 3350) were administered when neither were.
On [DATE] at 9:04 AM, an interview was conducted with Resident #26. Resident #26 reported that at about 5 AM, she was given a few medications.
On [DATE] at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked about the medications documented as having been given during the 8:16 AM, medication administration that was observed by two surveyors. LPN #6 confirmed that Lasix and MiraLAX had not been given because they were not available. When asked why they were documented as having been given, LPN #6 said, she was nervous.
Another review of the clinical record revealed that LPN #6 had not documented that the medications were not available for administration, nor had it been indicated that the physician was made aware of the medications not being available.
Review of the STAT box (emergency medication supply) contents listing revealed the Lasix was available in the STAT box and could have been retrieved to provide to the Resident.
3. For Resident #85, the facility staff failed to ensure that two medications were available for administration as ordered by the physician.
On [DATE] at 8:22 AM, LPN #6 was observed during the preparation and administration of medications to Resident #85. It was noted that Resident #85 was given 9 medications. There were 2 medications, a liquid iron supplement and Peridex Mouth/Throat Solution that were not given. The iron supplement that was in the medication cart had expired [DATE], and therefore was not able to be administered and the Peridex mouth solution was not available.
LPN #6 then continued her medication administration and moved on to the next resident to administer medications. She made no efforts to take measures to obtain the medications or notify the provider that the medications were not available for administration.
On [DATE] at approximately 9 AM, a clinical record review was conducted of Resident #85's chart. This review revealed no indication that the physician had been notified of the medication not being available nor the pharmacy being contacted to obtain/order the needed medications.
On [DATE] at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked to explain the process if a medication is not available. LPN #6 said, if a medication is not available, she would check the emergency supply box (STAT box) and see if the medication was available to be obtained/retrieved there and if not would call the pharmacy and doctor. When asked if this process had been followed for Resident #85, she indicated it had not been done.
The facility administration was asked to provide a copy of their facility policy regarding medication administration. The facility submitted an undated document titled, Preparing for Medication Administration. Excerpts from this document read, . Medications Administered: Initial appropriate book of the MAR immediately after administration of the medication. Medication Availability: If a medication is not administered because the medication is not available, make every effort to locate the medication. If the medication cannot be located, check the interim or emergency kit for the medication so that medication pass can be completed. Document unavailable medications appropriately per facility protocol. Contact the pharmacy and arrange for delivery of the medication.
On [DATE], in the later afternoon, the facility administration was made aware of the above observations.
On [DATE], the facility Administrator provided the survey team with evidence that LPN #6 had received disciplinary action on [DATE] and was suspended pending an investigation. Additionally, the facility administration had provided education to LPN #6 regarding medication administration following them being made aware of the above findings.
No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the medication error rate was less than 5%. There were 4 medication errors in 26 opportunities, affecting two (2) Residents (Resident #26 and #85), resulting in a 15.38% medication error rate.
The findings included:
On [DATE] at 8:16 AM, LPN #6 was observed to prepare and administer medications to Resident #26 & at 8:22 AM, administered medications to Resident #85.
During the medication administration observation, LPN #6 prepared the medications and provided Resident #26 with 4 medications, Coenzyme Q10 Capsule 100 MG, Coreg Tablet 12.5 MG (Carvedilol), Peridex Mouth/Throat Solution 0.12 % (Chlorhexidine Gluconate (Mouth-Throat), and boost (a nutritional supplement).
Following the administration a record review was conducted to reconcile the administration. It was noted that LPN #6 had documented that Lasix Oral Tablet 20 MG (Furosemide), and MiraLAX Packet 17 GM (Polyethylene Glycol 3350) were administered when neither were given.
On [DATE] at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked about the medications documented as having been given during the 8:16 AM, medication administration that was observed by two surveyors. LPN #6 confirmed that Lasix and MiraLAX had not been given because they were not available. When asked why they were documented as having been given, LPN #6 said, she was nervous.
Another review of the clinical record revealed that LPN #6 had not documented that the medications were not administered, nor had it been indicated that the physician was made aware of the medications not being available.
Review of the STAT box (emergency medication supply) contents listing revealed the Lasix was available in the STAT box and could have been retrieved to provide to the Resident.
On [DATE] at 8:22 AM, LPN #6 was observed during the preparation and administration of medications to Resident #85. It was noted that Resident #85 was given 9 medications. There were 2 medications, a liquid iron supplement and Peridex Mouth/Throat Solution that were not given. The iron supplement that was in the medication cart had expired [DATE], and therefore was not administered and the Peridex mouth solution was not available in the medication cart.
LPN #6 then continued her medication administration and moved on to the next resident to administer medications. LPN #6 took no measures to obtain the medications by checking the emergency medication supply or calling the pharmacy and did not notify the provider that the medications were not available for administration to see if the provider had another alternative order to provide.
On [DATE] at approximately 9 AM, a clinical record review was conducted of Resident #85's chart. This review revealed no indication that the physician had been notified of the medication not being available and not being administered nor the pharmacy being contacted to obtain/order the needed medications.
On [DATE] at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked to explain the process if a medication is not available. LPN #6 said, if a medication is not available, she would check the emergency supply box (STAT box) and see if the medication was available to be obtained/retrieved there and if not would call the pharmacy and doctor. When asked if this process had been followed for Resident #85, she indicated it had not been done.
The facility administration was asked to provide a copy of their facility policy regarding medication administration. The facility submitted an undated document titled, Preparing for Medication Administration. Excerpts from this document read, . Medications Administered: Initial appropriate book of the MAR immediately after administration of the medication. Medication Availability: If a medication is not administered because the medication is not available, make every effort to locate the medication. If the medication cannot be located, check the interim or emergency kit for the medication so that medication pass can be completed. Document unavailable medications appropriately per facility protocol. Contact the pharmacy and arrange for delivery of the medication.
On [DATE], in the later afternoon, the facility administration was made aware of the above observations.
On [DATE], the facility Administrator provided the survey team with evidence that LPN #6 had received disciplinary action on [DATE] and was suspended pending an investigation. Additionally, the facility administration had provided education to LPN #6 regarding medication administration following them being made aware of the above findings.
No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility documentation review the facility staff failed to ensure medications were stored in a secured location, accessible to designated staff for 7 of 55 residents: Resident #7, Resident #85, Resident #42, Resident #54, Resident #77, Resident #51 and Resident #78 in the survey sample.
The findings included:
1. The facility staff failed to ensure Hydrocortisone cream 1 percent (%) was stored in a secured location, accessible to designated staff only. Resident #7 was admitted to the facility on [DATE]. Diagnosis for Resident #7 included but not limited to major depressive disorder.
Resident #7's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 09/14/23, under cognitive status was not coded on the Brief Interview for Mental Status (BIMS) but was coded as independent for decisions being consistent and reasonable.
During the initial tour of the facility on 12/05/23 at approximately 1:59 p.m., observed on Resident #7's overbed table was an open tube of hydrocortisone cream 1%. The resident stated applied the cream to a rash located to her upper arms, upper back, and under her breast. She stated the cream dries up the rash and stops her skin from itching. She stated the hydrocortisone cream had been in her room for a while.
A review of Resident #7's December 2023, Medication Administration Record (MAR) revealed the following order: Hydrocortisone External Cream 1 %, apply to chest, and arms topically every 4 hours as needed for itching starting on 11/14/23.
An interview was conducted with the Unit Manager on 12/08/23 at 10:07 a.m. She stated she removed the hydrocortisone cream out of Resident #7's room. She stated the cream at beside was a house stock cream and should have been locked in the treatment care and applied by the nurse.
An interview was conducted with the Director of Nursing (DON) on 12/08/23 at 11:15 a.m., who stated Resident #7 had a self-administration assessment completed this morning and did not pass. She stated Resident #7 has a diagnosis of depression and with a diagnosis of depression who cannot self-administer your own medication. She stated Resident #7's hydrocortisone cream should have been stored in the medication cart and applied by the nurse.
A final meeting was held with the Administrator, Director of Nursing, and Regional Director of Clinical Services on 12/08/23 at 1:30 p.m., who were informed of the above findings. No further information was provided prior to exit.
The facility provided a document titled Medication Storage.
-Proper medication storage is a standard of practice.
Definitions:
-Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works (https://medlineplus.gov/ency/article/000945.htm).
-Hydrocortisone cream is used to treat redness, swelling, itching, and discomfort of various skin conditions. It works by activating natural substances in the skin to reduce swelling, redness, and itching (https://medlineplus.gov/ency/article/000945.htm)
2. On the 100 unit, the facility staff failed to ensure expired medications were removed from the medication cart and not available for administration.
On 12/6/23 at 8:22 AM, observations were made with LPN #6, during medication administration. LPN #6 was preparing medications for Resident #85. When LPN #6 retrieved the liquid iron from the medication cart, she poured the dose into a disposable medicine cup and then checked the bottle. She noted that the iron expired November 2023. Upon identification of this, LPN #6 discarded the poured medication and placed the bottle in the bottom drawer of the medication cart.
During the above observation, LPN #6 was interviewed. LPN #6 stated that expired medications are to be removed from the medication cart and discarded to ensure they are not given to Residents.
Resident #85's orders and medication administration record were reviewed. This review revealed that Resident #85 had an order dated 11/4/23, that read, Ferrous Sulfate Oral Solution (Ferrous Sulfate) Give 5 ml by mouth one time a day for Supplement. The medication administration record revealed that the medication had been signed off as being given/administered the 5 days prior. When LPN #6 was asked if the expired medication was given, she stated she didn't know but had no other supply to administer at this time.
The facility administration was made aware of the above observation. The facility policy for medication storage was requested.
The facility provided an undated document titled, Medication Storage. Excerpts from this document read, Proper medication storage is a standard of practice . Medication Carts: . Discontinued and/or expired medications should be removed from medication carts .
No further information was provided.
3. On the 100 unit of the facility, the facility staff failed to ensure medications were stored in a locked compartment and only authorized personnel had access.
On 12/5/23 at approximately 12:00 PM, observations were conducted of the 100 unit. Multiple Residents were noted to have over the counter medications at the bedside. They included:
a. Resident #42 had hair growth pills/supplement at bedside.
b. Resident #54 had Nutririte-800 multivitamins on the bedside table. The Resident said he takes 2 once a day, and reports he got them from dialysis and has been taking them about a year.
c. Resident #77 had refresh lubricating eye drops at the bedside and hemorrhoid cream in the bathroom.
d. Resident #51 had a tube of hydrocolloid cream and a bottle of [NAME] anti-itch cream on the bedside table. The [NAME] lotion had a prescription label, which indicated it belonged to Resident #394. Per the clinical record and an interview with CNA #1, Resident #394 had expired on 11/10/23.
e. Resident #78 had refresh eye drops with a prescription label and a container of roll-on bio freeze at the bedside. On 12/6/23, at approximately 1 PM, an additional observation was made of Resident #78's room. The bio freeze was still noted to be at the bedside.
On 12/05/23 at 02:14 PM, an interview was conducted with LPN #5. LPN #5 stated that all medications must be kept locked in the medication cart or medication room. When asked if medications can be kept in the Resident rooms, LPN #5 said, They should not keep meds in room, but it is based on their BIMS (brief interview for mental status) score. They have to score over a certain thing, to even be considered. Being a nursing home though we don't keep medications in the rooms. We have had people where families are non-complaint and go against what we ask, so if we find something we take it and notify the DON (Director of Nursing) and unit manager.
Following the above interview with LPN #5, LPN #5 accompanied the surveyors to Resident #78 and #77's room. LPN #5 confirmed the observations and removed the eye drops and hemorrhoid cream from Resident #77's room. LPN #5 also removed the eye drops from Resident #78's room but left the bio freeze. LPN #5 went on to say that they have difficulty with Resident #78 and her family with bringing items in. The surveyor explained that the items were easily identified upon observation and did not require that the Resident's personal items be inspected to locate the items. LPN #5 agreed that the items were easily identified and should have been removed by facility staff.
A review was conducted of the facility policy titled, Self-Administration of Medication. Excerpts from the policy read, . 6. When a resident is unable to self-administer medications, the medication will be held by the nurses until the resident can be reassessed by the Interdisciplinary Team. 7 . Medication(s) kept at the bedside must be kept in a locked drawer.
The facility provided an undated document titled, Medication Storage. Excerpts from this document read, Proper medication storage is a standard of practice . Medication Carts: . Medication carts and cabinets should be locked when unattended .
On 12/6/23, in the late afternoon, the facility Administrator was made aware of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interviews and clinical record review, the facility staff failed to ensure transportation arrangements were made for 1 resident's dental appointment in a survey sample of 55 residents (Resident #1).
The findings included:
Resident #1 was originally admitted to the facility on [DATE]. The current diagnoses included cerebral palsy.
The quarterly revised Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/07/23 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In sectionGG(Physical functioning) the resident was coded as being dependent on staff for eating, oral hygiene, toileting, shower and bathing.
The person centered care plan created on 8/03/21 read Resident #1 has a potential oral health problem. The goal set for the resident was they will have proper nutrition and hydration and will be free of pain or bleeding in the oral cavity. (revised on 12/23/22). Some of the interventions/approaches the staff would use to accomplish this goal was to assess oral cavity for pain, sensitivity, presence of lesions, ulcers, inflammation, bleeding, swelling or rashes, assist/provide mouth care as needed and referral to dental services (8/03/21).
On 12/06/23 at approximately 11:00 a.m., during the initial tour Resident #1 was observed lying in bed in a supine position, appeared restless at times and making sounds. A specialty wheel chair was observed near the resident's bed.
On 12/06/23 at approximately 12:32 p.m., a phone call was made to Family Member (FM) #1 concerning Resident #1. FM #1 said that Resident #1, has a lot of dental cavities. FM #1 said that he has mentioned this to the social worker (SW) and nurse at care plan meetings. The family member also said that he was concerned that the resident's teeth could be bothering her, but because she is non-verbal, pain may not be communicated to the facility staff.
On 12/08/23 at approximately 12:50 p.m. an interview was conducted with Other Staff Member (OSM) #6. OSM #6 was asked by the surveyor if resident could receive a Medicaid Advantage Plus (MAP) adjustment to receive dental services. She said that Resident #1 didn't qualify for a MAP adjustment. She was then ask if resident could be transported via wheelchair transport. She said that she would check with the staff.
An interview was conducted with the Director of Nursing (DON) and with Registered Nurse (RN), (Regional Clinical Nurse/RCN) #1 on 12/08/23 at approximately 2:10 p.m., concerning Resident #1 receiving transport services to the dental office. The DON said that the dental service could not accommodate the resident via stretcher in their office.
The following nurses' notes were received from RN #1 on 12/07/23 at 3:40 p.m., A call made to Doctor of Dental Surgery (DDS) at 2:45 p.m., Message left was regarding if they take [Name of Medicaid service]. A call was placed at 3:20 p.m., to Dental Services office to ask if they accepted the above insurance. Received a returned call from the Dental Services office at 3:25 p.m. They do accept Medicaid and their VA Beach office can accommodate patient's specialty wheelchair in their office. Appointment scheduled for 1/05/24 at 2:00 p.m.
On 12/08/23 at approximately 3:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to reassess Resident #7 for self-application of medication Hydrocortisone external cream 1 percent (%). Resident #7 was admitted to the facility on [DATE]. Diagnosis for Resident #7 included but not limited to major depressive disorder.
Resident #7's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of [DATE], under cognitive status was not coded on the Brief Interview for Mental Status (BIMS) but was coded as independent for decisions being consistent and reasonable.
The care plan with a created on [DATE] and a revision date of [DATE] identified Resident #7 on antidepressant therapy. The goal set for the resident by the staff to remain free from discomfort or adverse effects of antidepressant therapy. Some of the interventions/approaches the staff would use to accomplish this goal is administer antidepressant medication as prescribed by the physician, and consult with pharmacist, MD, medical director for gradual dose reduction if appropriate and monitor for side effects of antidepressant medications, e.g., suicidal ideations.
During the initial tour of the facility on [DATE] at approximately 1:59 p.m., observed on Resident #7's overbed table was an open tube of hydrocortisone cream 1%. The resident stated she has a rash to her upper arms, upper back and under her breast. She stated the cream dries up the rash and stops her skin from itching. She stated the hydrocortisone cream had been in her room for a while.
A review of Resident #7's [DATE], Medication Administration Record (MAR) revealed the following order: Hydrocortisone External Cream 1 %, apply to chest, and arms topically every 4 hours as needed for itching starting on [DATE].
A Self-Administration medication assessment was completed on [DATE] and [DATE] documented the resident did not wish to self-administer her own medications.
An interview was conducted with the Unit Manager on [DATE] at 10:07 a.m. She stated she had removed the hydrocortisone cream out of Resident #7's room. She stated the cream at beside was a house stock cream. She stated the nurse probably applied the mediation but forgot to remove it from the resident's room.
An interview was conducted with the Director of Nursing (DON) on [DATE] at 11:15 a.m., who stated Resident #7 had a self-administration assessment completed this morning and did not pass. She stated Resident #7 has a diagnosis of depression and with a diagnosis of depression who cannot self-administer your own medication.
A final meeting was held with the Administrator, Director of Nursing, and Regional Director of Clinical Services on [DATE] at 1:30 p.m., who were informed of the above findings. No further information was provided prior to exit.
The facility policy titled Self-Administration of Medication with a revision date of [DATE].
Residents who have the desire to, and who have been assessed to be capable and safe to, may self-administer medications.
Procedure read in part:
1. Verify physician's order in the resident's chart for self-administration of specific medications under considerations.
4. If the Interdisciplinary Team (IDT) has determined the resident safe to administer medication(s), administration of medication(s) will be care planned for approved self-administered medication.
5. Self-administration of medications must be reviewed by the (IDT) with each quarterly review.
6. When a resident is unable to self-administer medications, the medication will be held by the nurse until the resident can be reassessed by the (IDT).
7. The MAR must identity medications that are self-administered, and the medication nurse will need to follow-up with the resident as the documentation and storage of medications during each medication pass. Medication(s) kept at the bedside must be kept in a locked drawer.
Definitions:
-Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works (https://medlineplus.gov/ency/article/000945.htm).
-Hydrocortisone cream is used to treat redness, swelling, itching, and discomfort of various skin conditions. It works by activating natural substances in the skin to reduce swelling, redness, and itching (https://medlineplus.gov/ency/article/000945.htm).
Based on observation, resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to assess and determine if a Resident was safe to self-administer medications that were at the bedside, for six Residents (Resident #42, 54, 77, 51, 78 and #7) in a survey sample of 55 Residents.
The findings included:
1. For Residents #42, 54, 77, 51, and 78, all of whom had medications stored in their room, the facility staff failed to assess if the Residents were safe to self-administer medications.
On [DATE] at approximately 12:00 PM, observations were conducted of the 100 unit. Multiple Residents were noted to have over the counter medications at the bedside. They included:
a. Resident #42 had hair growth pills/supplement at bedside.
b. Resident #54 had Nutririte-800 multivitamins on the bedside table. The Resident said he takes 2 once a day, and reports he got them from dialysis and has been taking them about a year.
c. Resident #77 had refresh lubricating eye drops at the bedside and hemorrhoid cream in the bathroom.
d. Resident #51 had a tube of hydrocolloid cream and a bottle of [NAME] anti-itch cream on the bedside table. The [NAME] lotion had a prescription label, which indicated it belonged to Resident #394. Per the clinical record and an interview with CNA #1, Resident #394 had expired on [DATE].
e. Resident #78 had refresh eye drops with a prescription label and a container of roll-on bio freeze at the bedside. On [DATE], at approximately 1 PM, an additional observation was made of Resident #78's room. The bio freeze was still noted to be at the bedside.
On [DATE] at 02:14 PM, an interview was conducted with LPN #5. LPN #5 stated that all medications must be kept locked in the medication cart or medication room. When asked if medications can be kept in the Resident rooms, LPN #5 said, They should not keep meds in room, but it is based on their BIMS (brief interview for mental status) score. They have to score over a certain thing, to even be considered. Being a nursing home though we don't keep medications in the rooms. We have had people where families are non-complaint and go against what we ask, so if we find something we take it and notify the DON (Director of Nursing) and unit manager.
Following the above interview with LPN #5, LPN #5 accompanied the surveyors to Resident #78 and #77's room. LPN #5 confirmed the observations and removed the eye drops and hemorrhoid cream from Resident #77's room. LPN #5 also removed the eye drops from Resident #78's room but left the bio freeze. LPN #5 went on to say that they have difficulty with Resident #78 and her family with bringing items in. The surveyor explained that the items were easily identified upon observation and did not require that the Resident's personal items be inspected to locate the items. LPN #5 agreed that the items were easily identified and should have been removed by facility staff.
On [DATE]-[DATE], clinical record reviews were conducted of each of the Resident's charts. The findings were as follows:
a. Resident #42 had no assessment to determine if he/she was safe to self-administer medications. The care plan did not identify that the Resident was able to self-administer medications and keep them at the bedside. The physician orders did not include an order for any hair growth supplements.
b. Resident #54's clinical record revealed no current physician order for a multi-vitamin supplement. On [DATE] at 5:26 PM, a progress note was entered into the record that read, This nurse in to eval resident for self-administration of Multivitamin. Pt has BIMS of 14 however pt has a d/x of major depressive and per facility assessment resident is unable to self-administer meds. Pt educated on self-administering meds along with the risks associated with doing this without nurse and MD being aware due to possible interactions with already prescribed meds being administered by nurse. Pt verbalized understanding.
c. Resident #77's physician orders revealed an order dated [DATE], that read, Hemorrhoidal Relief Cream 5 % (Lidocaine (Anorectal)) Apply to rectum topically as needed for hemorrhoids apply to rectum as needed. On [DATE], an order was entered that read, Refresh Tears Solution (Carboxymethylcellulose Sodium) Instill 1 drop in right eye two times a day for dry eye syndrome. On [DATE] at 5:22 PM, the facility staff conducted an assessment to determine if Resident #77 could self-administer medications. The assessment identified that since Resident #77 had a diagnosis of dementia, they were not a candidate.
d. Review of Resident #51's chart revealed that the Resident had not been assessed for the ability to self-administer medication.
e. Resident #78 was assessed by facility staff for the ability to self-administer medications on [DATE] at 5:24 PM. The Resident was noted to not be a candidate. The Resident had not been previously assessed prior to being permitted to have medications at the bedside and had no physician order for the bio freeze.
