Every finding on record at Bland County Nursing & Rehab Center

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections by failing to follow transmission-based precautions for 1 of 3 sampled residents, Resident #3.The findings included:An admission Record revealed the facility admitted Resident #3 on 4/08/26. According to the admission Record, the resident had a medical history that included chronic respiratory failure with hypoxia, quadriplegia, central cord syndrome at C5 level of cervical spinal cord, dependence on ventilator, and chronic pain syndrome. An admission minimum data set (MDS) with an assessment reference date (ARD) of 4/14/26 indicated the resident had a Brief Interview for Mental Status (BIMS) summary score of 0 out of 15 which indicated the resident was severely cognitively impaired. On 5/05/26 at 1:50 PM, Registered Nurse (RN) #1 donned gloves only and entered Resident #3's room and proceeded to pull up the resident's gown to expose their enteral feeding tube site. RN #1 stated Resident #3 was on enhanced barrier precautions, and she was not working with the tubes and no gown was needed. Resident #3's clinical record included a lower respiratory culture report dated 4/29/26 which indicated the resident tested positive for carbapenem-resistant Pseudomonas aeruginosa (CRPA). According to the CDC, Pseudomonas aeruginosa bacteria are a common cause of infections in healthcare settings. They can cause pneumonia, bloodstream infections, urinary tract infections, and surgical site infections, and they are particularly dangerous for patients with chronic lung diseases. Carbapenems are last-line antibiotics used to treat serious multi-drug-resistant infections. CRPA infections are not susceptible to the effects of these antibiotics. Resident #3's current medical provider orders included an order dated 4/30/26 for contact isolation.Resident #3's comprehensive person-centered care plan included a focus area dated 4/30/26 stating the resident requires isolation related to CRP (carbapenem-resistant Pseudomonas) in the sputum with an intervention to maintain isolation precautions per infection control policy. The facility's Infection Preventionist (IP) was interviewed on 5/06/26 at 10:14 AM outside of Resident #3's room. The IP stated a gown, and gloves were required to enter Resident #3's room since they were on contact precautions. The IP stated there were currently two residents positive for CRPA. A contact isolation sign was posted by the resident's door indicating staff must put on a gown before room entry. A facility policy titled, Transmission-Based (Isolation) Precautions, revised 4/02/25, indicated Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. On 5/06/26 at 11:57 AM the Administrator, Director of Nursing, and the Regional Corporate Representative were notified of the concern regarding staff failing to follow contact precautions.No further information was provided prior to the exit conference on 5/06/26.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record by failing to document medical provider notification of an x-ray that could not be obtained as ordered for 1 of 3 sampled residents, Resident #3. The findings included:An admission Record revealed the facility admitted Resident #3 on 4/08/26. According to the admission Record, the resident had a medical history that included chronic respiratory failure with hypoxia, quadriplegia, central cord syndrome at C5 level of cervical spinal cord, dependence on ventilator, and chronic pain syndrome. An admission minimum data set (MDS) with an assessment reference date (ARD) of 4/14/26 indicated the resident had a Brief Interview for Mental Status (BIMS) summary score of 0 out of 15 which indicated the resident was severely cognitively impaired. Resident #3 was seen by the medical provider on 4/10/26 due to an elevated inflammatory panel indicating concern for osteomyelitis secondary to Stage IV wounds with bone exposure to the sacrum, iliac crests, and bilateral scapula. Orders included an x-ray of bilateral scapula. Resident #3's clinical record included a medical provider order dated 4/10/26 to obtain an x-ray of bilateral scapula; however, there were no results in the resident's clinical record. During an interview with the Director of Nursing (DON) on 5/06/26 at 9:19 AM, the DON stated the x-ray company would not obtain the bilateral scapula x-ray due to limitations caused by Resident #3's anatomy. The DON stated she notified the medical provider but failed to document the notification in Resident #3's clinical record. On 5/06/26 at 11:57 AM, the Administrator, DON, and the Regional Corporate Representative were informed of the concern regarding the lack of documentation of medical provider notification in the clinical record. No further information regarding this concern was presented prior to the exit conference on 5/06/26.