On [DATE] at 3:00 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that many of the Residents had assessments conducted the evening prior in response to the items found by the surveyors in the Resident's rooms.
A review was conducted of the facility policy titled, Self-Administration of Medication. Excerpts from the policy read, 1. Verify physician's order in the resident's chart for self-administration of specific medications under consideration. 2. Complete the Self-Administration of Medications Assessment with the resident . 4. If the interdisciplinary Team has determined the resident safe to administer medication(s), administration of medication(s) will be Care Planned for approved self-administered medications . 6. When a resident is unable to self-administer medications, the medication will be held by the nurses until the resident can be reassessed by the Interdisciplinary Team. 7 . Medication(s) kept at the bedside must be kept in a locked drawer.
On [DATE], in the late afternoon, the facility Administrator was made aware of the above findings.
No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for one of fifty five residents in the survey sample (Resident # 62).
The findings include:
Resident # 62's (R62's) MDS dated [DATE] was incomplete.
R62 was admitted with diagnoses that included alzhiemers, depression, dementia with psychotic disturbance, auditory hallucinations and epilepsy. The MDS daated 6/7/23 assessed R62 as being cognitively intact.
R62's clinical record documented a MDS dated [DATE]. Sections C0200, C0300, CO400 and CO500 were blank.
On 12/7/23 at 9:12 am, the licensed practical nurse MDS coordinator (LPN#4) responsible for completing the MDS was interviewed about R62's incomplete MDS. LPN#4 stated that social services usually completed section C and we help them. LPN#4 also stated the assessment was not completed during the look back period and it got missed.
The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Chapter 3 page C-2 documents steps for coding mental statusas, Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) . (1)
On 12/8/23 at 9:45 am these findings were reviewed with the administor, director of nursing and the regional nurse consultant with no further information presented.
(1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, Centers for Medicare & Medicaid Services, Revised October 2023.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to implement care plan interventions for one Resident (Resident #5) in a survey sample of 55 Residents.
The findings included:
For Resident #5 the facility staff failed to ensure a mattress was at the immediate bedside of the Resident as identified in the care plan as a fall intervention to prevent injury.
On 12/5/23 at approximately 12:30 PM, Resident #5 was observed lying in bed. In the room there was an additional mattress noted on the floor, but it was pushed mid-way of the room and not positioned beside the bed.
On 12/7/23 at 8:33 AM., Resident #5 was observed again, lying in bed. The additional mattress was noted to be lying on the floor, but not by the bed, it was placed mid-way of the room between the bed and wall.
On 12/7/23 at 8:35 AM, an interview was conducted with LPN #7, who is an MDS (minimum data set) nurse. When asked about the mattress in the floor, LPN #7 said it is to be positioned directly beside the bed as a fall precaution to protect from injury. LPN #7 was asked to observe the mattress and she said, They had to move it to clean in there, it was as if her catheter had leaked so housekeeping must have moved it. LPN #7 confirmed that it was to be directly beside the bed to prevent any injury if the Resident were to fall out of bed.
On 12/7/23, a clinical record review was conducted. This review revealed Resident #5's care plan was reviewed and revised on 11/8/23. One focus area read, [Resident #5's name redacted] is at risk for fall r/t [related to] impaired mobility, impaired cognition. Resident also has behavior of placing self on floor. Interventions for this focus area included, mattress to floor for comfort.
On 12/7/23, in the late afternoon, the facility administration was made aware of the above findings.
No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #85, the facility staff failed to apply a lidocain patch to the correct location as ordered by the physician.
On 12/6/23 at 8:22 AM, Resident #85 was observed and met during the survey teams observation of medication administration. it was noted that the Resident had a Lidcaine patch on her left posterior thigh.
Following the medication administration observation, reconcilliation of physician orders was conducted. During this review it was noted that Resident #85 had a physician order that read, Lidoderm External Patch 5 % (Lidocaine) Apply to left lower back topically one time a day related to polyarthritis. The physician order stated to apply to the lower back, observations revealed it was applied to the thigh.
On 12/6/23 at 9:04 AM, during an interview with Resident #85, it was noted that she had a lidocaine patch on her left posterior thigh. When asked about it, the Resident said she was unsure when it was put on but a nurse had applied it.
On 12/06/23 at 09:08 AM, an interview was conducted with LPN #6. The LPN was asked about Resident #85's lidocaine patch and reported, it is supposed to go on at bedtime and come off in the morning. When asked who takes it off, LPN #6 said, the 11 p.m. -7 a.m. shift. When asked if the Resident is currently supposed to have one in place, the LPN said she was not. When asked if she had looked to verify this, LPN #6 said she had not looked even though it was visible to the surveyor during the medication administration observation conducted at 8:22 AM. Does she have one on, I have not looked.
On 12/06/23 at 09:11 AM, LPN #6 accompanied the surveyors to the Resident's room and confirmed the patch was not on the correct location and removed it.
On 12/6/23, in the late afternoon, the facility Administration was made aware of the above findings and confirmed the facility follows [NAME] standards of nursing practice.
According to the Lippincott Manual of Nursing Practice, Eighth Edition, Common Legal Claims for Departure from Standards of Care were listed on page 18. The list included, but was not limited to, failure to administer medications properly and in a timely fashion .
3. For Resident #26, the facility staff failed to follow standards of nursing practice, as evidenced by documenting that medications were administered that were not.
On 12/6/23 at 8:16 AM, LPN #6 was observed to prepare and administer medications to Resident #26.
During the medication administration observation, LPN #6 prepared the medications and provided Resident #26 with 4 medications, Coenzyme Q10 Capsule 100 MG, Coreg Tablet 12.5 MG (Carvedilol), Peridex Mouth/Throat Solution 0.12 % (Chlorhexidine Gluconate (Mouth-Throat), and boost (a nutritional supplement).
Following the administration a record review was conducted to reconcile the administration. It was noted that LPN #6 had documented that Lasix Oral Tablet 20 MG (Furosemide), and MiraLAX Packet 17 GM (Polyethylene Glycol 3350) were administered when neither were given.
On 12/6/23 at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked about the medications documented as having been given during the 8:16 AM, medication administration that was observed by two surveyors. LPN #6 confirmed that Lasix and MiraLAX had not been given because they were not available. When asked why they were documented as having been given, LPN #6 said, she was nervous.
Another review of the clinical record revealed that LPN #6 had not documented that the medications were not administered, nor had it been indicated that the physician was made aware of the medications not being available.
Review of the STAT box (emergency medication supply) contents listing revealed the Lasix was available in the STAT box and could have been retrieved to provide to the Resident.
On 12/6/23 at 9:12 AM, an interview was conducted with LPN #6. LPN #6 was asked to explain the process if a medication is not available. LPN #6 said, if a medication is not available, she would check the emergency supply box (STAT box) and see if the medication was available to be obtained/retrieved there and if not would call the pharmacy and doctor. When asked if this process had been followed for Resident #85, she indicated it had not been done.
The facility administration was asked to provide a copy of their facility policy regarding medication administration. The facility submitted an undated document titled, Preparing for Medication Administration. Excerpts from this document read, . Medications Administered: Initial appropriate book of the MAR immediately after administration of the medication. Medication Availability: If a medication is not administered because the medication is not available, make every effort to locate the medication. If the medication cannot be located, check the interim or emergency kit for the medication so that medication pass can be completed. Document unavailable medications appropriately per facility protocol. Contact the pharmacy and arrange for delivery of the medication.
On 12/6/23, in the later afternoon, the facility administration was made aware of the above observations and confirmed the facility follows [NAME] standards of nursing practice.
According to the Lippincott Manual of Nursing Practice, Eighth Edition, Common Legal Claims for Departure from Standards of Care were listed on page 18. The list included, but was not limited to, failure to administer medications properly and in a timely fashion, or to report and administer omitted doses appropriately .
On 12/8/23, the facility Administrator provided the survey team with evidence that LPN #6 had received disciplinary action on 12/7/23 and was suspended pending an investigation. Additionally, the facility administration had provided education to LPN #6 regarding medication administration following them being made aware of the above findings.
No further information was received.
Based on observation, resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to follow standards of practice for two Residents (Resident #85 and #26) in a survey sample of 55 Residents.
The findings included:
1. For Resident #85 the facility staff failed to follow standards of nursing practice by failing to implement physician orders to apply compression stockings in the morning for edema.
Resident #85 has diagnosis of BLE (bilateral lower extremity) edema and CHF (congestive heart failure), and compression hose ordered for edema to be put on in the morning and removed in the evening.
On 12/6/23 in the morning and again in the afternoon, Resident #85 was observed sitting in her room and no compression stockings were on her BLE.
On 12/7/23 after lunch, Resident #85 was observed sitting in a wheelchair in her room and she didn't have on compression stockings.
On 12/8/23 in the morning, after breakfast, Resident #85 was observed in her room sitting in the bathroom in a wheelchair and no compression stockings were on her bilateral lower extremities.
A clinical record review was conducted and revealed a physician order for compression hose to be put on in the morning and removed in the evening due to the resident's edema. A nurses note from LPN #6 on 12/7/23 stated that the Resident would apply after shower and on 12/8/23 states resident didn't want applied now and would check back later.
On 12/6/23 at 2:00pm, an interview was conducted with Resident #85, resident stated that laundry took the hose and didn't return hose after being washed, so she is waiting on more to be ordered for her.
On 12/7/23 at 10:34am, an interview was conducted with LPN #6, and she verbalized that compression hose are put on the resident in the mornings and she tried to put them on yesterday and she disappeared off the unit.
On 12/8/23 at 10:00am, Resident #85 was interviewed again. The resident was in her room and no compression hose were on her lower extremities, she stated she didn't receive hose until last night and staff applied hose at 7:00pm and removed at 9:00pm and staff is to apply this morning after her shower. Resident stated staff has to apply because she isn't able to put the hose on herself.
The Lippincott Manual of Nursing Practice, eighth edition, was reviewed. On page 18, in box 2-3, Common Legal Claims for Departure from Standards of Care were noted to include, but not limited to: . failure to perform a nursing treatment or procedure properly, . failure to implement a physician/NP/PA order properly or in a timely fashion .
Administrator and DON made aware of findings on 12/7/23.
No further information was provided prior to the conclusion of the survey.

Based on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to respond to a Resident's request for ADL (activity of daily living) assistance for one Resident (Resident #48) in a survey sample of 55 Residents.
The findings included:
For Resident #48, the facility staff failed to respond to the Resident ringing the tap bell for an hour and a half to request assistance to bathe/wash up.
On 12/6/23 at approximately 10:05-10:10 AM, Resident #48 was observed to be ringing her tap bell. The surveyor remained on the unit making ongoing observations and noted no staff entered to respond to the resident. Throughout this time, Resident #48 was ringing the bell. At approximately 11:20 AM, Resident #48 began banging profusely on the bell.
On 12/6/23 at 11:29 AM, Resident #48 was asked by the surveyor what she needed and reported she had been waiting for staff to assist her with getting washed up. The Resident reported that this happens frequently that people don't come. She said she has waited as long as 3 hours because some people say they didn't hear the bell.
During the above observations, LPN #6 was observed sitting at the nursing station working on the computer and various other staff members were observed on the nursing unit.
Review of Resident #48's clinical record revealed that according to her ADL (activities of daily living) records and care plan, she required assistance of facility staff to complete her daily ADL's.
A review was conducted of the facility's policy titled, Resident Communication System and Call Light Policy. This policy read, . 3. Staff will respond to call lights promptly.
On the afternoon of 12/6/23, the facility's administration was made aware of the above findings.
No further information was provided.

Based on observation, staff interview and clinical record review, the facility staff failed to maintain quality of care and ensure care was in accordance with the Resident's care plan, for two Residents (Resident #54 and #72), in a survey sample of 55 Residents.
The findings included:
For Resident #54 and #72, who were both on a fluid restriction, the facility staff failed to maintain the restrictions of the fluid restrictions by providing water at the bedside.
On 12/6/23 at approximately 10 AM, observations were made in Resident #54's room. Resident #54 was noted to have a water pitcher at the bedside which was 3/4 full of ice water. It was observed that on the wall behind the bed, a sign noted a 1000 cc fluid restriction.
On 12/6/23 at approximately 10:21 AM, observations were made of Resident #72's room. On the over bed table there was a full water pitcher in his room, which contained approximately 960 cc., a 120-cc cup of juice was noted and another cup with approx. 120 cc of liquid was noted. A sign above bed says 1000 cc fluid restriction.
On 12/7/23 at 8:23 AM, observations were made in Resident #54's room. He was noted to have a water pitcher on the over bed table which was 3/4 full of ice water. A canned 12-ounce diet coke on the bedside table. Resident #54 also receives medications where water is provided and is provided beverages with meals. By having the water pitcher and other fluids at the bedside, the 1000 cc fluid restriction per day is exceeded.
Review of both Resident #54 and 72's care plan revealed they were both on a fluid restriction. There was no indication in the care plan that the Residents were non-compliant with the fluid restriction. Resident #54's physician order read, 1000ml fluid restriction: Dietary Breakfast 240ml, Lunch 120ml, Dinner 120ml==480ml total Nursing, A.M. 240ml, P.M. 220ml, NOC 60ml==520ml total every
shift.
Resident #72's physician order read, 1000ml Fluid restriction Dietary Breakfast=240cc, Lunch=240cc, dinner=240cc Total=720ml Nursing AM=120cc, PM=120cc, NOC=40cc Total=280ml every shift.
On 12/7/23 at approximately 8:40 AM, an interview was conducted with LPN #6. When asked about the two Residents being on fluid restrictions, she confirmed they were both on fluid restrictions. When asked about the water pitcher being at the bedside and asked how they maintained the fluid restriction, LPN #6 said, she was not sure and perhaps the water pitcher was there just as facility protocol.
On 12/7/23, in the late afternoon, the facility administration was made aware of the above findings.
No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to heart failure and renal insufficiency requiring hemodialysis. Resident #84's most recent MDS (minimum data set) assessment was an admission assessment with an ARD (assessment reference date) of 11/11/19. Resident #84 was coded as being cognitively intact scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam.
Review of Resident #84's clinical record revealed a readmission Agreement that documented in part, the following: I do/ I do not have an advanced directive. An X was marked by I do have an advanced directive. This form was signed by the resident on 12/19/19.
Review of Resident #84's clinical record revealed a DNR (Do not Resuscitate Order) form that was signed by the Resident on 12/12/19.
Further review of Resident #84's clinical record failed to evidence her advanced directive.
On 1/8/20 at 4:06 p.m., an interview was conducted with ASM (administrative staff member) #1, the Administrator. ASM #1 stated that upon admission the resident completes the admission or readmission agreement and checks whether they have an advanced directive or do not have an advanced directive. ASM #1 stated that the business office manager was responsible for going over advanced directive information with the resident. ASM #1 stated that if the resident does not have an advanced directive, staff will offer to formulate one. ASM #1 stated that residents are not required to have an advanced directive. ASM #1 stated that if a resident already has an advanced directive, staff will ask family to bring it in. When asked the process if family does not bring in the advanced directive, ASM #1 stated, Sometimes we just don't get it. ASM #1 then stated that sometimes staff will ask the resident or POA (power of attorney) if they would like to create a new advanced directive at the facility. When asked who was responsible for following up with the family or resident on the status of their advanced directive, ASM #1 stated that the social worker did the follow up and also created a new advanced directive with the resident/POA if one could not be provided. When asked if follow up and if the resident declines to create another advanced directive should be documented in the clinical record, ASM #1 stated that he was not sure.
On 1/9/20 at 1:45 p.m., an interview was conducted with OSM (other staff member) #4, the Director of Social Services. OSM #4 stated that if a resident has an advanced directive, she will ask the family or resident for a copy. OSM #4 stated that the copy is then placed in the electronic medical record. When asked the process if she could not obtain the advanced directive from the family or resident, OSM #4 stated that she did not do anything. When asked if she offers to formulate a new advanced directive with the resident and/or POA (power of attorney), OSM #4 stated that she did not.
On 1/9/20 at 2:55 p.m., an interview was conducted with OSM #5, admissions. When asked the process of obtaining advanced directives for residents, OSM #5 stated that upon admission, she will go over advanced directives and ask the resident whether or not they have one. OSM #5 stated that if the resident has an advanced directive, she will ask the family to bring it in. OSM #5 stated that she will then upload the advanced directive into the resident's medical chart. When asked the process if she could not obtain a copy of the advanced directive, OSM #5 stated that she did not do any further follow up. OSM #5 stated that she did not ask residents if they would like to formulate a new advanced directive if she could not obtain a copy. When asked if the advanced directive should be accessible for staff, OSM #5 stated that it probably should be. OSM #5 was asked if she could find an advanced directive for Resident #84.
On 1/9/20 at 3:12 p.m., OSM #5 stated that she could not find Resident #84's advanced directive.
On 1/9/20 at approximately 7:00 p.m., ASM #1, the Administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the ADON (Assistant Director of Nursing) were made aware of the above concerns.
Facility policy titled, Advanced Directives Policy documents in part, the following: An advanced directive is a written document that specified choices for health care services and/or names another individual(s) to make those choices on the Resident's behalf, and is every Resident's right to formulate such document. These choices may include the refusal or withdrawal of certain medical care and treatments. The Facility will honor advanced directives that are provided and developed in accordance with State law and appropriate to the level of care and services which the Facility is licensed to provide .If the Resident has an advanced directive, they must make it known, and provide the Facility with a copy for review and to be made part of the Residents medical record.
Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to have advanced directives accessible for five resident's (Resident #68, #14, #7, #45 and #84) in a survey sample of 37 residents.
The findings included;
1. Resident #68 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis for Resident #14 included but not limited to Type 2 diabetes Mellitus and Muscle Weakness.
The current Minimum Data Set (MDS), a Quarterly Revision assessment with an Assessment Reference Date (ARD) of 12/08/2019. The staff assessment for mental Status coded the Resident as having Short term and Long term memory problems. Section C1000-Coded the Resident's Cognitive Skills for Decision Making as being severely impaired.
A review of the clinical record on 01/08/2019 revealed there was no advanced directive in the clinical record concerning an advance directive.
On 1/9/20 at 1:45 p.m., an interview was conducted with OSM (other staff member) #4 the Director of Social Services. OSM #4 stated that if a resident has an advanced directive, she will ask the family or resident for a copy. OSM #4 stated that the copy is then placed in the electronic medical record. When asked the process if she could not obtain the advanced directive from the family or resident, OSM #4 stated that she did not do anything. When asked if she offers to formulate a new advanced directive with the resident and/or POA (power of attorney), OSM #4 stated that she did not.
On 1/9/20 at 2:55 p.m., an interview was conducted with OSM #5, the business office manager. When asked the process of obtaining advanced directives for residents, OSM # stated that upon admission, she will go over advanced directives and ask the resident whether or not they have one. OSM #5 stated that if the resident has an advanced directive, she will ask the family to bring it in. OSM #5 stated that she will then upload the advanced directive into the resident's medical chart. When asked the process if she could not obtain a copy of the advanced directive, OSM #5 stated that she did not do any further follow up. OSM #5 stated that she did not ask residents if they would like to formulate a new advanced directive if she could not obtain a copy. When asked if the advanced directive should be accessible for staff, OSM #5 stated that it probably should be. OSM #5 was asked if she could find an advanced directive for Resident #68.
On 01/09/20 OSM #5 presented A Care Planning Report dated on 02/26/16. It reads the following: Focus: Advance Directive Needs: As evidenced by resident's wishes to be a Full Code. Care givers are aware of the wishes. Goal/Evaluation: Staff will adhere to resident/family's Advance Directive decisions through next review. Intervention:Code Status: Full Code started 02/04/14-continuing. OSM #5 was asked if nursing was aware of the document? She stated that she didn't know. Briefly, thereafter the DON (Director of Nursing) appeared concerning the above document. He said that he was not aware of the document and that it would be hard to talk to Resident's family about having an Advanced Directive.
On 01/09/20 at approximately, 7:12 PM a Pre-exit interview was conducted concerning the above issues. The Administrator stated, that he felt like they were doing their job with the families concerning the Advanced Directives.
2. Resident #14 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis for Resident #14 included but not limited to Type 2 diabetes Mellitus and Muscle Weakness.
The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of 10/14/2019 coded the resident with a score of 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment.
A review of the clinical record on 01/08/2019 revealed there was no advanced directive in the clinical record.
#3. Resident #7 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Unspecified Dementia without Behavioral Disturbance and Functional Quadriplegia. Resident #7's Quarterly Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 10/08/2019 coded Resident #7 with a BIMS (Brief Interview for Mental Status) score of 08 indicating moderate cognitive impairment.
On 01/08/2020 a copy of Resident #7's Advance Directives - Acknowledgement form was received. Review of the form revealed that the resident's son had indicated that Resident #7 had a written advanced directive.
On 01/09/2020 at approximately 2:55 p.m., an interview was conducted with the Director of Admissions and when she was asked if she could provide a copy of Resident #7's Advanced Directive, the Director of Admissions stated, No, unable to locate a copy. When asked the process of obtaining Advanced Directives, the Director of Admissions stated, Upon admission I go over advanced directives with the resident or resident's responsible party and ask them if they have one. If they have one I ask the family to bring it in and I upload the advance directive into the resident's medical chart. When asked the process if she could not obtain a copy of the advance directive, the Director of Admissions stated, I do not do any further follow up. When the Director of Admissions was asked if the advanced directive should be accessible for staff, the Director of Admissions stated, It probably should be. The Director of Admissions stated, I have contacted the resident's family to bring in a copy of the advanced directive and I will add it to the resident's chart when I receive it. Moving forward I will have a follow up process in place.
The Administrator, Director of Nursing and Assistant Director of Nursing was informed of the finding at the pre-exit meeting on 01/09/2019 at approximately 7:10 p.m. The facility did not present any further information about the finding.
#4. Resident #45 was initially admitted to the facility on [DATE]. Resident #45's most recent discharge to the hospital was on 11/10/2019 and readmitted to the facility on [DATE]. Diagnosis for Resident #45 included but are not limited to, Pulmonary Fibrosis, Unspecified, and Diabetes Mellitus. Resident #45's Quarterly Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 11/20/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment.
On 01/08/2020 a copy of Resident #45's readmission Agreement dated 11/18/2019 was received. Review of the 'Acknowledgements section revealed that the resident has a advance directive.
On 01/09/2020 at approximately 2:55 p.m., an interview was conducted with the Director of Admissions and when she was asked if she could provide a copy of Resident #45's Advanced Directive, the Director of Admissions stated, No, unable to locate a copy. When asked the process of obtaining Advanced Directives, the Director of Admissions stated, Upon admission I go over advanced directives with the resident or resident's responsible party and ask them if they have one. If they have one I ask the family to bring it in and I upload the advance directive into the resident's medical chart. When asked the process if she could not obtain a copy of the advance directive, the Director of Admissions stated, I do not do any further follow up. When the Director of Admissions was asked if the advanced directive should be accessible for staff, the Director of Admissions stated, It probably should be. The Director of Admissions stated, I have contacted the resident's family to bring in a copy of the advanced directive and I will add it to the resident's chart when I receive it. Moving forward I will have a follow up process in place.
The Administrator, Director of Nursing and Assistant Director of Nursing was informed of the finding at the pre-exit meeting on 01/09/2019 at approximately 7:10 p.m. The facility did not present any further information about the finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and clinical record review the facility staff failed to ensure the quarterly Minimum Data Set (MDS) assessment accurately reflected 1 of 37 residents in the survey sample, Resident #48.
The findings included:
Resident #48 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Alzheimer's Disease With Late Onset and Anxiety Disorder. Resident #48's Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 11/21/2019 coded Resident #48 with a BIMS (Brief Interview for Mental Status) score of 03. indicating severe cognitive impairment. In addition, the Minimum Data Set coded Resident #48 as requiring extensive assistance of 1 with eating, total dependence with assistance of 1 for dressing, personal hygiene and bathing and total dependence with assistance of 2 for bed mobility, transfer and toilet use.
On 01/09/2019 at approximately 4:30 p.m., review of Resident #48's clinical record revealed the following:
Review of Resident #48's Quarterly Review Assessment with an Assessment Reference Date of 11/21/2019 revealed Section N N0410 Medications Received was coded as receiving an Antipsychotic during the last 7 days.
Review of Resident #48's Order Summary Report dated with Active Orders As Of 11/01/2019 did not evidence any orders for Antipsychotic medications.
On 01/09/2019 at 4:56 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #4, the MDS Coordinator. When the MDS Coordinator was asked if Resident #48 received an antipsychotic in November 2019, the MDS Coordinator stated, No she did not. I made an error inputting the data. I should have coded the resident as receiving an anti anxiety medication. When asked if the assessment was an inaccurate assessment, the MDS Coordinator stated, Yes.
The Administrator, Director of Nursing and the Assistant Director of Nursing was informed of the finding at the pre-exit meeting on 01/09/2019 at approximately 7:10 p.m. When the Director of Nursing was asked what his expectations were of the nurses when completing MDS's, the Director of Nursing stated, I will get back to you.
On 01/09/2019 at approximately 7:30 p.m., the Director of Nursing stated, Our expectation is that MDS Assessments be completed accurately according to the RAI (Resident Assessment Instrument) manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to follow physician orders and the comprehensive care plan for oxygen administration for one of 37 residents in the survey sample, Resident #12. The facility staff failed to administer the correct amount of oxygen per nasal cannula.
The findings included:
Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. Resident #12's most recent MDS (minimum data set) assessment was a Quarterly Revision assessment with an ARD (assessment reference date) of 10/10/19. Resident #12 was coded as being intact in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #12 was coded in section O, Special Treatments and Programs, as receiving respiratory therapy.
Review of Resident #12's POS (physician order summary) dated 12/13/ 2019, revealed the following oxygen orders: Oxygen @ (at) 4 L (liters) via N/C (nasal cannula) every shift.
Resident #12's care plan revised on 12/20/19 documented in part, the following: Resident has potential risk for Altered cardiac/respiratory status in Gas exchange r/t (related to) COPD (Chronic Obstructive Pulmonary Disease), Respiratory Failure and Heart Failure. Goal: No S/S of cardiac/Respiratory Issues. Initiated on 04/05/2016. Revised on: 07/22/2019. Interventions: Oxygen per MD order. Revised on 10/17/19.
The MAR (Medication Administration Record) included: Oxygen @ 4 liters via Nasal Cannula every shift. The January MAR was checked off by nursing staff for Day, evening and night shifts.
On 01/07/20 at 12:20 PM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set at 2 liters per minute.
On 01/08/20 at 10:51 AM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set on 2 liters.
On 01/09/20 at 9:23 AM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set on 2 liters. The reading was confirmed with the ADON (Assistant Director of Nursing). She was asked to provide a copy of the physicians order summary.
On 01/09/20 at approximately, 1:30 PM An interview was conducted with LPN (Licensed Practical Nurse) #2. She was asked to confirm how many liters of oxygen Resident #12 be administered? She stated, I thought that he was on two. She was given the opportunity to look up the Resident's Oxygen orders. She then stated, Oh the orders say 4 liters. She was then asked how many liters of oxygen should resident #12 be receiving? She stated, He should have been set on 4 liters. The ADON (Assistant Director of Nursing) Confirmed that Resident #12 should be receiving 4 liters of Oxygen.
On 01/09/20 at approximately, 7:12 PM a Pre-exit interview was conducted concerning the above issues. No further information was provided by the facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that facility staff failed to follow orders to change the nebulizer tubing every 7 days as ordered and failed to administer oxygen per physician orders, for one of 37 residents in the survey sample, Resident #12.
The findings included:
1a. Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. Resident #12's most recent MDS (minimum data set) assessment was a Quarterly Revision assessment with an ARD (assessment reference date) of 10/10/19. Resident #12 was coded as being intact in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #12 was coded in section O, Special Treatments and Programs, as receiving respiratory therapy.
Review of Resident #12's POS (physician order summary) dated 12/27/ 2019, revealed the following: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML inhale orally every 6 hours as need for shortness of breath or wheezing via nebulizer.
The TAR (Treatment Administration Record) included: Change any 02 tubing weekly on Sunday.
On 01/07/20 at 12:20 PM an observation was made of Resident #12's Nebulizer machine located on a side table. The tubing was in a plastic bag with an outside label reading 01/06/19. The tubing inside of the bag had a label affixed reading 12/29/19.
On 01/08/20 at 10:51 AM an observation was made of Resident #12's nebulizer machine. The tubing was inside a bag located on the side table. Labeling remained unchanged.
On 01/09/20 at 9:23 AM There was no nebulizer machine or tubing found in the Resident's room. The ADON (Assistant Director of Nursing) was informed that the nebulizer tubing and machine was on the side table in Resident's room for last two days.
On 01/09/20 at approximately, 1:30 PM an interview was conducted with LPN (Licensed Practical Nurse) #2. She was asked about Resident #12's nebulizer machine and tubing. She said she wasn't aware of anything concerning the nebulizer. The ADON (Assistant Director of Nursing) Confirmed that Resident #12's nebulizer machine and tubing had been removed from the resident's room by the Director of Nursing (DON).
On 01/09/20 at approximately, 4:40 PM, the DON confirmed that he had removed the nebulizer machine and discarded the outdated tubing yesterday. He stated that Resident #12 receives Nebulizer treatments as needed and the tubing is changed on Sundays. He also stated that Resident hasn't used his nebulizer in a while so the tubing should have been discarded by nursing staff.
1b. Review of Resident #12's POS (physician order summary) dated 12/13/ 2019, revealed the following oxygen orders: Oxygen @ (at) 4 L (liters) via N/C (nasal cannula) every shift.
Resident #12's care plan revised on 12/20/19 documented in part, the following: Resident has potential risk for Altered cardiac/respiratory status in Gas exchange r/t (related to) COPD (Chronic Obstructive Pulmonary Disease), Respiratory Failure and Heart Failure. Goal: No S/S of cardiac/Respiratory Issues. Initiated on 04/05/2016. Revised on: 07/22/2019. Interventions: Oxygen per MD order. Revised on 10/17/19.
The MAR (Medication Administration Record) included: Oxygen @ 4 liters via Nasal Cannula every shift. The January MAR was checked off by nursing staff for Day, evening and night shifts.
On 01/07/20 at 12:20 PM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set at 2 liters per minute.
On 01/08/20 at 10:51 AM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set on 2 liters.
On 01/09/20 at 9:23 AM an observation was made of Resident #12's oxygen concentrator which was in use. The flow meter was set on 2 liters. The reading was confirmed with the ADON (Assistant Director of Nursing). She was asked to provide a copy of the physicians order summary.
On 01/09/20 at approximately, 1:30 PM An interview was conducted with LPN (Licensed Practical Nurse) #2. She was asked to confirm how many liters of oxygen Resident #12 be administered? She stated, I thought that he was on two. She was given the opportunity to look up the Resident's Oxygen orders. She then stated, Oh the orders say 4 liters. She was then asked how many liters of oxygen should resident #12 be receiving? She stated, He should have been set on 4 liters. The ADON (Assistant Director of Nursing) Confirmed that Resident #12 should be receiving 4 liters of Oxygen.
On 01/09/20 at approximately, 7:12 PM a pre-exit interview was conducted concerning the above issues with the Administrator and DON. No additional information was provided by facility staff.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure Registered Nurse (RN) coverage for 8 hours, 7 days a week. The facility staff failed to ensure RN coverage for 8 hours for four days.
The findings included:
On 01/09/20 at approximately 2:00 PM, the facility's actual worked schedule was reviewed with the DON (Director of Nursing) and revealed there was no RN coverage for the following days: 1/19/19, 1/20/19, 5/5/19, 5/27/19. The DON was asked what should have been done concerning providing Registered Nursing Coverage? He stated, We should have gotten RN coverage.
On 01/09/20 at approximately, 7:12 PM a pre-exit interview was conducted with The Director of Nursing (DON), the ADON (Assistant Director of Nursing) and the facility Administrator concerning the above issue. No further information was provided by the facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility documentation, the facility staff failed to ensure infection control practices were followed during wound care for 1 of 37 residents in the survey sample, Resident #302.
The findings included:
Resident #302 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Cerebral Ischemia and Unspecified Severe Protein-Calorie Malnutrition. Resident #302's Nurse admission Evaluation with an evaluation date of 12/30/2019 revealed that the resident was AOx4 (Alert and Oriented times 4). In addition, the Nurse admission Evaluation revealed that the resident was evaluated as requiring assistance of 1 with ADL's (Activities of Daily Living).
On 01/08/2020 at 11:35 a.m., Resident #302's wound care was observed. Licensed Practical Nurse (LPN) #3, Wound Care Nurse, was assisting the physician during wound care. LPN #3 performed hand hygiene and then placed a barrier on the bedside table top. LPN #3 obtained needed wound care supplies from the treatment cart outside the resident's room. LPN #3 used her bandage scissors to cut the dirty kling wrapping from around Resident #302's right heel. LPN #3 then removed the dirty kling wrapping and dressing from around the right heel and then cleansed the wound with wound cleanser and 4x4 gauze sponge. The physician measured the resident's right heel wound and then used a scalpel to debride the wound while LPN #3 held the resident's leg. LPN #3 then laid the resident's foot down on a barrier pad and the LPN removed her gloves. LPN #3 performed hand hygiene, applied clean gloves and then applied Medihoney with a applicator to the right heel wound. LPN #3 covered the wound with a dry 4x4 gauze dressing and wrapped the heel with gauze kling. LPN #3 removed her dirty gloves and performed hand hygiene. LPN #3 failed to remove her dirty gloves and perform hand hygiene after removing the dirty dressing from the right heel and prior to cleansing the wound.
On 01/08/2020 at approximately 12:48 p.m., observation was reviewed and an interview was conducted with LPN #3. When LPN #3 was asked what she should do when going from a dirty procedure to a clean procedure, LPN #3 stated, I should have removed my gloves and washed my hands after removing the dirty dressing and before I cleaned the wound on the right heel. I always do that but I guess I was nervous.
Observation was reviewed and an interview was conducted with the Director of Nursing (DON) on 01/09/2010 at 2:20 p.m., and when the DON was asked what his expectations were of nurses when performing wound care, the DON stated, I expect them to wash their hands and don new gloves between feet.
The Administrator, Director of Nursing and Assistant Director of Nursing was informed of the finding at the pre-exit meeting on 01/09/2020 at approximately 7:10 p.m. The facility did not present any further information about the finding.

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5%. There were 2 errors in 28 opportunities for a medication error rate of 7.14%. These errors effected Resident #101.
The findings included:
The facility nursing staff failed to administer the Residents miralax and eye drops.
The record review revealed that Resident #101 had been admitted to the facility 10/15/18. Diagnoses included, but were not limited to, diabetes, blindness left eye, transient ischemic attack and cerebral infarcon without residual deficits, and acute appendicitis.
There was no completed MDS (minimum data set) assessment completed on this Resident. The Resident was alert and orientated.
On 10/17/18 beginning at approximately 7:53 a.m., the surveyor observed LPN (licensed practical nurse) #2 prepare and administer the following medications amlodipine, carvedilol, furosemide, lisinopril, cipro, iron, aspirin, thera tab vitamin, and a PPD to Resident #101.
After observing the medication administration the surveyor reconciled the Residents medications using the Residents EHR (electronic health record). The Residents orders included two medications the surveyor did not observe being administered miralax and carboxymethylcellulose eye drops.
The surveyor approached LPN #2 and asked about the missing medications. LPN #2 stated that she did not recall the Resident receiving miralax. However, after checking the EHR LPN #2 stated when she finished him up she would administer the miralax. In regards to the Resident's eye drops LPN #2 stated she would put an order in for them.
On 10/18/18 at 8:20 a.m., the DON (director of nursing) provided the surveyor with a cop of a policy titled 7.0 Medication Shortages/Unavailable Medications. This policy read in part, .Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy .If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery .If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions .
A review of the stat box list revelaed that these medications were not available at the facility for administration.
The administrative team was notified of the medication errors during a meeting with the survey team on 10/17/18 at 3:20 p.m.
No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to ensure that comprehensive care plans were prepared, reviewed and revised by an interdisciplinary team that included the necessary members.
The findings included:
The facility staff failed to ensure that all facility residents care plans were prepared by an interdisciplinary team that included nursing assistants.
On 10/16/18 at 4:40 pm, the surveyor observed a Care Plan Conference Summary sheet in the clinical record for Resident # 89. The surveyor observed several signatures documented under the Attendees of Care Plan Conference section. The surveyor did not observe a documented signature of a certified nursing assistant.
On 10/16/18 at 5:03 pm, the surveyor interviewed unit manager RN # 1 (registered nurse). The surveyor asked RN # 1 if she could identify the titles of the persons listed as attending the care plan conference. RN # 1 identified the attendees as the social worker, dietary, herself RN #1, activity director, and Resident # 89's daughter. The surveyor asked RN # 1 how certified nursing assistant staff was involved in the care planning process. RN # 1 stated,CNAs (certified nursing assistants) don't come to the care plan meetings.
On 10/16/18 at 5:16 pm, the surveyor spoke with the facility social worker. The surveyor asked the social workers if certified nursing assistants participated in the care plan meetings. The social worker stated, No. The social worker asked the surveyor why she was inquiring about certified nursing assistants participating in the care planning process. The surveyor informed the social worker that the interdisciplinary team must include a certified nursing assistant with responsibility for the resident. The social worker stated, I was not aware CNAs had to attend.
The facility policy on Care Plan, contained documentation that included but was not limited to:
.Policy: An interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis. The Procedure includes documentation that includes but is not limited to: E) The Interdisciplinary Care Planning Team may consist of:
4. CNA assigned to the resident.
On 10/17/18 at 4:30 pm, the administrative team was made aware of the findings as stated above. The surveyors asked the administrative team if certified nursing assistants have ever participated in the care planning process. The facility administrator informed the survey team that nursing assistants participating in the care planning process had not been the facility practice and the facility had already made efforts to initiate changes to include nursing assistants in the care planning process.
No further information was provided to the survey team prior to the exit conference on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to obtain physician ordered laboratory tests for 3 of 26 residents (Resident #21, Resident #33, and Resident #56).
The findings included:
1. The facility staff failed to obtain a physician ordered urinalysis, culture, and sensitivity for Resident #21.
The clinical record of Resident #21 was reviewed 10/16/18 through 10/18/18. Resident #21 was admitted to the facility 9/20/17 and readmitted [DATE] with diagnoses that included but not limited to Type 2 diabetes mellitus, symbolic dysfunction, dysphagia, repeated falls, cardiomyopathy, cerebellar stroke syndrome, alcohol-induced chronic pancreatitis, chronic pain syndrome, anemia, transient ischemic attacks, gastric diverticulum, altered mental status, Barrett's esophagus without dysplasia, hypertension, hemiplegia affecting left dormant side, bipolar disorder, anxiety disorder, atrial fibrillation, acute respiratory infection, viral hepatitis without hepatic coma, and cerebral infarction due to embolism.
Resident #21's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/7/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Section H Bowel and Bladder assessed the resident to be frequently incontinent of both.
The clinical record of Resident #21 had a physician order dated 8/19/18 that read Obtain a UA C&S (urinalysis, culture and sensitivity) resend, one time only for routine monitoring for 1 day re/obtain UA C&S.
The surveyor reviewed the laboratory section of the electronic clinical record. On the lab results report dated 8/20/18, the following was written 8/21/18 09:35 Problem Test 8/20/18 No DOB (date of birth ) on UC (urine container) >UA/C*S. Resolution: RN #2 notified. The urinalysis was never re-obtained.
The surveyor informed the unit manager registered nurse #1 on 10/17/18 at 1:45 p.m. The unit manager R.N. #1 stated she was unable to locate the results of the UA C&S ordered to be resent.
The surveyor informed the administrative staff of the above concern in the end of the day meeting on 10/17/18 at 3:20 p.m.
No further information was provided prior to the exit conference on 10/18/18.
2. The facility staff failed to obtain physician ordered laboratory tests for Resident #33. The staff failed to obtain an albumin level, CBC (complete blood count) and a BMP (basic metabolic panel) for Resident #33.
The clinical record of Resident #33 was reviewed 10/16/18 through 10/18/18. Resident #33 was admitted to the facility on [DATE] with diagnoses, that included but not limited to hypomagnesia, insomnia, chronic pain syndrome, dry eye syndrome, hypertension, chronic diastolic heart failure, lymphedema, acute frontal sinusitis, gastroesophageal reflux disease, urinary tract infection, left knee hemarthosis, right elbow contracture, major depressive disorder, nutritional deficiency, and dysthymic disorder.
Resident #33's significant change in minimum data set (MDS) with an assessment reference date (ARD) of 8/16/18 assessed the resident with a BIMS (brief interview for mental status) as 12 out of 15 in Section C. Section H Bladder and Bowel was coded for an indwelling catheter.
Resident #33's current comprehensive care plan was reviewed 10/16/18 through 10/18/18. Resident #33 had the focus area that read Resident #33 has indwelling catheter for wound healing. Interventions: Indwelling cath (catheter) per order. Cath care per physician's orders.
Resident #33's October 2018 physician orders were reviewed. The physician ordered a pre-albumin level on 10/1/18. A review of the laboratory results did not reveal the pre-albumin level had been obtained.
Resident #33 also had a physician order dated 10/8/18 to obtain a CBC and a BMP. After reviewing the laboratory section of the clinical record, the surveyor was unable to locate those results and informed the unit manager registered nurse #1 of the concerns listed above.
The unit manager registered nurse #1 informed the surveyor on 10/17/18 at 1:19 p.m. that the pre-albumin was entered incorrectly into the computer. R.N. #1 stated the order was just sitting there with no direction on when to obtain the lab. R.N. #1 stated the contracting laboratory was contacted and the pre-albumin was not done. R.N. #1 also stated the CBC and BMP were not obtained and had no reason why they weren't.
The surveyor informed the administrative staff of the physician ordered laboratory tests that were not obtained on 10/17/18 at 3:20 p.m.
No further information was provided prior to the exit conference on 10/18/18.