Based on staff interview and clinical record review, the facility staff failed to provide laboratory services to meet the needs of 1 of 3 residents in the survey sample, Resident #3.The findings included:For Resident #3, the facility staff failed to obtain a urinalysis as ordered by the medical provider on 4/22/26.An admission Record revealed the facility admitted Resident #3 on 4/08/26. According to the admission Record, the resident had a medical history that included chronic respiratory failure with hypoxia, quadriplegia, central cord syndrome at C5 level of cervical spinal cord, dependence on ventilator, and chronic pain syndrome. An admission minimum data set (MDS) with an assessment reference date (ARD) of 4/14/26 indicated the resident had a Brief Interview for Mental Status (BIMS) summary score of 0 out of 15 which indicated the resident was severely cognitively impaired.A nursing progress note dated 4/22/26 at 10:11 AM indicated the medical provider was notified of Resident #3's elevated temperature of 103.0 and hypotension. New orders were provided, which included urinalysis with reflex. An order dated 4/22/26 for a urinalysis with reflex was present in the resident's clinical record. Resident #3's clinical record failed to include results or evidence of the urinalysis being obtained as ordered. During an interview with the Director of Nursing (DON) on 5/06/26 at 9:19 AM, the DON stated the urinalysis was not obtained and she did not know the reason, but Resident #3 was being treated for pneumonia. On 5/06/26 at 11:57 AM, the Administrator, DON, and the Regional Corporate Representative were informed facility staff failed to obtain a urinalysis as ordered for Resident #3. No further information regarding this concern was presented prior to the exit conference on 5/06/26.

Based on staff interview and clinical record review, the facility staff failed to ensure that a provider ordered medication was available for administration for 1 of 3 sampled residents, Resident #3.The findings included:For Resident #3, the facility staff failed to ensure the antibiotic Cefepime was available for administration on 5/05/26 and 5/06/26. An admission Record revealed the facility admitted Resident #3 on 4/08/26. According to the admission Record, the resident had a medical history that included chronic respiratory failure with hypoxia, quadriplegia, central cord syndrome at C5 level of cervical spinal cord, dependence on ventilator, and chronic pain syndrome. An admission minimum data set (MDS) with an assessment reference date (ARD) of 4/14/26 indicated the resident had a Brief Interview for Mental Status (BIMS) summary score of 0 out of 15 which indicated the resident was severely cognitively impaired.Resident #3 was seen by the medical provider on 4/30/26 for pneumonia with the final sputum culture positive for CRP (carbapenem-resistant Pseudomonas) with new orders to add Cefepime 1 gram intramuscularly twice a day for seven days. Resident #3's medical provider orders included an order dated 4/30/26 for Cefepime 1 gram intramuscularly two times a day for seven days for pneumonia. Resident #3's comprehensive person-centered care plan included a focus area dated 4/23/26 stating the resident had a pneumonia infection with an intervention for medications as ordered. A review of Resident #3's May 2026 Medication Administration Record (MAR) revealed Cefepime was not administered on 5/05/26 at 5:00 AM and 5:00 PM, and 5/06/26 at 5:00 AM. During an interview with the Director of Nursing on 5/06/26 at 9:33 AM, the DON stated Resident #3 had received nine doses of Cefepime since 4/30/26. She stated the pharmacy sent a partial supply of six doses on 4/30/26 and three doses had been pulled from the Omnicell and there were no more doses available in the Omnicell. The DON stated Resident #3's Medicaid coverage was pending and that often created problems when the pharmacy tried to bill for medication. The DON stated the pharmacy did not send a pre-authorization request to the facility regarding the Cefepime. Resident #3's clinical record included a pharmacy Non-Covered Medication Notification form dated 5/03/26 which indicated Resident #3's Cefepime refill was canceled because the facility instructions for non-covered medications indicate facility authorization is required for this fill therefor pharmacy has initiated an insurance prior authorization. The form included an area to check to indicate if the facility was accepting financial responsibility or responsible party had been notified by the facility and is accepting financial responsibility. The form was not addressed, and all options were left blank and scanned into the resident's medical record. The cost of the medication was listed as $16.64. The form included fax documentation across the top indicating the form was faxed on 5/03/26 at 9:55 AM. On 5/06/26 at 11:57 AM during a meeting with the Administrator, DON, and Regional Corporate Representative, the concern of Resident #3 failing to receive Cefepime as ordered was discussed including the unaddressed pre-authorization present in the resident's clinical record. No further information regarding this concern was presented to the survey team prior to the exit conference on 5/06/26.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow medical provider orders for the administration of Gabapentin for 1 of 3 sampled residents, Resident #3.The findings included: An admission Record revealed the facility admitted Resident #3 on 4/08/26. According to the admission Record, the resident had a medical history that included chronic respiratory failure with hypoxia, quadriplegia, central cord syndrome at C5 level of cervical spinal cord, dependence on ventilator, and chronic pain syndrome. An admission minimum data set (MDS) with an assessment reference date (ARD) of 4/14/26 indicated the resident had a Brief Interview for Mental Status (BIMS) summary score of 0 out of 15 which indicated the resident was severely cognitively impaired.Resident #3's comprehensive person-centered care plan included a focus area dated 4/09/26, that indicated the resident had pain related to pressure injuries, muscle spasms, neuropathy, C5 fracture and contractures with an intervention to administer pain medication as per MD orders. Resident #3's clinical record included a medical provider order dated 4/08/26 for Gabapentin 100 mg via peg-tube three times a day for neuropathy. A review of Resident #3's April 2026 Medication Administration Record (MAR) revealed Gabapentin was not administered on 4/09/26 at 2:00 PM and 10:00 PM. A nursing progress note dated 4/09/26 at 2:18 PM documented Gabapentin was on hold until prescription comes in. A 4/09/26 10:02 PM nursing progress documented Gabapentin was on hold. The facility's onsite medication back-up system, Omnicell, Inventory List indicated Gabapentin 100 mg capsules were available for administration. During an interview on 5/06/26 at 9:58 AM, the Director of Nursing (DON) stated staff should have pulled the Gabapentin from the Omnicell to administer to Resident #3 on 4/09/26. A facility policy titled, Medication Shortage/Unavailable Medications, revised 8/01/24, indicated 3. If a medication is unavailable is discovered after normal Pharmacy hours: 3.1 A facility nurse should obtain the ordered medication from the Emergency Medication Supply.On 5/06/26 at 11:57 AM, the concern of staff failing to administer Gabapentin on two occasions on 4/09/26 was discussed with the Administrator, DON, and Regional Corporate Representative.No further information regarding this concern was presented prior to the exit conference on 5/06/26.