3. The facility staff failed to obtain urinalysis' ordered 8/7/18 and 9/5/18 for Resident #56.
The clinical record of Resident #56 was reviewed 10/16/18 through 10/18/18. Resident #56 was admitted to the facility 5/15/18 with diagnoses that included but not limited to dysphagia, symbolic dysfunctions, chronic atrial fibrillation, hypertension, atherosclerotic heart disease, acute on chronic systolic heart failure, nutritional anemia, pneumothorax, gastroesophageal reflux disease, dementia without behavioral disturbances, transient ischemic attacks, gout, restlessness and agitation, urine retention, left heel pressure ulcer, sacral pressure ulcer, and left femur fracture.
Resident #56's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/11/18 assessed the resident with a BIMS (brief interview for mental status) as 9 out of 15. Section H Bladder and Bowel assessed the resident to be incontinent of bowel and bladder always.
Resident #56's current comprehensive care plan had the focus area for urinary incontinence and inability to control urination r/t (related to) cognitive deficit, prostate cancer. Goal: No infection through next review. Interventions: Note any changes in amount, frequency, color or odor. Report any abnormalities to nursing/MD (medical doctor).
Resident #56 had an order dated 8/7/18 and 9/5/18 for a UA/C&S (urinalysis, culture and sensitivity). The surveyor was unable to locate the results of the UA/C&S ordered 8/7/18 and 9/5/18 when the clinical record was reviewed 10/17/18 at 7:54 a.m.
The surveyor informed the unit manager registered nurse #1 of the missing laboratory results on 10/17/18 at 9:21 a.m.
The unit manager stated the staff were unable to obtain the UA/C&S on 8/8/18 due to an obstruction. R.N. #1 stated the staff failed to document the reason why the UA/C&S was not obtained and the staff did not document the physician was notified.
The unit manager R.N. #1 provided the surveyor with a progress note dated 9/6/18 at 5:53 a.m. The progress note read UA (urinalysis) attempted x1 on resident with no success, when writer went to try again resident was already up and dressed in wheelchair. Will pass on to oncoming nurse to try to attempt.
On 10/17/18 at 1:17 p.m., the unit manager R.N. #1 stated the UA/C&S ordered 9/5/18 was not obtained and she stated she would expect the staff to notify the MD and document physician notification if the UA/C&S was not obtained.
The surveyor informed the administrative staff of the concern with the failure to obtain Resident #56's two physician ordered urinalysis, cultures and sensitivies in the end of the day meeting on 10/17/18 at 3:20 p.m.
No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to obtain a physician order prior to obtaining laboratory tests for 1 of 26 residents (Resident #59).
The findings included:
The facility staff failed to obtain a physician order before the CBC (complete blood count) and BMP (basic metabolic panel) were obtained on 9/18/18 for Resident #59.
The clinical record of Resident #59 was reviewed 10/16/18 through 10/18/18. Resident #59 was admitted to the facility 8/12/17 and readmitted [DATE] with diagnoses that included but not limited to metabolic encephalopathy, severe sepsis with shock, dysphagia, neuromuscular dysfunction of the bladder, hypertension, atherosclerotic heart disease, obsessive compulsive personality disorder, rhabdomyolysis, end stage renal disease, anxiety disorder, mental disorder, repeated falls, hyperkalemia, urinary tract infection, Parkinson's disease, and major depressive disorder.
Resident #59's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/12/18 assessed the resident with a BIMS (brief interview for mental status) as 9/15.
The surveyor reviewed the laboratory section of the clinical record and located the results of a CBC and BMP obtained 9/18/18. The surveyor was unable to locate a physician order for the laboratory tests.
The surveyor informed the administrative staff of the laboratory tests obtained for Resident #59 without a physician order in the end of the day meeting on 10/18/18 at 3:08 p.m.
No further information was provided prior to the exit conference on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 3 of 26 Residents, Residents #21, #31, and #249.
The findings included:
1. The facility staff failed to ensure the physician's orders for PROM (passive range of motion) were entered into the computer accurately for Resident #21.
The clinical record of Resident #21 was reviewed 10/16/18 through 10/18/18. Resident #21 was admitted to the facility 9/20/17 and readmitted [DATE] with diagnoses that included but not limited to Type 2 diabetes mellitus, symbolic dysfunction, dysphagia, repeated falls, cardiomyopathy, cerebellar stroke syndrome, alcohol-induced chronic pancreatitis, chronic pain syndrome, anemia, transient ischemic attacks, gastric diverticulum, altered mental status, Barrett's esophagus without dysplasia, hypertension, hemiplegia affecting left dormant side, bipolar disorder, anxiety disorder, atrial fibrillation, acute respiratory infection, viral hepatitis without hepatic coma, and cerebral infarction due to embolism.
Resident #21's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/7/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15.
Resident #21's October 2018 physician orders read PROM upper and lower extremities: 15 reps (repetitions) Order date: 6/22/2018.
The surveyor reviewed the current comprehensive care plan read Resident #21 is on restorative program for stand pivot transfer. Interventions: Stand-by assist with transfers, limited assist, use gait belt at all times, skills practice 6/7 days a week, skills practice twice a day. A second care plan read Resident #21 is on restorative for AROM (active range of motion) capable of performing 15 reps decreased ROM (range of motion). Interventions: Skills practice: qd (everyday), Passive ROM, Complete 15 repetitions to each extremity below: hands, fingers, elbow, shoulder, neck, knees, legs, feet.
The quarterly MDS with ARD of 8/7/18 was reviewed. Section O Special Treatments, Procedures, and Programs and specifically Section O0500 Restorative Nursing Programs was coded that the resident received 7 days of range of motion (active) during the look back period and 6 days of transfers during the look back period. PROM had not been coded that the resident received any during the look back period or that the physician ordered had been followed for PROM.
The surveyor informed the assistant director of nursing (ADON) of the above concern on 10/18/18 at 1:19 p.m. The ADON stated Resident #21 was receiving AROM and the order for PROM was operator error.
The surveyor informed the administrative staff of the documentation concerns between PROM ordered for Resident #21 and AROM performed and charted in the end of the day meeting on 10/18/18 at 3:08 p.m.
No further information was provided prior to the exit conference on 10/18/18.
3. For Resident #249, the facility nursing staff failed to document that they had administered the Residents prilosec, insulin, and the results of the Residents blood sugar and documented they had administered the Residents adderall when it was not available at the facility for administration.
The clinical record review revealed that Resident #249 had been admitted to the facility 10/05/18. Diagnoses included, but were not limited to, attention deficit hyperactivity disorder (ADHD), hypertension, depression, diabetes, and neuropathy.
There was no completed MDS assessment for this Resident. The Resident was alert and orientated.
When reviewing the Residents eMARs (electronic medication administration records) for 10/2018 the surveyor observed holes where the nursing staff had failed to document they had administered the following medications.
Prilosec on 10/14 at 6:00 a.m.
Blood sugars at 6:00 a.m. on 10/06 and 10/14 and for any insulin if required.
On 10/12 and 10/13 at 9:00 p.m., LPN (licensed practical nurse) #3 had documented that she had administered the Residents adderall. When this medication was not available at the facility for administration.
On 10/17/18 at 6:05 a.m., the surveyor interviewed LPN #3 via phone regarding the adderall medication. LPN #3 verbalized to the surveyor that she had not administered the adderall and she had marked that she had in error, as the medication was not available.
No further information regarding this issue was provided to the survey team prior to the exit conference.
2. For Resident #31, facility staff failed to document administration of medication in the clinical record.
Resident # 31 is a [AGE] year-old-female who was originally admitted to the facility on [DATE] with a readmission date of 11/07/17. Diagnoses included but were not limited to muscle weakness, type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, and unspecified fracture of sacrum.
The clinical record for Resident #31 was reviewed on 11/16/18 at approximately 3:23pm. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 08/14/18 coded the Resident as 15 of 15 in section C, cognitive patterns.
Resident #31's CCP (comprehensive care plan) was reviewed and contained a focus area for; At risk for impaired skin integrity related to impaired mobility, diabetes mellitus, and edema. History of bilateral lower extremities weeping. Resident is noncompliant with thrombo-embolic deterrent hose, has interventions that included but were not limited to, Administer medication as ordered and administer treatments as ordered.
During clinical record review, the surveyor noted blanks in the medication administration record on 09/01 and 09/14/18 for administration of Levothyroxine Sodium Tablet 75 microgram by mouth in the morning related to hypothyroidism, and the 06:00 dose of Clonidine Hydrochloride 0.1 milligrams by mouth every six hours related to hypertension. There were blanks on the medication administration record on 09/01, 09/04, and 09/14 for the 0630 dose of Novolog Flex Pen solution pen-injector 100 units per milliliter (Insulin Aspart) Inject per sliding scale subcutaneously before meals and at bedtime: If blood sugar 201-250 give 2 units; 251-300 give 4 units; 301-350 give 6 units; 351-400 give 8 units; 401-499 give10 units; for diabetes mellitus type 2, call MD (medical doctor) for BS (blood sugar) less than 60 or greater than 450.
The surveyor reported the concern to the director of nursing, assistant director of nursing, regional director of clinical services, and administrator during meeting on 10/17/18 at approximately 3:18 pm.
No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure 2 of 26 Residents were free of significant medication errors. Residents #72 and #21
Findings included:
1. For Resident #72 the facility staff failed to administer blood pressure medication as ordered by the physician.
Resident #72 was admitted to the facility on [DATE]. Diagnoses included but not limited to hypertension, diabetes mellitus, depression, cerebral infarction due to embolism, and chronic kidney disease.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 09/26/18 coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS.
Resident #72's CCP (comprehensive care plan) was reviewed and contained a focus area for Resident has altered cardiac status, has interventions that included but were not limited to, Administer medications as directed by the physician.
Resident #72's clinical record was reviewed on 10/17/18. It contained a POS (physician's order summary) which read in part: Coreg Tablet 12.5 MG (milligrams) (Carvedilol) Give 12.5 mg by mouth two times a day for CVA (cerebral vascular accident), take with meals; Norvasc Tablet 10 MG (AmLODIPine Besylate) Give 10mg by mouth one time a day for CVA; Prinivil Tablet 20 MG (Lisinopril) Give 20mg by mouth one time a day for HTN (hypertension).
Resident #72's eMAR (electronic medication administration record) for the month of September 2018 were reviewed and contained an entry which read in part, Norvasc Tablet 10 MG (AmLODIPine Besylate) Give 10mg by mouth one time a day for CVA . This entry was coded 16 on 09/07/18 at 0900, 09/19/18 at 0900, and 09/20/18 at 0900 which is the equivalent of see progress notes. This entry was also coded 7 on 09/08/18 at 0900, 09/09/18 at 0900, 09/12/18 at 0900 and 09/21/18 at 0900 which is the equivalent of vitals outside of parameters. EMAR for the month of September 2018 also contained an entry which read in part, Prinivil Tablet 20 MG (Lisinopril) Give 20mg by mouth one time a day for HTN. This entry was coded 16 on 09/07/18 at 0900, and 09/20/18 at 0900 which is the equivalent of see progress notes. This entry was also coded 7 on 09/08/18 at 0900, 09/09/18 at 0900, 09/12/18 at 0900, 09/23/18 at 0900, and 09/26/18 at 0900 which is the equivalent of vitals outside of parameters. EMAR for the month of September 2018 also contained an entry which read in part, Coreg Tablet 12.5 MG (Carvedilol) Give 12.5 mg by mouth two times a day for CVA, take with meals. This entry was coded 16 on 09/19/18 at 0830, 09/20/18 at 0830, and 09/25/18 at 0830 which is the equivalent of see progress notes.
Resident #72's progress notes were reviewed and contained medication administration notes for: 09/07/18 at 1053, which read in part bp (blood pressure) 82/49, 09/08/18 at 1046 bp low 99/57, 09/09/18 at 1121 bp 89/57, 09/12/18 at 1140 87/48, 09/19/18 at 1112 .90/56 ., 09/19/18 at 1114 .90/56 ., 09/20/18 at 1140 .104/56 ., 09/20/18 at 1140 .104/56 ., 09/20/18 at 1142 .104/56 ., and 09/25/18 at 1107 .102/72 .
The surveyor reviewed Resident #72's physician's orders and could not locate an order stating to hold the following medications for vitals outside of parameters: Coreg Tablet 12.5 MG, Norvasc Tablet 10 MG, and Prinivil Tablet 20 MG.
The surveyor spoke with the administrative team on 10/17/18 at approximately 3:18pm regarding Resident #72's medications being held for vitals outside of parameters without a physician's order.
No further information was provided prior to exit.
2. The facility staff failed to ensure Resident # 21's insulin (Basaglar) was administered as ordered.
The clinical record of Resident #21 was reviewed 10/16/18 through 10/18/18. Resident #21 was admitted to the facility 9/20/17 and readmitted [DATE] with diagnoses that included but not limited to Type 2 diabetes mellitus, symbolic dysfunction, dysphagia, repeated falls, cardiomyopathy, cerebellar stroke syndrome, alcohol-induced chronic pancreatitis, chronic pain syndrome, anemia, transient ischemic attacks, gastric diverticulum, altered mental status, Barrett's esophagus without dysplasia, hypertension, hemiplegia affecting left dormant side, bipolar disorder, anxiety disorder, atrial fibrillation, acute respiratory infection, viral hepatitis without hepatic coma, and cerebral infarction due to embolism.
Resident #21's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/7/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15.
Resident #21's current comprehensive care plan had the focus area that read Resident #21 is at risk for hypo/hyperglycemia episodes r/t (related to): DM (diabetes mellitus). Requires daily insulin, requires sliding scale insulin. Interventions: Medication as ordered.
The September 2018 physician orders were reviewed. Resident #21 had orders for Basaglar KwikPen Solution Pen-Injector 100 unit/ml (milliliter) Inject 35 units subcutaneously at bedtime for DM.
The surveyor reviewed the September 2018 electronic medication administration records (eMAR). The box for the administration of Basaglar on 9/4/18 at 2100 (9:00 p.m.) was blank and on 9/30/18, the box for the administration of the Basaglar had 19. The legend read 19=Other/See Nurse Notes.
The surveyor reviewed the September 2018 progress notes. There was not a progress note written for 9/4/18 explaining the reason Basaglar had not been administered. The 9/30/18 progress note read Basaglar not available from pharmacy.
The surveyor informed the administrative staff that the insulin Basaglar was not available for administration on 9/30/18 in the end of the day meeting on 10/18/18 at 3:08 p.m. and requested the product information sheet for Basaglar, the facility policy on obtaining medications from the pharmacy, the facility policy on medication administration and the September 2018 progress notes.
The surveyor reviewed the facility policy titled Medication Shortages/Unavailable Medications on 10/18/18. The policy read in part 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility should notify pharmacy and arrange for an emergency delivery. 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions.
The surveyor reviewed the facility policy titled 6.0 General Dose Preparation and Medication Administration. The policy read in part 6. After medication administration, facility should take all measures required by facility policy and applicable law, including, but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, prn (whenever needed) medications, application sight) on appropriate forms.
The product information sheet for Insulin Glargine Solution for Injection (Trade Names Basaglar, Lantus, Lantus SoloStar, Toujeo Max SoloStar, and Toujeo SoloStar) was reviewed 10/18/18. Insulin Glargine is a human-made form of insulin. This drug lowers the amount of sugar in your blood. It is a long-acting insulin that is usually given once a day. This medicine is for injection under the skin. Use this medicine at the same time each day. It is important not to miss a dose. Your health care professional or doctor should discuss a plan for missed doses with you. If you do miss a dose, follow their plan. Do not take double doses.
No further information was provided prior to the exit conference on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to ensure call bell was in reach for 1 of 26 Residents, Resident #31.
The findings include:
The facility staff failed to ensure that that the call bell remained within reach for Resident # 31.
Resident # 31 is a [AGE] year-old-female who was originally admitted to the facility on [DATE] with a readmission date of 11/07/17. Diagnoses included but were not limited to muscle weakness, type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, and unspecified fracture of sacrum.
The clinical record for Resident #31 was reviewed on 11/16/18 at approximately 3:23pm. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 08/14/18 coded the Resident as 15 of 15 in section C, cognitive patterns. Section G assesses functional status. In Section G0110, the facility staff documented that Resident #31 required extensive assistance with one-person physical assist for locomotion on and off the unit, dressing, and personal hygiene. The facility staff also documented that Resident #31 was totally dependent requiring assistance of two or more persons in bed mobility, transfers, and toilet use.
Resident #31's CCP (comprehensive care plan) was reviewed and contained a focus area for At risk for falls related to: History of fall with fracture, generalized muscle weakness and anxiety, has interventions that included but were not limited to, Maintain safe environment and transfer with hoyer (lift) and two staff.
On 10/16/18 at approximately 11:40am, the surveyor observed Resident # 31 setting in wheel chair in the middle of room. The call bell was observed hanging off the top of the left side of the bed touching the floor and was not within reach of Resident # 31.
On 10/17/18 at approximately 9:12 am, the surveyor observed Resident # 31 watching television setting in wheel chair with bedside table positioned in the front of Resident #31. The call bell was clipped to the other end of the call bell cord next to the wall. Resident #31 was facing away from the area the call bell was located a few feet away. Call bell was not within the reach of Resident #31.
On 10/17/18 at approximately 2:00pm, the surveyor observed Resident #31 setting in wheel chair in the middle of room with the call bell on top of the left side of the bed. Call bell was not within the reach of Resident #31.
On 10/18/18 at approximately 3:08pm, the administrative staff was made aware of the findings as stated above.
No further information regarding this issue was provided to the survey team prior to the exit conference on 10/18/18.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate DDNR (durable do not resuscitate) order for 1 of 26 Residents Resident #8.
The findings included:
The facility staff failed to ensure the Residents DDNR was complete. Section's 1 and 2 had been left blank.
The clinical record review revealed that Resident #8 had been admitted to the facility 08/13/13. Diagnoses included, but were not limited to, Alzheimer's disease, hypothyroidism, nutritional deficiency, chronic pain syndrome, hypertension, and heart failure.
Section C (cognitive patterns) of the Residents significant change MDS (minimum data set) assessment with an ARD (assessment reference date) of 07/06/18 had been coded 1/1/2 to indicate the Resident had problems with long and short term memory and was moderately impaired in cognitive skills for daily decision making. Section O (special treatments, procedures, and programs) had been coded to indicate the Resident was receiving hospice services.
The Residents clinical record included a DDNR order form from the Virginia Department of Health. This form was dated 06/07/11 and read in part.
Under section 1 I further certify [must check 1 or 2]:
1.
The patient is CAPABLE of making an informed decision .
2.
The patient is INCAPABLE of making an informed decision .
Neither box had been checked.
Section 2 read, If you checked 2 above, check A, B, or C below . All three boxes had been left blank.
The Residents authorized representative had signed this form.
The administrative team were notified of the inaccurate DDNR during a meeting with the survey team on 10/17/18 at 3:20 p.m.
No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide advance notice of end of coverage in regards to medicare benefits for 1 of 26 Residents, Resident #74.
The findings included:
The facility failed to provide Resident #74 advance notice that the medicare part A services were ending.
The clinical record review revealed that Resident #74 had been readmitted to the facility 03/23/18. Diagnoses included, but were not limited to, muscle weakness, nutritional deficiency, major depressive disorder, chronic pain, anxiety disorder, glaucoma, and bipolar disorder.
Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 09/27/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points.
Resident #74 was one of three residents chosen for the task beneficiary protection notification review.
The facility provided the surveyor with two forms regarding this task and this resident:
1. SNFABN (skilled nursing facility advance beneficiary notice of non-coverage).
2. Notice of medicare non-coverage.
Both of these forms gave the date of 04/13/18 as the day the resident's medicare covered days would end. Both of these forms had been signed by the POA (power of attorney) on 04/13/18 indicating no advance notice had been given.
On 10/16/18 at 2:58 p.m., the surveyor interviewed the SW (social worker) regarding this resident's notice of medicare non-coverage and SNFABN. During this interview, the SW verbalized to the surveyor that no advance notice had been given to this resident and the SW that provided these notices to the resident was no longer employed at the facility.
The facility policy/procedure titled Medicare Cut Letter Policy read in part, .For Residents who will remain in the facility for any length of time following their last Medicare covered day and have days remaining in their benefit period, the Social Worker, or Designee, will notify the Resident/Authorized Representative when the resident is approaching the end of coverage but no later than 2 days prior to the last covered Medicare Part A day, and issue both the following Notices in the order indicated .Notice of Medicare Provider Non-Coverage CMS-10123 .Skilled Nursing Facility Advance Beneficiary notice CMS-10055 .
The administrative team were notified of the above issue during a meeting with the survey team on 10/17/18 at 3:20 p.m.
No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to complete a discharge MDS (minimum data set) assessment for 1 of 26 Residents, Resident #2.
The findings included:
The facility failed to complete a discharge MDS assessment. The Resident had been discharged from the facility on 06/29/18.
The record review revealed that Resident #2 had been admitted to the facility on [DATE], readmitted on [DATE], and discharged on 06/29/18. Diagnoses included, but were not limited to, muscle weakness, dysphagia, depressive disorder, heart failure, and hypertension.
Section C (cognitive patterns) of the Residents quarterly MDS assessment with an ARD (assessment reference date) of 05/21/18 included a BIMS (brief interview for mental status) summary score of 12 out of a possible 15 points.
Resident #2 was flagged in the long-term care survey process as having an overdue MDS assessment.
A review of the EHR (electronic health record) revealed that this Resident had been discharged from the facility on 06/29/18. However, the surveyor was unable to locate a discharge MDS assessment.
On 10/18/18 at 10:50 a.m., MDS nurse #1 and the surveyor reviewed the Residents EHR. After reviewing the EHR MDS nurse #1 verbalized to the surveyor that a discharge assessment had not been completed on this Resident but one would be completed today.
The administrative team of the facility was made aware of the missing MDS assessment during a meeting with the survey team on 10/18/18 at 3:08 p.m.
No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review the facility failed to complete a level 1 PASARR (preadmission screening and annual resident review) for 1 of 26 Residents, Resident #74.
The findings included:
The facility failed to ensure a level 1 PASARR was completed. A PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long-term care.
The clinical record review revealed that Resident #74 had been readmitted to the facility 03/23/18. Diagnoses included, but were not limited to, muscle weakness, nutritional deficiency, major depressive disorder, chronic pain, anxiety disorder, glaucoma, and bipolar disorder.
Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 09/27/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points.
During the clinical record review, the surveyor was unable to locate a PASARR in the Residents EHR (electronic health record).
On 10/16/18 at 4:43 p.m., the surveyor interviewed the SW (social worker) concerning the missing PASARR. The SW reviewed the EHR with the surveyor and then stated she would see if she could find anything in the previous SW's office.
On 10/16/18 at 4:49 p.m., the SW approached the surveyor and stated she was unable to locate the missing PASARR.
The administrative team were notified of the missing PASARR during a meeting with the survey team on 10/17/18 at 3:20 p.m.
No further information regarding the missing PASARR was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for 2 of 26 residents (Resident #33 and Resident #66).
The findings included:
1. The facility staff failed to develop a care plan for comfort care for Resident #33.
The clinical record of Resident #33 was reviewed 10/16/18 through 10/18/18. Resident #33 was admitted to the facility on [DATE] with diagnoses, that included but not limited to hypomagnesia, insomnia, chronic pain syndrome, dry eye syndrome, hypertension, chronic diastolic heart failure, lymphedema, acute frontal sinusitis, gastroesophageal reflux disease, urinary tract infection, left knee hemarthosis, right elbow contracture, major depressive disorder, nutritional deficiency, and dysthymic disorder.
Resident #33's significant change in minimum data set (MDS) with an assessment reference date (ARD) of 8/16/18 assessed the resident with a BIMS (brief interview for mental status) as 12 out of 15 in Section C.
The October 2018 physician orders were reviewed. The physician ordered Resident #33 to have comfort care on 10/6/18. The surveyor reviewed the current comprehensive care plan that was not dated. The surveyor was unable to locate a care plan for comfort care.
The surveyor informed licensed practical nurse#3/minimum data set nurse of the above concern on 10/18/18 at 1:44 p.m. L.P.N.#3/MDS nurse stated the floor nurses were responsible for the day-to-day update of the care plan and should have updated the care plan to include comfort care. L.P.N. #3/MDS stated the comprehensive care plan for the admission, annual, and significant changes were the responsibility of the MDS nurses.
The surveyor informed the administrative staff of the above concern on 10/18/18 at 3:08 p.m.
No further information was provided prior to the exit conference on 10/18/18.
2. Resident #66 was admitted to the facility on [DATE] with diagnoses including muscle weakness, dysphagia, dementia in other diseases classified elsewhere without behavioral disturbance, cerebral infarction due to embolism of other cerebral artery, type II diabetes mellitus without complications, essential primary hypertension, other specified anxiety disorders, major depressive disorders, insomnia, and chest pain. On the quarterly minimum data set assessment with assessment reference date 9/17/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting care. The resident's medication assessment was coded under Medications received (N0410 A) as receiving anti-psychotic medications 7 of the 7 days prior to the assessment. Under Anti-psychotic Medication Review (0450), the resident was coded as not receiving anti-psychotic medications since admission or the prior assessment.
The resident's comprehensive care plan did not list dementia as a problem. No interventions under other care areas addressed symptoms of the resident's dementia. The comprehensive care plan did not address the resident's use of anti-psychotic medication or the symptoms and behaviors to be addressed by the anti-psychotic medication.
The surveyor asked the director of nursing for documentation of the symptoms for which the anti-psychotic Seroquel 100 milligram daily for anxiety with behaviors was being used along with documentation of the need for the anti-psychotic medication for anxiety rather than an anxiolytic medication.
Seroquel 100 mg daily was ordered 9/5/18 for anxiety with behaviors. There was no documentation of behavior symptoms. This was reportedly an increase to the prior dose after a gradual dose reduction attempt started 8/27/18. On 9/13/18, an administrative order for non-pharmacologic intervention codes for anxiety with behaviors was entered. No interventions were documented. An order to monitor for side effects associated with Seroquel documented no side effects.
Review of physician notes, psychiatric evaluations, and nursing progress notes revealed no documentation of the symptoms for which the resident was being treated with anti-psychotic medication. A nursing note dated 8/27/18 15:13 Resident continues to holler help, help. When staff asks resident what he needs his response varies: Can you move my covers, can you straighten my leg, can you pull me up. In no case after yelling help, help is the resident in any danger of falling off bed, no bleeding, no distress. Both he and his mother are very impatient when it comes to ADL(activity of daily living) care. The next note on 8/28/18 18:54 Resident turns light on shortly after receiving dinner tray staff feeding other residents and passing out trays when staff answers light resident state he is wet needing to be changed CNA told resident she would be back after taking cart to kitchen resident turns light back on before CNA can take cart to kitchen and come back. A note dated 9/2/18 18:39 Resident put on light at 1630 and 1715 stating he was wet CNA in both times resident was dry. No other notes concerning behavior or symptoms were documented before 9/5/18 17:09 FNP (family nurse practitioner) made aware that since Seroquel dosage change, resident has been experiencing increased anxiety and agitation. New orders received to restart previous dosage. The surveyor inferred that the behaviors for which the resident was being treated with an anti-psychotic medication were ringing the call bell when not bleeding or in danger of falling, and requesting help during meal times. No other behaviors or symptoms were documented by nursing or medical staff.
The resident was hospitalized after the initial brief contact on 10/16/18, so the surveyor was unable to complete the resident interview and assess for the use of chemical restraint for staff convenience.
The administrator, director of nursing and assistant director of nursing were notified of the concern during a summary meeting on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide mouth care to 1 of 26 residents (Resident #59).
The findings included:
The facility staff failed to provide mouth care to Resident #59.
The clinical record of Resident #59 was reviewed 10/16/18 through 10/18/18. Resident #59 was admitted to the facility 8/12/17 and readmitted [DATE] with diagnoses that included but not limited to metabolic encephalopathy, severe sepsis with shock, dysphagia, neuromuscular dysfunction of the bladder, hypertension, atherosclerotic heart disease, obsessive compulsive personality disorder, rhabdomyolysis, end stage renal disease, anxiety disorder, mental disorder, repeated falls, hyperkalemia, urinary tract infection, Parkinson's disease, and major depressive disorder.
Resident #59's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/12/18 assessed the resident with a BIMS (brief interview for mental status) as 9/15. Section G Functional Status was marked that the resident was totally dependent on 2 persons for personal hygiene, which includes brushing teeth. Section L was not coded with any broken or loosely fitting dentures, mouth or facial pain, discomfort or difficulty chewing.
Resident #59's current comprehensive care plan had the focus area that read Resident #59 has self-care deficit. Requires assist with all levels of care. Date initiated: 04/03/2018 Revision on: 09/21/2018. Interventions: Assist with activities of daily living, dressing, grooming, toileting, feeding, oral care.
The surveyor interviewed Resident #59 on 10/16/18 at 5:12 p.m. During the interview, Resident #59 was asked how often staff brush his teeth. Resident #59 stated his teeth had not been brushed in ages. The surveyor checked the bathroom for toothpaste and toothbrush but found none. With the resident's permission, the surveyor checked the dresser drawers. The surveyor was unable to locate toothpaste but did find a toothbrush still in the packaging. The surveyor asked certified nursing assistant #1 the location of Resident #59's toothbrush and toothpaste. C.N.A. #1 was unable to locate a toothbrush or toothpaste and stated, This was the first day she had been assigned to Resident #59.
The surveyor interviewed Resident #59's nurse licensed practical nurse #2 on 10/16/18 at 5:15 p.m. L.P.N. #2 stated staff should be doing mouth care twice per day.
The surveyor requested the activities of daily living for mouth care records for September 2018 and October 2018 from the corporate registered nurse on 10/17/18.
The surveyor reviewed the October 2018 ADL records for mouth care. The staff had failed to provide mouth care on the evening shift 10/1/18 through 10/5/18 and on 10/12/18 on day shift.
The surveyor informed the administrative staff of this concern in the end of the day meeting on 10/17/18 at 3:20 p.m.
No further information was provided prior to the exit conference on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review, and clinical record review, it was determined that facility staff failed to follow physician's orders for 1 of 25 Residents in the survey sample, Resident # 90.
The findings included:
The facility staff failed to follow physician's orders for dressing changes twice a day for Resident # 90.
Resident # 90 was an [AGE] year-old female who was originally admitted to the facility on [DATE] with a readmission date of 3/5/18. Diagnoses included but were not limited to: osteoarthritis, cellulitis of right lower limb, hypertension, and non-pressure chronic ulcer of right lower leg.
The clinical record for Resident # 90 was reviewed on 10/17/18 at 9:51 am. The most recent MDS assessment (minimum data set) was a quarterly assessment with an ARD date (assessment reference date) of 9/28/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 90 had a BIMS score (brief interview for mental status) of 12 out of 15 which indicated that Resident # 90's cognitive status was moderately impaired. Section M of the MDS assesses skin conditions. In Section M1030, the facility staff documented that Resident # 90 had 1 venous or arterial ulcer. In Section M1200, the facility staff documented that Resident # 90 had received ointment/medications and nonsurgical dressings during the lookback period for the 9/28/18 ARD.
The plan of care for Resident # 90 was reviewed and revised on 8/28/18. The facility staff documented a focus area for Resident # 90 as Resident # 90 has impaired skin integrity related to vascular wound to right lower extremity and 8/28/18 surgical to right thigh. Interventions included but were not limited to: Administer treatments as ordered.
The physician signed the current order for Resident # 90 on 9/23/18. Orders included but were not limited to: Cleanse right lower leg with wound cleanser, liberally apply barrier cream to periwound-apply the barrier cream to the edges of the wound bed follow with 0.125% Dakin's moistened 4x4 gauze directly to wound bed and cover with ABD (abdominal) pad wrap with Kerlix BID (twice daily) and as needed.
On 10/17/18 at 8:54 am, the surveyor conducted an interview with Resident # 90. During the interview Resident # 90 stated, The doctor says they want my leg done twice a day and they don't do it. I talked to the head nurse and she says it's written down that they are doing it but they are not. So I have started writing down when they do it, but they don't know I'm doing it. Resident # 90 also stated, they came in at 5:30 this morning and did my dressing. Resident # 90 provided the surveyor with a handwritten note that contained the following documentation:
Leg
10/9/18 at Dr. (doctor) office
10/10/18-3:45 pm
10/11/18-4pm
10/12/18-6:30pm
10/13/18-11:30 am
10/14/18-11am
10/15/18-4:30pm
10/16/18-10:45am
10/17/18-5:30am/Doc (doctor)
On 10/17/18 at 9:15 am, the surveyor reviewed the October 2018 treatment administration record for Resident # 90. The surveyor observed that there was no documentation that the treatment Resident # 90's right lower leg was completed on the night shift on 10/5/18. The surveyor also reviewed the treatment administration record for the dates that Resident # 90 had presented to the surveyor on the handwritten note. The surveyor noted that the documentation in the clinical record reflected that the treatment had been completed twice a day as ordered by the physician from 10/9/18 through 10/16/18. The surveyor reviewed the progress notes for Resident # 90 and did not locate any documentation that Resident # 90 had a doctor's appointment on 10/9/18.
On 10/17/18 at 9:37 am, the surveyor spoke with the unit manager RN # 1 (registered nurse). The surveyor asked RN #1 if Resident # 90 had gone out for a doctor's appointment on 10/9/18. RN # 1 looked at her calendar and confirmed that Resident # 90 did go out of the facility to a doctor's appointment on 10/9/18.
On 10/17/18 at 9:42 am, the surveyor spoke with unit manager RN # 1 (registered nurse) in the presence of the survey team and made her aware of Resident # 90's concerns that the treatment to her right lower leg was not being completed twice a day as ordered by the physician. The surveyor asked RN # 1 if Resident # 90 had reported to her that her treatments had not been done twice a day as ordered by the physician. RN # 1 stated that Resident # 90 had not reported to her that her treatments had not been done twice a day as ordered.
On 10/17/18 at 4:50 pm, the surveyor interviewed RN # 2. RN # 2 documented that she had completed Resident # 90's treatment to her right lower leg on the day/evening shift on 10/9/18. The surveyor asked RN # 2 if she was responsible for taking care of Resident # 90 on 10/9/18. RN # 2 stated that she did care for Resident # 90 on 10/9/18. The surveyor asked RN # 2 if she had completed a treatment to Resident # 90's right lower leg on 10/9/18. RN # 2 stated that she did not do the dressing because Resident # 90 went to the doctor and they did the dressing there. The surveyor reviewed the treatment administration record along with RN # 2. The surveyor showed RN # 2 that the documentation on the treatment administration record for 10/9/18 reflects that she completed the dressing to Resident # 90's right lower leg, even though she stated that she had not done the treatment.
The facility policy on General Dose Preparation and Medication Administration contained documentation that included but was not limited to: .6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN (as needed) medications, application sight) on appropriate forms.
On 10/18/18 at 3:15 pm, the administrative team was made aware of the findings as stated above.
No further information was provided to the survey team prior to the exit conference on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide appropriate treatments for pressure ulcers for 3 of 26 residents (Resident #33, Resident #56 and Resident #97).
The findings included:
1. The facility staff failed to provide treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from forming for Resident #33.
The clinical record of Resident #33 was reviewed 10/16/18 through 10/18/18. Resident #33 was admitted to the facility on [DATE] with diagnoses, that included but not limited to hypomagnesia, insomnia, chronic pain syndrome, dry eye syndrome, hypertension, chronic diastolic heart failure, lymphedema, acute frontal sinusitis, gastroesophageal reflux disease, urinary tract infection, left knee hemarthosis, right elbow contracture, major depressive disorder, nutritional deficiency, and dysthymic disorder.
Resident #33's significant change in minimum data set (MDS) with an assessment reference date (ARD) of 8/16/18 assessed the resident with a BIMS (brief interview for mental status) as 12 out of 15 in Section C. Section M Skin Conditions assessed the resident was at risk for the development of pressure ulcers and that there was at least one unhealed pressure ulcer at a stage 1 or higher. Resident #33 was coded to have one stage 3 pressure ulcer and one unable to stage (UTS) pressure ulcer with slough and/or eschar. Skin and ulcer treatments marked were a pressure-reducing device for bed, application of nonsurgical dressings and application of ointments/medications.
Resident #33's current comprehensive care plan was reviewed 10/16/18 through 10/18/18. Resident #33 had the focus area that read At risk for skin integrity/t (related to) hx (history) of gluteal healing and reopening, assistance with bed mobility, disease progression, and incontinent of bowels-8/6/18 Open area to sacrum. Interventions: 8/6/18 Treatment to sacrum daily. Low air loss mattress, off load in bed, inspect skin during routine daily care, and treatment as ordered.
Resident #33's current wound care orders dated 10/4/18 read to cleanse wound with ¼ strength Dakin's solution daily. Apply Santyl and Bactroban ointment and Dakin's moistened kerlix to wound bed daily. Cover with dry dressing daily.
The surveyor observed wound care on 10/18/18 at 10:55 a.m. with licensed practical nurse #2. L.P.N. #2 had already prepared the over the bed table stating the table had been cleaned with Sani-wipes, a barrier had been placed, and supplies had been placed on the table (gauze, a tube of santyl ointment, Dakin's solution bottle and a tube of Bactroban ointment). L.P.N. #2 washed hands, donned gloves, and unfastened brief. Resident #33 was observed with bunny boots on both heels. L.P.N. #2 removed the old dressing and placed the dressing in a red bag and removed the gloves. L.P.N. #2 washed hands and donned gloves. The sacral wound was cleaned with quarter strength Dakin's solution. L.P.N. #2 removed scissors from the uniform pocket and placed them on the over the bed table. L.P.N. #2 then used the scissors to cut the kerlix and placed the scissors back on the table. L.P.N. #2 did not change gloves or wash hands after cleaning the wound. L.P.N. #2 did not clean the scissors before the kerlix was cut to be used for packing Resident #33's sacral wound. L.P.N. #2 moistened the gauze with Dakin's solution and applied Bactroban and Santyl on the moistened gauze. L.P.N. #2 then packed the wound with gauze. L.P.N. #2 removed gloves and washed hands. L.P.N. #2 donned gloves and applied border dressing, dated tape and then applied to dressing. All supplies were removed from table. L.P.N. #2 placed scissors back into uniform pocket without cleaning them. L.P.N. #2 discarded bag in trash can in bathroom, removed gloves, washed hands and cleaned table with sani-cloth. Resident #33 was repositioned to back.
The surveyor requested the facility policy on dressing changes from the director of nursing on 10/18/18 at 12:00 noon.
The director of nursing (DON) informed the surveyor 10/18/18 at 12:29 p.m. that the facility did not have a policy for dressing changes. When asked if scissors should be cleaned before use and if the nurse should change gloves, wash hands and apply new gloves after cleaning a pressure ulcer, the DON stated she would expect scissors to be cleaned before use and gloves changed and hands washed after cleaning a wound.
The surveyor informed the administrative staff of the above concern during the end of the day meeting on 10/18/18 at 3:20 p.m.
No further information was provided prior to the exit conference on 10/18/18.
2. The facility staff failed to ensure skin checks had accurate documentation for Resident #56.
The clinical record of Resident #56 was reviewed 10/16/18 through 10/18/18. Resident #56 was admitted to the facility 5/15/18 with diagnoses that included but not limited to dysphagia, symbolic dysfunctions, chronic atrial fibrillation, hypertension, atherosclerotic heart disease, acute on chronic systolic heart failure, nutritional anemia, pneumothorax, gastroesophageal reflux disease, dementia without behavioral disturbances, transient ischemic attacks, gout, restlessness and agitation, urine retention, left heel pressure ulcer, sacral pressure ulcer, and left femur fracture.
Resident #56's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/11/18 assessed the resident with a BIMS (brief interview for mental status) as 9 out of 15. Section M Skin Conditions was marked that the resident was at risk for the development of pressure ulcers and the resident did have one or more currently that are greater than stage 1. Resident #56 was marked to have 1 unstageable-deep tissue injury pressure ulcer.
Resident #56's comprehensive care plan identified a focus area that read Resident #56 has impaired skin integrity to sacrum and (L) (left) heel. Interventions: 7/25/18 Monitor skin integrity. Administer medications and treatments as ordered. Assess and document the status of the area (healing vs declining).
The surveyor reviewed the October 2018 Bi-Weekly Skin Checks. The 10/10/18, 10/13/18, and 10/16/18 skin assessments read that the resident had current skin issues but there was nothing marked on the picture diagram or under the site/description of the skin issues.
The surveyor informed the director of nursing of the above concern and shown the skin assessments for October 2018. The DON stated the documentation on the skin assessments was missing and documentation should be done.
The surveyor requested the skin assessments for 10/10/18, 10/13/18, and 10/16/18 on 10/18/18 at 10:30 a.m.
The surveyor informed the administrative staff of the above concern during the end of the day meeting on 10/18/18 at 3:20 p.m.
The surveyor reviewed the facility policy titled Pressure Ulcer Policy Wound Management on 10/18/18. The policy read in part Monitoring: 1. Should evaluate and document when there are identified changes. 3. Twice weekly, on bath/shower days, the nursing assistant will look at the resident's skin and place the identified area on the shower sheet. The nursing assistant will report any reddened and/or areas of concern to the licensed nurse. 4. The licensed nurses will complete a head to toe body review twice a week as well. This head to toe body review is in addition to the nursing assistant's skin review.
No further information was provided prior to the exit conference on 10/18/18.
3. The facility staff failed to follow the physician's orders for the Magic Butt Paste bid (twice a day) for prevention to Resident #97's sacral pressure ulcer.
The clinical record of Resident #97 was reviewed 10/16/18 through 10/18/18. Resident #97 was admitted to the facility on [DATE] for respite care. Diagnoses included but were not limited to chronic obstructive pulmonary disease, psoriasis, major depressive disorder, gastro-esophageal reflux disease, nausea with vomiting, constipation, and chronic pain syndrome.
An entry minimum data set (MDS) assessment was completed on 3/9/18 and a discharge MDS with an assessment reference date (ARD) of 3/11/18 was completed 3/11/18. Section C Summary Score assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #97 required extensive support for bed mobility, transfers, and locomotion on and off the unit. Resident #97 was totally dependent on staff for dressing, toilet use, and personal hygiene. Resident #97 was assessed to be incontinent of bladder occasionally and bowel frequently.
Resident #97's initial care plan identified self-care deficits and staff to assist with activities of daily living, dressing, grooming, toileting, feeding, and oral care. Also identified on the care plan was at risk for impaired skin integrity, fragile skin and impaired mobility. Interventions: inspect skin during routine care daily, lotion to skin as needed, pressure reduction devices if needed, treatments per order, and turn and repositions per specific routine and/or as needed. Resident has history of diagnosis of depression and or anxiety, difficulty sleeping/insomnia. Interventions: Medications as ordered by physician and provide a calm, reassuring and non-threatening environment.
The hospice communication note dated 3/9/18 read Resident has a small stage 2 pressure injury to his sacrum. Orders to keep area clean and dry, cover with Magic Butt Paste twice daily.
The admission skin check and weekly wound assessment completed 3/9/18 at 12:50 p.m. read the resident does have current skin issues. Resident has an area on sacrum that measures 1 cm (centimeter) x 1 cm, tx (treatment) in place. Treatment: Butt Paste to sacrum bid (twice a day).
The bi-weekly skin check completed 3/9/18 at 8:50 p.m. read the resident does have current skin issues on sacrum with treatment in place.
Resident #97's March 2018 admission orders included Magic Butt Paste two times a day for Preventive-start date 3/9/18.
The surveyor reviewed Resident #97's clinical record and was unable to locate any documentation that the twice a day treatment ordered by the physician had been done. There were no treatment administration records for March 2018 or documentation in the progress notes that the treatment to the sacral pressure ulcer had been completed.
No further information was provided prior to the exit conference on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure a hazard free environment for 1 of 26 residents (Resident #28).
The findings included:
The facility staff failed to follow the physician order for bilateral floor mats for Resident #28.
The clinical record of Resident #28 was reviewed 10/16/18 through 10/18/18. Resident #28 was admitted to the facility 9/7/16 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, dysphagia, right shoulder contracture, major depressive disorder, Type 2 diabetes mellitus, seizures, iron deficiency anemia, urine retention, anxiety disorder, moderate protein calorie malnutrition, peripheral vascular disease, gastroesophageal reflux disease, bradycardia, diabetic neuropathy, chronic pain syndrome, paraplegia, acute renal failure, gastritis, bacteremia, hyperkalemia, insomnia, and hypertension.
Resident #28's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/10/18 assessed the resident with a BIMS (brief interview for mental status) as 15 out of 15. Section J1800 Health Conditions/Falls assessed that the resident did not have any falls since admission, reentry, or prior assessment.
Resident #28's current comprehensive care plan identified a focus area that the resident was at risk for falls r/t (related to) paraplegia and hx (history) of seizures. Date initiated: 08/14/2018 revision on: 08/15/2018. Interventions: Bil (bilateral) floor mats, maintain call light within reach. Educate resident to use call light, maintain needed items within reach, PT (physical therapy)/OT (occupational therapy)/SLP (speech/language pathologist) evaluation.
The surveyor observed Resident #28 during the initial tour on 10/16/18 beginning at 9:10 a.m. Resident #28 was in bed. The surveyor did not observe any mats placed on either side of the bed.
The surveyor interviewed Resident #28 on 10/16/18 at 10:53 a.m. The surveyor asked if the resident had had any recent falls and the resident stated it had been over a year since he had fallen.
The surveyor observed Resident #28 on 10/17/18 at 10:50 a.m. The resident was in bed. There were no mats on either side of the bed. The surveyor interviewed certified nursing assistant #1 on 10/17/18 at 10:50 a.m. C.N.A. #1 stated the resident does not have floor mats.
The surveyor reviewed Resident #28's October 2018 physician orders. The resident has an order for bil (bilateral) mats at bedside ordered to start 8/15/18.
The surveyor informed the administrative staff of the above concern in the end of the day meeting on 10/17/18 at 3:20 p.m.
The assistant director of nursing informed the surveyor on 10/18/18 at 11:52 a.m. that the order for the mats had been discontinued. When asked where the staff document the placement of the mats, the ADON stated they don't document the placement of the mats on the medication records or the treatment records.
No further information was provided prior to the exit conference on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. For Resident #35 the facility staff failed to ensure Foley catheter tubing was anchored.
Resident #35 was admitted to the facility on [DATE]. Diagnoses included but not limited to unspecified dementia with behavioral disturbance, heart failure, pressure ulcer of sacral region, and encounter for palliative care.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 08/17/18 coded the Resident 00 of 15 in section C, cognitive patterns.
Resident #35's CCP (comprehensive care plan) was reviewed and contained a focus area of requires urinary catheter related to wound on sacrum. Interventions included but were not limited to, maintain drainage bag below the bladder level, and change catheter and draining system as indicated by the physician.
Resident #35's clinical record was reviewed on 10/17/18. It contained a physician's order summary which read in part, Anchor catheter tubing and check placement every shift.
Resident #35 was observed by the surveyor on 10/16/18 at approximately 11:02 am. Resident was resting in bed. Surveyor asked if Resident's catheter was anchored, LPN (licensed practical nurse) #1 checked Resident #35. Catheter tubing was not anchored and was positioned in Resident's groin area. Surveyor asked LPN #1 if Foley catheter should be anchored, and LPN #1 stated that she would have to check the Resident's orders and left the room. LPN#1 reentered the room with a StatLock foley catheter stabilization device. LPN#1 proceeded to apply device to the Resident's left thigh and stabilized catheter.
The concern of the Foley catheter not being anchored was discussed with the administrative team during a meeting on 10/17/18 at approximately 3:18 pm. The surveyor requested a policy on catheter care at this time. The administrator provided the surveyor with said policy titled Catheter Care Urinary Male-Female on 10/17/18. This policy read in part 18. Secure catheter utilizing a leg band.
No further information was provided prior to exit.
4. The facility staff failed to ensure that catheter tubing was positioned to prevent the backflow of urine into the bladder and failed to ensure that the catheter was secured for Resident # 36.
Resident # 36 was an [AGE] year-old-female who was originally admitted to the facility on [DATE] with a readmission date of 5/17/18. Diagnoses included but were not limited to: Stage 4 pressure ulcer, dementia, anxiety disorder, and hypertension.
The clinical record for Resident # 36 was reviewed on 10/17/18 at 9:09 am. The most recent MDS assessment (minimum data set) was a quarterly assessment with an ARD date (assessment reference date) of 8/20/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 36 had a BIMS score (brief interview for mental status) of 0 out of 15, which indicated that Resident # 36's cognitive status was severely impaired. Section H of the MDS assesses bladder and bowel. In Section H0100, the facility staff documented that Resident # 36 had an indwelling catheter.
The current plan of care for Resident # 36 was initiated on 5/17/18. The facility staff documented a focus area for Resident # 36 as Resident # 36 requires urinary catheter to promote wound healing. Interventions included but were not limited to: Foley securement devise as ordered, and Maintain drainage bag below the bladder level.
Resident # 36 had current orders that were initiated on 5/17/18 that included but were not limited to: Anchor catheter tubing and check placement every shift, and Maintain catheter drainage bag below the level of the bladder every shift.
On 10/18/18 at 11:10 am, the surveyor observed wound care of Resident # 39. During the wound care observation the surveyor observed that the Resident # 36's Foley catheter was not secured, and that the catheter tubing was positioned over a bed bolster on the right side of Resident # 36 promoting the flow of urine back into the bladder. The surveyor asked LPN # 1 (licensed practical nurse) if the Foley catheter for Resident # 36 should be secured. LPN # 1 stated, I will get one and get it on her. I probably came off during ADL care. (Activities of daily living) The surveyor asked LPN # 1 if Resident # 36's catheter tubing should be positioned over the bed bolster. LPN # 1 repositioned Resident # 36's catheter tubing to run along the side of the bed bolster.
The facility policy on Catheter Care Urinary Male-Female contained documentation that included but was not limited to:
. 18. Secure catheter utilizing a leg band.
19. Check drainage tubing and bag to insure that the catheter is draining properly.
On 10/18/18 at 3:15 pm, the administrative team was made aware of the findings as stated above.
No further information regarding this issue was provided to the survey team prior to the exit conference on 10/18/18.
Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide appropriate treatment and services for care of residents with a clinically justified indwelling catheter for 5 of 26 residents (Resident # 28, Resident #33, Resident #59, Resident #36, and Resident #35).
The findings included:
1. The facility staff failed to ensure the indwelling Foley catheter was anchored and failed to obtain a physician order for the size of the catheter and the balloon for the indwelling Foley catheter for Resident #28.
The clinical record of Resident #28 was reviewed 10/16/18 through 10/18/18. Resident #28 was admitted to the facility 9/7/16 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, dysphagia, right shoulder contracture, major depressive disorder, Type 2 diabetes mellitus, seizures, iron deficiency anemia, urine retention, anxiety disorder, moderate protein calorie malnutrition, peripheral vascular disease, gastroesophageal reflux disease, bradycardia, diabetic neuropathy, chronic pain syndrome, paraplegia, acute renal failure, gastritis, bacteremia, hyperkalemia, insomnia, and hypertension.
Resident #28's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/10/18 assessed the resident with a BIMS (brief interview for mental status) as 15 out of 15. Section H Bladder and Bowel was coded for the presence of an indwelling catheter.
The current comprehensive care plan for Resident #28 identified the focus area that read Resident requires suprapubic r/t (related to) paraplegia and neurogenic bladder. Date initiated: 08/14/2018 Revision on: 08/15/2018. Interventions: Catheter care every shift, maintain drainage bag below bladder and provide privacy, change catheter and drainage system as indicated by the physician.
The surveyor observed Resident #28 during the initial tour of the facility beginning at 9:10 a.m. on 10/16/18. Resident #28 was observed in bed. The surveyor observed a Foley drainage bag hooked to the left side of the bed and asked the resident if the tubing was secure with a band. The resident stated No.
The surveyor and the unit manager registered nurse #1 checked Resident #28's thigh for the presence of a leg band. R.N. #1 stated the tubing was not anchored and stated she would get one. R.N. #1 was asked to check the size of the current catheter. R.N. #1 stated the size was 16 Fr (French) with a 10 cc (cubic centimeter) balloon.
The surveyor reviewed the October 2018 physician orders. There were no physician orders for the size of the catheter or the balloon. Resident #28 had physician orders to anchor catheter tubing and check placement every shift, catheter care every shift, maintain drainage bag below bladder and provide privacy bag, change catheter prn (as needed) for protocol change as needed-all orders dated 8/13/18. The surveyor informed the unit manager R.N. #1 of these concerns on 10/16/18 at the conclusion of the initial tour.
The surveyor requested the facility policy on Foley catheters from the director of nursing on 10/16/18 at 1:30 p.m. The surveyor reviewed the facility policy titled Catheter Care Urinary Male-Female on 10/16/18. The policy read in part 18. Secure catheter utilizing a leg band.
The surveyor informed the administrative staff of the above concern on 10/17/18 at 3:20 p.m.
No further information was provided prior to the exit conference on 10/18/18.
2. The facility staff failed to ensure the indwelling Foley catheter bag was not touching the floor and the facility staff failed to follow the physician order for the size of the catheter and balloon for Resident #33.
The clinical record of Resident #33 was reviewed 10/16/18 through 10/18/18. Resident #33 was admitted to the facility on [DATE] with diagnoses, that included but not limited to hypomagnesia, insomnia, chronic pain syndrome, dry eye syndrome, hypertension, chronic diastolic heart failure, lymphedema, acute frontal sinusitis, gastroesophageal reflux disease, urinary tract infection, left knee hemarthosis, right elbow contracture, major depressive disorder, nutritional deficiency, and dysthymic disorder.
Resident #33's significant change in minimum data set (MDS) with an assessment reference date (ARD) of 8/16/18 assessed the resident with a BIMS (brief interview for mental status) as 12 out of 15 in Section C. Section H Bladder and Bowel was coded for an indwelling catheter.
Resident #33's current comprehensive care plan was reviewed 10/16/18 through 10/18/18. Resident #33 had the focus area that read Resident #33 has indwelling catheter for wound healing. Interventions: Indwelling cath (catheter) per order. Cath care per physician's orders.
During the initial tour on 10/16/18 beginning at 9:10 a.m., the surveyor observed Resident #33 in bed. The surveyor observed the bed to be in a low position with the indwelling Foley catheter drainage bag touching the floor.
The surveyor observed Resident #33 still in bed with the Foley catheter drainage bag touching the floor at 9:47 a.m.
The surveyor and the unit manager registered nurse #1checked the Foley catheter drainage bag on 10/16/18 at 9:47 a.m. The indwelling Foley catheter was not anchored and was still touching the floor. The unit manager R.N. #2 stated she would have to figure out what to do with the catheter bag with the bed in the lowest position. The surveyor asked the unit manager R.N. #2 if indwelling Foley catheters were to be anchored. R.N. #2 stated yes.
Resident #33's clinical record was reviewed for catheter size and frequency of Foley changes. The Foley catheter order dated 8/11/18 read Foley catheter 14 Fr (French) continuous drainage for wound healing every shift for monitoring. A balloon size for the indwelling Foley catheter was not included in the physician order.
The surveyor and the unit manager checked the size of the catheter with the resident's permission on 10/17/18 at 11:11 a.m. The size of Resident #33's indwelling Foley catheter was a 16 Fr with a 30 cc (cubic centimeter) balloon. The 8/11/18 Foley catheter order was for 14 French and a balloon size had not been ordered by the physician.
The surveyor requested the facility policy on Foley catheters from the director of nursing on 10/16/18 at 1:30 p.m. The surveyor reviewed the facility policy titled Catheter Care Urinary Male-Female on 10/16/18. The policy read in part 18. Secure catheter utilizing a leg band.
The surveyor informed the administrative staff of the above concern with the placement of the indwelling Foley catheter drainage bag, the indwelling Foley catheter not anchored, the physician order did not include the balloon size for the Foley catheter, and no physician order for the 14 Fr catheter the resident currently had in the end of the day meeting on 10/17/18 at 3:20 p.m.
No further information was provided prior to the exit conference on 10/18/18.
3. The facility staff failed to ensure Resident #59's indwelling Foley catheter care was not touching the floor.
The clinical record of Resident #59 was reviewed 10/16/18 through 10/18/18. Resident #59 was admitted to the facility 8/12/17 and readmitted [DATE] with diagnoses that included but not limited to metabolic encephalopathy, severe sepsis with shock, dysphagia, neuromuscular dysfunction of the bladder, hypertension, atherosclerotic heart disease, obsessive compulsive personality disorder, rhabdomyolysis, end stage renal disease, anxiety disorder, mental disorder, repeated falls, hyperkalemia, urinary tract infection, Parkinson's disease, and major depressive disorder.
Resident #59's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/12/18 assessed the resident with a BIMS (brief interview for mental status) as 9/15. Section H Bladder and Bowel was coded for the presence of an indwelling catheter. The current comprehensive care plan had the focus area that read Resident #59 has nephrostomy tube and Foley catheter. At risk for UTI (urinary tract infection). Date initiated: 04/03/2018 Revision on: 09/21/2018. Interventions: Staff to position catheter bag and tubing below the level of the bladder and away from entrance room door. Privacy bag in place.
The surveyor observed Resident #59 during the initial tour on 10/16/18 at 10:02 a.m. Resident #59 was lying in bed. The surveyor observed an indwelling Foley catheter drainage bag on the floor along with the tubing. The surveyor requested the unit manager registered nurse #1. The unit manager registered nurse #1 was asked if the Foley drainage bag should be touching the floor. R.N. #1 stated no, got a pair of gloves and hooked the drainage bag to the bed frame.
The surveyor informed the administrative staff of the above observation during the end of the day meeting on 10/17/18 at 3:20 p.m. The surveyor asked if the Foley drainage bag should be touching the floor. The director of nurses stated no. The surveyor requested the facility policy for placement of Foley catheter drainage bags.
No further information was provided prior to the exit conference on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain orders in regards to PICC line dressing changes for 1 of 26 Residents in the survey sample, Resident # 100.
The findings included:
The facility staff failed to ensure that Resident # 100 had orders for PICC (peripherally inserted central catheter) line dressing changes.
Resident # 100 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to: MRSA (methicillin-resistant staphylococcus aureus), Parkinson's disease, schizophrenia, and muscle weakness.
The clinical record for Resident # 100 was reviewed on 10/16/18 at 11:22 am. During the time of the survey, there was no completed MDS assessment (minimum data set) for Resident # 100.
The plan of care for Resident # 100 was reviewed and revised on 10/16/18. The facility staff documented a focus area for Resident # 100 as, Resident # 100 is on antibiotic therapy related to MRSA to left elbow. Interventions included but were not limited to: Administer the full course of antibiotics as prescribed by the physician.
The current orders for Resident # 100 were initiated by the physician on 10/9/18. Orders included but were not limited to: Admit to (facility's name withheld) under the care of (Physician's name withheld) for skilled services. Diagnosis of left elbow MRSA, scoliosis, spinal cord stimulator, IV ABT (intravenous antibiotics) via inguinal PICC. The surveyor did not locate any orders for dressing changes to the PICC line site in the clinical record.
On 10/16/18 at 1:01 pm, the surveyor interviewed LPN # 2 (licensed practical nurse). The surveyor asked LPN # 2 how often residents that have PICC lines in the facility have dressing changes. LPN # 2 stated that PICC line dressings are changed every 7 days. LPN # 2 reviewed the clinical record along with the surveyor and agreed that Resident # 100 did not have orders for dressing changes to her PICC line site. LPN # 2 stated, I will get that taken care of.
The facility policy on Short Peripheral Catheter Dressing Change contained documentation that included but was not limited to:
. Considerations:
3. Licensed nurses caring for patients receiving infusion therapies are expected to follow infection control and safety compliance procedures.
On 10/17/18 at 4:00 pm, the administrative team was made aware of the findings as stated above.
No further information regarding this issue was provided to the survey team prior to the exit conference on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide non-pharmacological interventions in regards to pain management for 3 of 26 Residents in the survey sample, Resident #100, Resident #90, and Resident #21.
The findings included:
1. The facility staff failed to provided non-pharmacological interventions prior to the administration of PRN (as needed) pain medication for Resident # 100.
Resident # 100 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to: MRSA (methicillin-resistant staphylococcus aureus), Parkinson's disease, schizophrenia, and muscle weakness.
The clinical record for Resident # 100 was reviewed on 10/16/18 at 11:22 am. During the time of the survey, there was no completed MDS assessment (minimum data set) for Resident # 100.
The current plan of care for Resident # 100 was reviewed and revised on 10/15.18. The facility staff documented a focus area for Resident # 100 as Resident # 100 has impaired skin integrity related to skin tears, right shin, right distal shin and left elbow incision. Interventions included but were not limited to: Administer medications as ordered.
Resident # 100 had current orders that were initiated by the physician on 10/9/18. Orders included but were not limited to: Percocet 5-325 mg (milligram) Give 1 tablet by mouth every 4 hours as needed for pain or fever.
On 10/16/18 at 12:17 pm, the surveyor reviewed the medication administration record for Resident # 100. The surveyor noted that Resident # 100 had received physician ordered prn (as needed) Percocet 5-325 mg on the following dates and times:
10/12/18 at 8:45 am
10/13/18 at 8:27 am
10/13/18 at 4:02 pm
10/14/18 at 8:35 am
10/15/18 at 8:24 am
10/15/18 at 9:50 pm
10/16/18 at 6:14 am
The surveyor further reviewed the medication administration record and the nurse's notes and did not locate any documentation of non-pharmacological interventions attempted prior to the administration of the PRN Percocet 5-325 mg.
On 10/16/18 at 1:17 pm, the surveyor spoke with unit manager RN # 1 (registered nurse) regarding non-pharmacological interventions for Resident # 100. RN # 1 reviewed the clinical record for Resident # 100 along with the surveyor and RN # 1 agreed that there were no non-pharmacological interventions documented prior to the administration of pain medication for Resident # 100. RN # 1 stated, I will take care of it.
The facility policy on Pain Management and Pain Protocol included documentation that included but was not limited to:
.Procedure
A pain evaluation will occur on admission to the facility, at each quarterly review, whenever significant change in condition and with any onset of new pain.
5. The information on the pain flow record will identify:
g. Non pharmacological interventions will be attempted prior to the administration of PRN pain medications.
On 10/17/18 at 4:00 pm, the administrative team was made aware of the findings as stated above.
No further information regarding this issue was presented to the survey team prior to the exit conference on 10/18/18.
2. The facility staff failed to provide non-pharmacological interventions prior to the administration of PRN (as needed) pain medications for Resident # 90.
Resident # 90 was an [AGE] year-old female who was originally admitted to the facility on [DATE] with a readmission date of 3/5/18. Diagnoses included but were not limited to: osteoarthritis, cellulitis of right lower limb, hypertension, and non-pressure chronic ulcer of right lower leg.
The clinical record for Resident # 90 was reviewed on 10/17/18 at 9:51 am. The most recent MDS assessment (minimum data set) was a quarterly assessment with an ARD date (assessment reference date) of 9/28/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 90 had a BIMS score (brief interview for mental status) of 12 out of 15, which indicated that Resident # 90's cognitive status was moderately impaired. Section J of the MDS assesses health conditions.
In Section J0100, the facility staff documented that Resident # 90 was offered or had received PRN pain medication during the lookback period for the 9/28/18 ARD. The facility staff also documented in Section J0100 that Resident # 90 had not received non medication intervention for pain during the lookback period for the 9/28/18 ARD.
The current plan of care for Resident # 90 was reviewed and revised on 8/28/18. The facility staff documented a focus are for Resident # 90 as, Resident # 90 has acute/chronic pain r/t (related to) depression, wound, hx (history) of diverticulitis, GERD, (gastroesophageal reflux disease) sciatica, osteoarthritis, DVT (deep vein thrombosis), dorsalgia, gout. Interventions included but were not limited to: Assess/record/report to nurse resident complaints of pain or requests for pain treatment.
Resident # 90 had current orders that were initiated by the physician on 3/24/18. Orders included but were not limited to: Oxycodone 10-325 mg (milligram) Give 1 tablet by mouth every 4 hours as needed for pain.
On 10/17/18 at 9:55 am, the surveyor reviewed Resident # 90's medication administration record for October 2018. The surveyor noted that Resident # 90 had been administered Oxycodone 10-325 mg per the physician's PRN (as needed) order on the following dates:
10/1/18 at 9:13 am
10/1/18 at 4:30 pm
10/1/18 at 10:00pm
10/2/18 at 8:25 am
10/2/18 at 5:18 pm
10/2/18 at 10:07 pm
10/5/18 at 4:10 am
10/5/18 at 8:42 am
10/5/18 at 5:25 am
10/6/16 at 12:00 am
10/6/18 at 5:00 am
10/6/18 at 10:25 am
10/6/18 at 5:04 pm
10/7/18 at 2:27 am
10/7/18 at 9:45 am
10/7/18 at 4:47 pm
10/7/18 at 10:00 pm
10/8/18 at 2:00 am
10/8/18 at 6:00 am
10/8/18 at 4:33 pm
10/10/18 at 11:04 am
10/10/18 at 5:22 pm
10/10/18 at 9:30 pm
10/11/18 at 9:15 am
10/11/18 at 5:00 pm
10/12/18 at 2:41 pm
10/13/18 at 3:50 pm
10/15/18 at 9:34 am
10/15/18 at 10:34 pm
10/16/18 at 9:24 am
10/16/18 at 4:30 pm
10/16/18 at 10:36 pm
10/17/18 at 3:07 am
10/17/18 at 9:47 am
The surveyor reviewed the medication administration record and the nurse's notes and did not locate any documented non-pharmacological interventions for pain management prior to PRN medication administration.
On 10/17/18 at 10:50 am, the surveyor spoke with unit manager RN # 1(registered nurse) regarding the documentation of non-pharmacological interventions prior to the PRN administration of physician ordered Oxycodone 10-325 mg. RN # 1 reviewed the clinical record along with the surveyor and agreed that there were no documented non-pharmacological interventions prior to the PRN administration of Oxycodone 10-325 mg for Resident # 90.
The facility policy on Pain Management and Pain Protocol included documentation that included but was not limited to:
.Procedure
A pain evaluation will occur on admission to the facility, at each quarterly review, whenever significant change in condition and with any onset of new pain.
5. The information on the pain flow record will identify:
g. Non pharmacological interventions will be attempted prior to the administration of PRN pain medications.
On 10/17/18 at 4:00 pm, the administrative team was made aware of the findings as stated above.
No further information regarding this issue was presented to the survey team prior to the exit conference on 10/18/18.
3. The facility staff failed to offer non-pharmacological interventions for pain management to Resident #21.
The clinical record of Resident #21 was reviewed 10/16/18 through 10/18/18. Resident #21 was admitted to the facility 9/20/17 and readmitted [DATE] with diagnoses that included but not limited to Type 2 diabetes mellitus, symbolic dysfunction, dysphagia, repeated falls, cardiomyopathy, cerebellar stroke syndrome, alcohol-induced chronic pancreatitis, chronic pain syndrome, anemia, transient ischemic attacks, gastric diverticulum, altered mental status, Barrett's esophagus without dysplasia, hypertension, hemiplegia affecting left dormant side, bipolar disorder, anxiety disorder, atrial fibrillation, acute respiratory infection, viral hepatitis without hepatic coma, and cerebral infarction due to embolism.
Resident #21's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/7/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Section J Health Conditions was coded for the use of prn (whenever needed) medications and without the use of non-medication intervention for pain. Pain frequency was assessed to be occasionally and rated at 4 out of 10. A pain assessment by staff was not indicated (Section J0700).
The current comprehensive care plan identified Resident #21 to be at risk for pain and discomfort r/t (related to) dx (diagnosis) of chronic pain syndrome. Interventions: Administer pain medication as ordered. Monitor for pain. Assess for pain q (every) shift. Eliminate or reduce causative factors. Staff to attempt non-pharmacological interventions.
The October 2018 physician's order were reviewed. Resident #21 had orders for Percocet tablet 5-325 mg (milligrams) 1 tablet every 4 hours as needed for pain-start date 9/8/18. The October 2018 electronic medication administration records were reviewed. Resident #21 received Percocet 5-325 mg thirty-nine times in October 2018. Of the 39 times administered, Percocet was administered eight times (8) with a pain rating of zero (0).
The surveyor interviewed licensed practical nurse #1 on 10/17/18 at 12:26 p.m. where non-pharmacological interventions were offered prior to the administration of pain medication. The surveyor did not receive a response to the question.
The surveyor requested the September and October progress notes from the corporate registered nurse on 10/18/18 at 12:57 p.m.
The surveyor was not provided any October 2018 progress notes.
The surveyor reviewed the facility policy titled Pain Management and Pain Control on 10/18/18. The policy read in part 3. Non pharmacological intervention will be attempted prior to the administration of prn pain medications. When it is determined the resident's pain will need pharmacologic interventions: a. Documentation of administration of medications will be located on the Medication Administration Record. B. The response of the medication (s) will be identified on the pain flow record for effectiveness of the response of the medication on the back of the MAR.
The surveyor informed the administrative staff that Resident #21 received pain medication without attempting non-pharmacological interventions initially and failed to identify specific non-pharmacological interventions on the care plan for pain in the end of the day meeting on 10/18/18 at 3:08 p.m.
No further information was provided prior to the exit conference on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Facility staff failed to address the resident's dementia and its treatment with antipsychotic medications in the plan of care for 1 of 26 residents in the survey sample (Resident #66).
The findings included:
Resident #66 was admitted to the facility on [DATE] with diagnoses including muscle weakness, dysphagia, dementia in other diseases classified elsewhere without behavioral disturbance, cerebral infarction due to embolism of other cerebral artery, type II diabetes mellitus without complications, essential primary hypertension, other specified anxiety disorders, major depressive disorders, insomnia, and chest pain. On the quarterly minimum data set assessment with assessment reference date 9/17/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting care. The resident's medication assessment was coded under Medications received (N0410 A) as receiving anti-psychotic medications 7 of the 7 days prior to the assessment. Under Anti-psychotic Medication Review (0450), the resident was coded as not receiving anti-psychotic medications since admission or the prior assessment.
The resident's comprehensive care plan did not list dementia as a problem. No interventions under other care areas addressed symptoms of the resident's dementia. The comprehensive care plan did not address the resident's use of anti-psychotic medication or the symptoms and behaviors to be addressed by the anti-psychotic medication.
The surveyor asked the director of nursing for documentation of the symptoms for which the anti-psychotic Seroquel 100 milligram daily for anxiety with behaviors was being used along with documentation of the need for the anti-psychotic medication for anxiety rather than an anxiolytic medication.
Seroquel 100 mg daily was ordered 9/5/18 for anxiety with behaviors. There was no documentation of behavior symptoms. This was reportedly an increase to the prior dose after a gradual dose reduction attempt started 8/27/18. On 9/13/18, an administrative order for non-pharmacologic intervention codes for anxiety with behaviors was entered. No interventions were documented. An order to monitor for side effects associated with Seroquel documented no side effects.
Review of physician notes, psychiatric evaluations, and nursing progress notes revealed no documentation of the symptoms for which the resident was being treated with anti-psychotic medication. A nursing note dated 8/27/18 15:13 Resident continues to holler help, help. When staff asks resident what he needs his response varies: Can you move my covers, can you straighten my leg, can you pull me up. In no case after yelling help, help is the resident in any danger of falling off bed, no bleeding, no distress. Both he and his mother are very impatient when it comes to ADL(activity of daily living) care. The next note on 8/28/18 18:54 Resident turns light on shortly after receiving dinner tray staff feeding other residents and passing out trays when staff answers light resident state he is wet needing to be changed CNA told resident she would be back after taking cart to kitchen resident turns light back on before CNA can take cart to kitchen and come back. A note dated 9/2/18 18:39 Resident put on light at 1630 and 1715 stating he was wet CNA in both times resident was dry. No other notes concerning behavior or symptoms were documented before 9/5/18 17:09 FNP (family nurse practitioner) made aware that since Seroquel dosage change, resident has been experiencing increased anxiety and agitation. New orders received to restart previous dosage. The surveyor inferred that the behaviors for which the resident was being treated with an anti-psychotic medication were ringing the call bell when not bleeding or in danger of falling, and requesting help during meal times. No other behaviors or symptoms were documented by nursing or medical staff.
The resident was hospitalized after the initial brief contact on 10/16/18, so the surveyor was unable to complete the resident interview and assess for the use of chemical restraint for staff convenience.
The administrator, director of nursing and assistant director of nursing were notified of the concern during a summary meeting on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to ensure Resident # 21's insulin (Basaglar) was available for administration.
The clinical record of Resident #21 was reviewed 10/16/18 through 10/18/18. Resident #21 was admitted to the facility 9/20/17 and readmitted [DATE] with diagnoses that included but not limited to Type 2 diabetes mellitus, symbolic dysfunction, dysphagia, repeated falls, cardiomyopathy, cerebellar stroke syndrome, alcohol-induced chronic pancreatitis, chronic pain syndrome, anemia, transient ischemic attacks, gastric diverticulum, altered mental status, Barrett's esophagus without dysplasia, hypertension, hemiplegia affecting left dormant side, bipolar disorder, anxiety disorder, atrial fibrillation, acute respiratory infection, viral hepatitis without hepatic coma, and cerebral infarction due to embolism.
Resident #21's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/7/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15.
Resident #21's current comprehensive care plan had the focus area that read Resident #21 is at risk for hypo/hyperglycemia episodes r/t (related to): DM (diabetes mellitus). Requires daily insulin, requires sliding scale insulin. Interventions: Medication as ordered.
The September 2018 physician orders were reviewed. Resident #21 had orders for Basaglar KwikPen Solution Pen-Injector 100 unit/ml (milliliter) Inject 35 units subcutaneously at bedtime for DM.
The surveyor reviewed the September 2018 electronic medication administration records (eMAR). On 9/30/18, the box for the administration of the Basaglar had 19. The legend read 19=Other/See Nurse Notes.
The surveyor reviewed the September 2018 progress notes. The 9/30/18 progress note read Basaglar not available from pharmacy.
The surveyor informed the administrative staff that the insulin Basaglar was not available for administration on 9/30/18 in the end of the day meeting on 10/18/18 at 3:08 p.m. and requested the product information sheet for Basaglar, the facility policy on obtaining medications from the pharmacy, and the September 2018 progress notes.
The surveyor reviewed the facility policy titled Medication Shortages/Unavailable Medications on 10/18/18. The policy read in part 1. Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy. 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, facility should notify pharmacy and arrange for an emergency delivery. 4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions.
The product information sheet for Insulin Glargine Solution for Injection (Trade Names Basaglar, Lantus, Lantus SoloStar, Toujeo Max SoloStar, and Toujeo SoloStar) was reviewed 10/18/18. Insulin Glargine is a human-made form of insulin. This drug lowers the amount of sugar in your blood. It is a long-acting insulin that is usually given once a day. This medicine is for injection under the skin. Use this medicine at the same time each day. It is important not to miss a dose. Your health care professional or doctor should discuss a plan for missed doses with you. If you do miss a dose, follow their plan. Do not take double doses.
No further information was provided prior to the exit conference on 10/18/18.
Based on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications were available for administration for 4 of 26 Residents, Residents #74, #249, #21, and #43.
The findings included:
1. For Resident #74, the facility staff failed to ensure the Residents exelon patch, lubricant eye night ointment, and nexium were available for administration.
The clinical record review revealed that Resident #74 had been readmitted to the facility 03/23/18. Diagnoses included, but were not limited to, muscle weakness, nutritional deficiency, major depressive disorder, chronic pain, anxiety disorder, glaucoma, and bipolar disorder.
Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 09/27/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points.
A review of the resident's eMARs (electronic medication administration records) revealed that the facility staff had coded the resident's lubricant eye ointment and nexium with a 16 on 09/26/18 and the resident's exelon patch with a 16 on 09/27/18. Per the preprinted code on the eMARs a 16 meant Hold/See Nurses Notes.
A review of the resident's nursing entries for these dates revealed that the nursing staff had documented the following for the lubricant eye ointment .none available and for the nexium .none available awaiting pharmacy. The surveyor was unable to find a note that referenced the exelon patch.
A review of the stat box list revealed that these medications would not have been available in the stat box for administration.
On 10/18/18 at 8:20 a.m., the DON (director of nursing) provided the surveyor with a copy of a policy titled 7.0 Medication Shortages/Unavailable Medications. This policy read in part, .Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy .If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery .If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions .
The administrative staff were made aware that the Residents medications were not available for administration during a meeting with the survey team on 10/17/18 at 3:20 p.m.
No further information regarding this issue was provided to the survey team prior to the exit conference.
2. For Resident #249, the facility failed to ensure the resident's lyrica and adderall were available for administration.
The clinical record review revealed that Resident #249 had been admitted to the facility 10/05/18. Diagnoses included, but were not limited to, attention deficit hyperactivity disorder (ADHD), hypertension, depression, diabetes, and neuropathy.
There was no completed MDS assessment for this Resident. The resident was alert and orientated.
The Residents POS (physician order summary) included physicians orders for-adderall 30 mg 1 tab by mouth two times a day for ADHD and lyrica 100 mg two times a day for neuropathy.
A review of the Residents eMARs (electronic medication administration records) for 10/2018 revealed that for the medication adderall the facility nursing staff had documented a 19 on 10/12, 10/13, and 10/14 at 9:00 a.m. and 9:00 p.m. For 9:00 p.m. on 10/12 and 10/13 the nursing staff had indicated that they had administered this medication.
For the medication lyrica, the nursing staff had documented a 19 on 10/06, 10/07, and 10/08 at 9:00 a.m. and 9:00 p.m.
Per the preprinted codes on the eMARs a 19 meant Other/See Nurses Notes.
A review of the resident's progress notes indicated that for the medication adderall the nursing staff had documented the following.
10/12-Adderall Tablet 30 MG .pharmacy notified.
10/13-Adderall Tablet .hard scripted refaxed to pharmacy.
10/14-Adderall Tablet .on order.
10/14-Adderall Tablet .hard script refaxed to pharmacy.
For the medication lyrica the facility nursing staff had documented the following.
10/06-Lyrica Capsule 100 MG .no script on file. must wait for dr. on Monday per oncall doctor.
10/06-Lyrica Capsule 100 MG .Not available.
10/07-Lyrica Capsule .Not available.
10/08-Lyrica Capsule 100 MG Give 1 capsule by mouth two times a day for neuropathy.
10/08-Lyrica Capsule 100 MG .in route from RX.
On 10/17/18 at 6:05 a.m., the surveyor interviewed LPN (licensed practical nurse) #3 via phone regarding the medication adderall. LPN #3 verbalized to the surveyor that she had not administered the adderall and she had marked that she had in error as the medication was not available. LPN #3 stated she had called the pharmacy regarding the medication and that sometimes it takes forever for the pharmacy to send us some stuff.
A review of the stat box list revealed that these medications would not have been available in the stat box for administration.
On 10/18/18 at 8:20 a.m., the DON (director of nursing) provided the surveyor with a copy of a policy titled 7.0 Medication Shortages/Unavailable Medications. This policy read in part, .Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy .If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery .If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions .
The administrative staff were made aware that the Residents medications were not available for administration during a meeting with the survey team on 10/17/18 at 3:20 p.m.
No further information regarding this issue was provided to the survey team prior to the exit conference.
4. For Resident #43 the facility staff failed to ensure the medication Klonopin was available for administration for three consecutive doses.
Resident #43 was admitted to the facility on [DATE]. Diagnoses included but not limited to dementia, major depressive disorder, Alzheimer's disease, schizoaffective disorder, and heart failure.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 08/28/18 coded the Resident as 00 of 15 in section C, cognitive patterns. This is a quarterly MDS.
Resident #43's CCP (comprehensive care plan) was reviewed and contained a focus area for Resident is on antianxiety therapy, has interventions that included but were not limited to, Administer antianxiety med as prescribed by the physician.
Resident #43's clinical record was reviewed on 10/17/18. It contained a POS (physician's order summary) for the month of September which read in part KlonoPIN tablet 0.5mg (milligrams) give 0.5 mg by mouth two times a day for anxiety *hold for sedation*. The Resident's eMAR (electronic medication administration record) for the month of September was reviewed and contained an entry which read in part, KlonoPIN tablet 0.5mg (ClonazePAM) give 0.5 mg by mouth two times a day for anxiety * hold for sedation *. This entry was coded 19 on 09/05/18 at 1700, 09/06/18 at 0900, and 09/06/18 at 1700 which is the equivalent of medication unavailable. Resident #43's progress notes were reviewed and contained medication administration notes for 09/05/18 at 1644, 09/06/18 at 0853, and 09/06/18 at 1754 which read in part KlonoPIN tablet 0.5mg give 0.5 mg by mouth two times a day for anxiety *hold for sedation * Awaiting medication from pharmacy.
The surveyor requested and was provided with a copy of facility policy entitled Medication Shortages/Unavailable Medications, which read in part Procedure: 1. Upon discovery that Facility has an inadequate supply of a medication to administer to a Resident, Facility staff should immediately initiate action to obtain the medication form pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action specified in Section 2 .of this policy, as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available causes delay or a missed dose in the Resident's medication schedule, facility nurse should obtain the medication form the Emergency Medication Supply to administer the dose. 2.3If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery.4. If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions .
The surveyor requested and was provided with a list of medications located in the facility stat box on 10/18/18 at approximately 0820. The medication Klonopin was unavailable in the stat box.
The surveyor reviewed Resident #43's progress notes and could not locate a note related to nursing staff contacting the pharmacy and/or the attending physician.
The surveyor spoke with the administrative team on 10/17/18 at approximately 1518 regarding the concern of Resident #43's medications not being available for administration.
No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to follow up on pharmacy recommendations for 1 of 26 Residents, Resident #35.
Findings included:
For Resident #35, the facility failed to provide evidence that the attending nurse practitioner had reviewed a pharmacy recommendation dated 08/23/18.
Resident #35 was admitted to the facility on [DATE]. Diagnoses included but not limited to unspecified dementia with behavioral disturbance, heart failure, pressure ulcer of sacral region, and encounter for palliative care.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 08/17/18 coded the Resident 00 of 15 in section C, cognitive patterns.
The DON (director of nursing) provided the surveyor with a copy of a pharmacy recommendation dated 08/23/18. The attending nurse practitioner that it was addressed to had not signed the recommendation.
On 10/18/18 at approximately 2:30pm, the DON (director of nursing) verbalized to the surveyor that a pharmacy review was completed in August and the recommendation provided could possibly be in medical records signed. The DON stated the Resident was placed on hospice in August, so she didn't know.
The facility was unable to provide any evidence to the surveyor that the attending nurse practitioner had reviewed the recommendation.
The administrative staff were notified of the issue regarding the pharmacy recommendation during a meeting with the survey team on 10/18/18 at approximately 3:08pm.
No further information regarding this issue was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure 1 of 26 residents was free of an unnecessary medication (Resident #33).
The findings included:
The facility staff failed to follow the physician ordered parameters for the administration of Metoprolol for Resident #33.
The clinical record of Resident #33 was reviewed 10/16/18 through 10/18/18. Resident #33 was admitted to the facility on [DATE] with diagnoses, that included but not limited to hypomagnesia, insomnia, chronic pain syndrome, dry eye syndrome, hypertension, chronic diastolic heart failure, lymphedema, acute frontal sinusitis, gastroesophageal reflux disease, urinary tract infections, left knee hemarthosis, right elbow contracture, major depressive disorder, nutritional deficiency, and dysthymic disorder.
Resident #33's significant change in minimum data set (MDS) with an assessment reference date (ARD) of 8/16/18 assessed the resident with a BIMS (brief interview for mental status) as 12 out of 15 in Section C.
Resident #33's current comprehensive care plan had the focus area that read Resident #33 is at risk for altered cardiac/resp (respiratory) status r/t (related to) dx (diagnosis) HTN (hypertension), CHF (congestive heart failure). Interventions: VS (vital signs) as ordered and prn (as needed), notify MD (medical doctor) of any abnormalities.
Resident #33's October 2018 physician orders included the following physician order that read Metoprolol Succinate ER (extended release) Tablet Extended Release 24 Hour Give 25 mg (milligrams) by mouth one time a day for HTN Give 12.5 mg (1/2/tab) *DO NOT CRUSH* Hold if systolic is less than 100/diastolic is less than 60. Start Date: 6/26/2016.
The surveyor reviewed the October 2018 electronic medication records (eMARs). The administration boxes for 10/6/18, 10/7/18, 10/11/18, 10/12/18, and 10/16/18 did not have a recorded blood pressure.
The surveyor reviewed the October 2018 Weights and Vitals Summary.
On 10/6/18, blood pressures were obtained at 2:44 a.m., 2:47 a.m., and 8:22 p.m. None of the blood pressures obtained were prior to the administration of Metoprolol.
On 10/7/18, blood pressures were obtained at 00:57 a.m., 4:51 a.m., and 5:42 p.m. None of the blood pressures were obtained prior to the administration of Metoprolol.
On 10/11/18, blood pressures were obtained at 00:52 a.m., 1:47 a.m., and 10:59 p.m. None of the blood pressures were obtained prior to the administration of the medication.
On 10/12/18, blood pressures were obtained at 1:55 a.m., 2:55 a.m., and 2:59 p.m. None of the blood pressures were obtained prior to the medication administration.
On 10/16/18, blood pressures were obtained at 1:08 a.m. and 11:21 p.m. None of the blood pressures were obtained prior to the administration.
The surveyor informed the corporate registered nurse of the above concern with obtaining the blood pressure prior to administering Resident #33's Metoprolol on 10/17/18 at 11:21 a.m. The surveyor requested the October 2018 eMARs, the October progress notes and the October vital signs.
The surveyor discussed the vital signs and the administration of the medication with the assistant director of nursing on 10/18/18 at 10:30 a.m. The ADON was asked if the vital signs obtained would be an accurate blood pressure on which to administer the medication Metoprolol since all were obtained greater than 2 hours prior to administration. The ADON stated the blood pressures should have been obtained a little closer to the time the medications were administered.
The surveyor informed the administrative staff of the above concern during the end of the day meeting on 10/17/18 at 3:20 p.m.
No further information was provided prior to the exit conference on 10/18/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure 9 of 26 Residents were free of unnecessary medications. Residents #66, #89, #90, #100, #21, #28, #33, #59, #42.
The findings included:
1. For Resident #66, staff failed to ensure the resident received an anti-psychotic medication only to treat specific conditions and symptoms as documented in the clinical record.
Resident #66 was admitted to the facility on [DATE] with diagnoses including muscle weakness, dysphagia, dementia in other diseases classified elsewhere without behavioral disturbance, cerebral infarction due to embolism of other cerebral artery, type II diabetes mellitus without complications, essential primary hypertension, other specified anxiety disorders, major depressive disorders, insomnia, and chest pain. On the quarterly minimum data set assessment with assessment reference date 9/17/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting care. The resident's medication assessment was coded under Medications received (N0410 A) as receiving anti-psychotic medications 7 of the 7 days prior to the assessment. Under Anti-psychotic Medication Review (0450), the resident was coded as not receiving anti-psychotic medications since admission or the prior assessment.
The resident's comprehensive care plan did not list dementia as a problem. No interventions under other care areas addressed symptoms of the resident's dementia. The comprehensive care plan did not address the resident's use of anti-psychotic medication or the symptoms and behaviors to be addressed by the anti-psychotic medication.
The surveyor asked the director of nursing for documentation of the symptoms for which the anti-psychotic Seroquel 100 milligram daily for anxiety with behaviors was being used along with documentation of the need for the anti-psychotic medication for anxiety rather than an anxiolytic medication.
Seroquel 100 mg daily was ordered 9/5/18 for anxiety with behaviors. There was no documentation of behavior symptoms. This was reportedly an increase to the prior dose after a gradual dose reduction attempt started 8/27/18. On 9/13/18, an administrative order for non-pharmacologic intervention codes for anxiety with behaviors was entered. No interventions were documented. An order to monitor for side effects associated with Seroquel documented no side effects.
Review of physician notes, psychiatric evaluations, and nursing progress notes revealed no documentation of the symptoms for which the resident was being treated with anti-psychotic medication. A nursing note dated 8/27/18 15:13 Resident continues to holler help, help. When staff asks resident what he needs his response varies: Can you move my covers, can you straighten my leg, can you pull me up. In no case after yelling help, help is the resident in any danger of falling off bed, no bleeding, no distress. Both he and his mother are very impatient when it comes to ADL(activity of daily living) care. The next note on 8/28/18 18:54 Resident turns light on shortly after receiving dinner tray staff feeding other residents and passing out trays when staff answers light resident state he is wet needing to be changed CNA told resident she would be back after taking cart to kitchen resident turns light back on before CNA can take cart to kitchen and come back. A note dated 9/2/18 18:39 Resident put on light at 1630 and 1715 stating he was wet CNA in both times resident was dry. No other notes concerning behavior or symptoms were documented before 9/5/18 17:09 FNP (family nurse practitioner) made aware that since Seroquel dosage change, resident has been experiencing increased anxiety and agitation. New orders received to restart previous dosage. The surveyor inferred that the behaviors for which the resident was being treated with an anti-psychotic medication were ringing the call bell when not bleeding or in danger of falling, and requesting help during meal times. No other behaviors or symptoms were documented by nursing or medical staff.
The resident was hospitalized after the initial brief contact on 10/16/18, so the surveyor was unable to complete the resident interview and assess for the use of chemical restraint for staff convenience.
The administrator, director of nursing and assistant director of nursing were notified of the concern during a summary meeting on 10/18/18.
5. The facility staff failed to identify and monitor resident specific targeted behaviors, identify non-pharmacological interventions, and monitor for effectiveness associated with the use of Abilify and Cymbalta for Resident #21.
The clinical record of Resident #21 was reviewed 10/16/18 through 10/18/18. Resident #21 was admitted to the facility 9/20/17 and readmitted [DATE] with diagnoses that included but not limited to Type 2 diabetes mellitus, symbolic dysfunction, dysphagia, repeated falls, cardiomyopathy, cerebellar stroke syndrome, alcohol-induced chronic pancreatitis, chronic pain syndrome, anemia, transient ischemic attacks, gastric diverticulum, altered mental status, Barrett's esophagus without dysplasia, hypertension, hemiplegia affecting left dormant side, bipolar disorder, anxiety disorder, atrial fibrillation, acute respiratory infection, viral hepatitis without hepatic coma, and cerebral infarction due to embolism.
Resident #21's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8/7/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. Resident #21 was assessed to have inattention continuously present, no psychosis, and no behaviors that affected others.
Resident #21's current comprehensive care plan had the focus area that read the resident was at risk for adverse effects r/t (related to) psychoactive medication use: antidepressant for depression; antipsychotic for mood stabilizer. Interventions: Monitor for side effects: sedation, hypotension, EPS (extrapyramidal symptoms), anticholinergic sx (symptoms), H/A (headache), insomnia, anorexia, constipation. Monitor for effectiveness of medications, Report changes in behavior or mood state, report to physician any negative outcomes associated with use of psychoactive drug.
Resident #21's October 2018 physician orders included orders for Abilify 5 mg (milligrams) in the morning for mood disorder and Cymbalta delayed release capsule 60 mg in the morning for depression and pain.
The surveyor reviewed the October 2018 electronic medication administration records (eMARS) but was unable to locate any targeted behaviors the staff were monitoring for Abilify and Cymbalta. There were no completed behavior monitoring records.
The current comprehensive care plan did not include targeted behaviors for the use of Abilify and Cymbalta.
The surveyor informed the corporate registered nurse of the above concern with monitoring of Abilify and Cymbalta on 10/17/18 12:07 PM. The surveyor requested the October 2018 eMARS.
The surveyor informed the administrative staff of the above concern on 10/17/18 at 3:20 p.m. in the end of the day meeting.
The surveyor reviewed the facility policy titled Psychotropic Medication Documentation and Review on 10/18/18. The policy read in part A. Residents receiving psychotropic medication will have a Behavior/Intervention Monthly Flow Record (BFR) (Form 4.11) initiated on admission or whenever psychotropic meds are ordered.
No further information was provided prior to the exit conference on 10/18/18.
6. The facility staff failed to identify and monitor resident specific targeted behaviors, identify non-pharmacological interventions, and monitor for effectiveness associated with the use of Elavil for Resident #28.
The clinical record of Resident #28 was reviewed 10/16/18 through 10/18/18. Resident #28 was admitted to the facility 9/7/16 and readmitted [DATE] with diagnoses that included but not limited to symbolic dysfunction, dysphagia, right shoulder contracture, major depressive disorder, Type 2 diabetes mellitus, seizures, iron deficiency anemia, urine retention, anxiety disorder, moderate protein calorie malnutrition, peripheral vascular disease, gastroesophageal reflux disease, bradycardia, diabetic neuropathy, chronic pain syndrome, paraplegia, acute renal failure, gastritis, bacteremia, hyperkalemia, insomnia, and hypertension.
Resident #28's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 8/10/18 assessed the resident with a BIMS (brief interview for mental status) as 15 out of 15. Resident #28 was assessed without any signs or symptoms of delirium, psychosis or behaviors that affected others.
Resident #28's current comprehensive care plan was reviewed and a care plan had not been developed for psychotropic medication.
The October 2018 physician orders were reviewed. Resident #28 had orders for Elavil 25 mg (milligrams) (Amitriptyline HCL) 1 tablet by mouth at bedtime for antidepressant Start Date 8/13/18.
The surveyor reviewed the October 2018 electronic medication administration records (eMARS) and the October 2018 behavior monitoring records but found no evidence monitoring of Elavil had been done, no targeted behaviors identified or a care plan been developed for the use of the antidepressant.
The surveyor informed the unit manager registered nurse #1 on 10/17/18 10:33 AM. R.N. #1 stated the nurses were not monitoring antidepressants use. The unit manager R.N. #1 stated she was not aware antidepressants needed to be monitored.
The surveyor informed the administrative staff of the above concern during the end of the day meeting on 10/17/18 at 3:20 p.m.
The surveyor reviewed the facility policy titled Psychotropic Medication Documentation and Review on 10/18/18. The policy read in part A. Residents receiving psychotropic medication will have a Behavior/Intervention Monthly Flow Record (BFR) (Form 4.11) initiated on admission or whenever psychotropic meds are ordered.
No further information was provided prior to the exit conference on 10/18/18.
7. The facility staff failed to identify targeted behaviors for Zoloft and failed to monitor the behavior of Resident #33.
The clinical record of Resident #33 was reviewed 10/16/18 through 10/18/18. Resident #33 was admitted to the facility on [DATE] with diagnoses, that included but not limited to hypomagnesia, insomnia, chronic pain syndrome, dry eye syndrome, hypertension, chronic diastolic heart failure, lymphedema, acute frontal sinusitis, gastroesophageal reflux disease, urinary tract infection, left knee hemarthosis, right elbow contracture, major depressive disorder, nutritional deficiency, and dysthymic disorder.
Resident #33's significant change in minimum data set (MDS) with an assessment reference date (ARD) of 8/16/18 assessed the resident with a BIMS (brief interview for mental status) as 12 out of 15 in Section C. Resident #33 was assessed without signs or symptoms of delirium, psychosis, or behaviors that affected others.
Resident #33's current comprehensive care plan identified that the resident was at risk for adverse effects r/t (related to) psychoactive medication use: Depression, insomnia. At risk for falls and over sedation. Interventions: Monitor for effectiveness of medications, Report changes in behavior or mood state, report to physician any negative outcomes associated with use of psychoactive drug.
Resident #33's October 2018 physician's orders were reviewed. The physician order dated 9/28/18 read Zoloft tablet 100 mg (Sertraline HCL) 1 tablet by mouth one time a day for depression.
The surveyor reviewed the October 2018 electronic medication administration records (eMARS) but was unable to locate any behavior monitoring of Zoloft-no identified targeted behaviors and no side effect monitoring.
The surveyor informed the administrative staff of the concern with Resident #33's Zoloft monitoring in the end of the day meeting on 10/18/18 at 3:08 p.m.
No further information was provided prior to the exit conference on 10/18/18.
8. The facility staff failed to ensure the antidepressant medication Fluvoxamine used to treat specific symptoms or behaviors associated with a diagnosis requiring treatment by an antidepressant medication and to ensure monitoring of the symptoms for which the antidepressant medication was ordered for Resident #59. Resident # 59's clinical record did not document the symptoms which the antidepressant medication was to address. There was no ongoing behavior monitoring of a resident receiving antidepressant medications.
The clinical record of Resident #59 was reviewed 10/16/18 through 10/18/18. Resident #59 was admitted to the facility 8/12/17 and readmitted [DATE] with diagnoses that included but not limited to metabolic encephalopathy, severe sepsis with shock, dysphagia, neuromuscular dysfunction of the bladder, hypertension, atherosclerotic heart disease, obsessive compulsive personality disorder, rhabdomyolysis, end stage renal disease, anxiety disorder, mental disorder, repeated falls, hyperkalemia, urinary tract infection, Parkinson's disease, and major depressive disorder.
Resident #59's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/12/18 assessed the resident with a BIMS (brief interview for mental status) as 9/15. Resident #59 was assessed to have hallucinations, but no signs or symptoms of delirium or psychosis.
Resident #59's current comprehensive care plan identified the resident to be at risk for adverse effects r/t (related to) psychoactive medication use: antidepressant and antipsychotic Date initiated: 07/17/2018 Revision on: 09/21/2018. Interventions: Monitor for effectiveness of medications, Report changes in behavior or mood state, report to physician any negative outcomes associated with use of psychoactive drug.
Resident #59's October physician orders were reviewed. Resident #59 had an order for Fluvoxamine Maleate 100 mg tablet Give 200 mg by mouth in the evening related to Obsessive-Compulsive Disorder.
FLUVOXAMINE is an antidepressant. It is used to treat obsessive-compulsive disorder.
The surveyor reviewed the October 2018 electronic medication administration record but was unable to locate any behavior monitoring of Fluvoxamine-no identified targeted behaviors and no side effect monitoring.
The surveyor informed the administrative staff of the concern with Resident #59's Fluvoxamine monitoring in the end of the day meeting on 10/17/18 at 3:20 p.m.
No further information was provided prior to the exit conference on 10/18/18.
9. For Resident #42, the facility staff failed to monitor the Residents prozac.
The clinical record review revealed that Resident #42 had been admitted to the facility 05/20/16. Diagnoses included, but were not limited to, depressive disorder, anxiety disorder, chronic pain, gastro-esophageal reflux disease, and hypertension.
Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 08/24/18 included a BIMS (brief interview for mental status) summary score of 15 out of a possible 15 points. Section N (medications) was coded to indicate the Resident had received antidepressant medication.
The Residents comprehensive care plan included the focus area is on antidepressant therapy. Interventions were administer antidepressant med as prescribed by the physician and refer to psych services.
The Residents current POS (physician order summary) included an order for prozac 40 mg one time a day.
During the clinical record review, the surveyor was unable to locate any information that the facility were offering and/or providing any behavioral interventions or monitoring for any side effects of this medication until after the survey team began asking questions regarding other Residents in the survey sample.
On 10/18/18, the facility provided the surveyor with a copy of the Residents behavior monitoring and side effect monitoring forms for the medication prozac. These forms revealed that the facility began using these forms on night shift on 10/16/18.
The administrative staff were notified of the above during a meeting with the survey team on 10/18/18 at 3:08 p.m.
No further information regarding this issue was provided to the survey team prior to the exit conference.
2. The facility staff failed to monitor effectiveness and identify target behaviors associated with the use of Risperdal for Resident # 89.
Resident # 89 was an [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to: schizoaffective disorder, hypertension, bipolar disorder, and hypothyroidism.
The clinical record for Resident # 89 was reviewed on 10/16/18 at 4:14 pm. The most recent MDS assessment (minimum data set) was a quarterly assessment with an ARD date (assessment reference date) of 9/24/18. Section C of the MDS assesses cognitive patterns. In section C0500, the facility staff documented that Resident # 89 had a BIMS score (brief interview for mental status) of 10 out of 15, which indicated that Resident # 89's cognitive status was moderately impaired. Section N of the MDS assesses medications. In Section N0410, the facility staff documented that Resident # 89 received an antipsychotic medication for 7 days during the look back period for the 9/24/18 ARD.
The plan of care for Resident # 89 was reviewed and revised on 7/31/18. The facility staff documented a focus area for Resident # 89 as Resident # 89 uses psychotropic medications related to bipolar and schizoaffective disorder. Interventions included but were not limited to: Administer medications as ordered. Monitor/document for side effects and effectiveness. The surveyor did not locate any documented target behaviors associated with the use of Risperdal on the plan of care for Resident # 89.
Resident # 89 had a current order that was signed by the physician on 10/9/18 for Risperdal tablet 0.5 mg (milligram) Give 0.5 mg by mouth one time a day for schizoaffective disorder. The surveyor reviewed the medication administration record for Resident # 89 and did not locate any documentation of monitoring target behaviors or effectiveness for the physician ordered Risperdal.
On 10/16/18 at 4:33 pm, the surveyor interviewed CNA # 1 (certified nursing assistant). The surveyor asked CNA # 1 if Resident # 89 displayed any abnormal behaviors. CNA # 1 stated, No she is sweet as pie.
On 10/16/18 at 4:35 pm, the surveyor interviewed unit manager RN # 1 and asked if Resident # 89 displayed any abnormal behaviors. RN # 1 stated, She is sweet as pie. The surveyor asked RN # 1 what behaviors Resident # 89 displayed to warrant the administration of Risperdal. RN # 1 stated that Resident # 89 had been admitted on the medication and that she was not aware of what behaviors Resident # 89 displayed to warrant the use of Risperdal. RN # 1 reviewed the clinical record for Resident # 89 along with the surveyor and agreed that there were no documented target behaviors or monitoring for effectiveness for the physician ordered Risperdal for Resident # 89.
The facility policy on Psychotropic Medication Documentation and Review contained documentation that included but was not limited to:
. Procedure
A.
Residents receiving psychotropic medication will have a behavior /Intervention Monthly Flow Record (BFR) (Form 4.11) initiated on admission or whenever psychotropic meds are ordered.
a.
Each psychotropic medication will be entered on BFR.
b.
Resident specific behaviors related to medication use will be entered on BFR.
B.
Nurses will document on the following every shift:
a.
Number of behavior episodes
d. any side effect(s) observed.
On 10/17/18 at 4:00 pm, the administrative team was made aware of the findings as stated above.
No further information regarding this issue was provided to the survey team prior to the exit conference on 10/18/18.
3. The facility staff failed to monitor physician ordered Duloxetine for effectiveness for Resident # 90.
Resident # 90 was an [AGE] year-old female who was originally admitted to the facility on [DATE] with a readmission date of 3/5/18. Diagnoses included but were not limited to osteoarthritis, cellulitis of right lower limb, major depressive disorder, and non-pressure chronic ulcer of right lower leg.
The clinical record for Resident # 90 was reviewed on 10/17/18 at 9:51 am. The most recent MDS assessment (minimum data set) was a quarterly assessment with an ARD date (assessment reference date) of 9/28/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 90 had a BIMS score (brief interview for mental status) of 12 out of 15 which indicated that Resident # 90's cognitive status was moderately impaired. Section N of the MDS assesses medications. In Section N0141, the facility staff documented that Resident # 90 had received antidepressant medication for 7 days during the look back period for the 9/28/18 ARD.
The plan of care for Resident # 90 was reviewed and revised on 8/28/18. The facility staff documented a focus area for Resident # 90 as, Resident # 90 uses psychotropic medications r/t (related to) dx (diagnosis) of depression. Interventions included but were not limited to: Administer medications as ordered. Monitor/document for side effects and effectiveness.
Resident # 90 had current orders that were initiated by the physician on 3/5/18. Orders included but were not limited to: Duloxetine 30 mg (milligram) Give 1 capsule by mouth one time a day related to major depressive disorder.
On 10/17/18 at 9:55 am, the surveyor reviewed Resident # 90's medication administration record for October 2018. The surveyor did not locate any monitoring for effectiveness for the physician ordered Duloxetine.
On 10/18/18 at 12:25 pm, the surveyor spoke with unit manager RN # 1 (registered nurse) and made her aware that there was no monitoring for effectiveness for the physician ordered Duloxetine for Resident # 90. RN # 1 stated that she would get it taken care of.
The facility policy on Psychotropic Medication Documentation and Review contained documentation that included but was not limited to:
. Procedure
C.
Residents receiving psychotropic medication will have a behavior /Intervention Monthly Flow Record (BFR) (Form 4.11) initiated on admission or whenever psychotropic meds are ordered.
c.
Each psychotropic medication will be entered on BFR.
d.
Resident specific behaviors related to medication use will be entered on BFR.
D.
Nurses will document on the following every shift:
b.
Number of behavior episodes
d. any side effect(s) observed.
On 10/18/18 at 3:00 pm, the administrative team was made aware of the findings as stated above.
No further information was provided to the survey team prior to the exit conference on 10/18/18.
4. The facility staff failed to monitor physician ordered Seroquel for effectiveness for Resident # 100.
Resident # 100 was a [AGE] year-old-female who was admitted to the facility on [DATE]. Diagnoses included but were not limited to: MRSA (methicillin-resistant staphylococcus aureus), Parkinson's disease, schizophrenia, and muscle weakness.
The clinical record for Resident # 100 was reviewed on 10/16/18 at 11:22 am. During the time of the survey, there was no completed MDS assessment (minimum data set) for Resident # 100.
The plan of care for Resident # 100 was reviewed and revised on 10/16/18. The facility staff documented a focus area for Resident # 100 as. Resident # 100 uses psychotropic medications r/t (related to) schizoaffective disorder. Interventions included but were not limited to: Administer medications as ordered. Monitor/document for side effects and effectiveness.
Resident # 100 had current orders that were initiated by the physician on 10/10/18. Orders included but were not limited to: Seroquel tablet 25 mg (milligram) Give 1 tablet by mouth two times a day for paranoid schizophrenia.
On 10/16/18 at 12:17 pm, the surveyor reviewed the medication administration record and nurse's notes for Resident # 100. The surveyor did not locate any documentation of monitoring for effectiveness for the physician ordered Seroquel for Resident # 100.
On 10/16/18 at 12:48 pm, the surveyor interviewed LPN # 2 (licensed practical nurse). The surveyor asked LPN # 2 where the nursing staff documented the effectiveness of psychotropic medications. LPN # 2 stated, We have a behavior grid and we document the behaviors on there. LPN # 2 reviewed the clinical record for the behavior grid and LPN # 2 stated, She doesn't have one.
The facility policy on Psychotropic Medication Documentation and Review contained documentation that included but was not limited to:
. Procedure
E.
Residents receiving psychotropic medication will have a behavior /Intervention Monthly Flow Record (BFR) (Form 4.11) initiated on admission or whenever psychotropic meds are ordered.
e.
Each psychotropic medication will be entered on BFR.
f.
Resident specific behaviors related to medication use will be entered on BFR.
F.
Nurses will document on the following every shift:
c.
Number of behavior episodes
d. any side effect(s) observed.
On 10/17/18 at 4:00 pm, the administrative team was made aware of the findings as stated above.
No further information regarding this issue was provided to the survey team prior to the exit conference on 10/18/18.