Based on staff interview and clinical record review, the facility staff failed to review, revise and/or reassess the effectiveness of the interventions of the comprehensive person-centered activity care plan for 3 of 18 current residents, Resident #7, Resident #9 and Resident #35. The findings included:1.For Resident #7, the facility staff failed to review, revise, and/or reassess the effectiveness of the interventions of the comprehensive person-centered activity care plan to meet the resident's needs. Resident #7's diagnosis list indicated diagnoses that included but were not limited to, pain in right hip, chronic kidney disease-stage 3, unsteadiness on feet, and multiple sclerosis. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/29/25, assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of the current comprehensive person-centered activity care plan disclosed an initiated date of 2/13/23 with a revision date of 3/6/25 for the focus. The goal associated with the focus had a revision date of 3/17/25. The interventions had only initiation dates of 2/13/23. A review of the clinical record did not disclose any evidence of activity progress notes. Further review of the clinical record disclosed an admission Activity Evaluation dated 3/10/25. A review of the completed MDS schedule revealed the following MDS assessments were completed on the following dates with no evidence of a completed activity assessment, activity care plan review, and/or activity progress note: 3/1/25-annual5/29/25-quarterly8/29/25-quarterly11/29/25-quarterly Requested evidence of activity progress notes, activity assessments, and/or care plan revisions for Resident #7. On 2/19/26 at 2:38 PM, the facility administrator stated quarterly activity progress notes had not been completed. On 2/19/26 at 3:10 PM, the activity director (AD) was interviewed. The AD stated the activity care plan is not changed unless the resident voices a change or if the resident gets a new interest. AD agreed the activity care plan is not reviewed or revised unless there is a significant change. When asked the process to document the effectiveness of activity care plan focus, goals, and/or interventions during MDS reviews, the AD agreed progress is not being documented for the residents as there is not a lot of change with resident activities. This concern was discussed on 2/19/26 at 4:15 PM during the end of day meeting with the administrator, director of nursing, regional director of clinical services, vice president of operations, and regional director of maintenance. Requested a facility policy for activity documentation and/or a facility policy for care plans and was informed by the facility administrator on 2/19/26 at 2:46 PM, that facility staff follow the regulations for care plan documentation and do not have these requested policies. No further information regarding this concern was presented to the survey team prior to the exit on 2/20/26. 2. For Resident #9 the facility staff failed to review, revise, and/or reassess the effectiveness of the interventions of the comprehensive person-centered activity care plan to meet the resident's needs. Resident #9's diagnosis list indicated diagnoses that included but were not limited to, chronic respiratory failure with hypoxia, tracheostomy, gastrostomy, dependence on respirator, peripheral vascular disease, altered mental status, anxiety, intracerebral hemorrhage, anoxic brain damage, and cognitive communication deficit. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 12/25/25, Section C (Cognitive Patterns) was coded to reflect the resident was rarely/never understood with severe impairment in cognitive skills for daily decision making and never/rarely made decisions. A review of the current comprehensive person-centered activity care plan disclosed an initiated date of 9/25/25 for the focus. The goal associated with the focus had a revision date of 10/8/25. One intervention had an initiated date of 10/16/25 and the other intervention had an initiated date of 9/26/25 with a revision date of 10/16/25. A review of the clinical record did not disclose any evidence of activity progress notes. Further review of the clinical record disclosed an admission Activity Evaluation dated 9/18/25. A review of the completed MDS schedule revealed the following MDS assessments were completed on the following dates with no evidence of a completed activity assessment, activity care plan review, and/or activity progress note: 12/25/25-quarterly Requested evidence of activity progress notes, activity assessments, and/or care plan revisions for Resident #9. On 2/19/26 at 2:38 PM, the facility administrator stated quarterly activity progress notes had not been completed. On 2/19/26 at 3:10 PM, the activity director (AD) was interviewed. The AD stated the activity care plan is not changed unless the resident voices a change or if the resident gets a new interest. AD agreed the activity care plan is not reviewed or revised unless there is a significant change. When asked the process to document the effectiveness of activity care plan focus, goals, and/or interventions during MDS reviews, the AD agreed progress is not being documented for the residents as there is not a lot of change with resident activities. This concern was discussed on 2/19/26 at 4:15 PM during the end of day meeting with the administrator, director of nursing, regional director of clinical services, vice president of operations, and regional director of maintenance. Requested a facility policy for activity documentation and/or a facility policy for care plans and was informed by the facility administrator on 2/19/26 at 2:46 PM, that facility staff follow the regulations for care plan documentation and do not have these requested policies. No further information regarding this concern was presented to the survey team prior to the exit on 2/20/26. 3. For Resident #35 the facility staff failed to review, revise, and/or reassess the effectiveness of the interventions of the comprehensive person-centered activity care plan to meet the resident's needs. Resident #35's diagnosis list indicated diagnoses that included but were not limited to, chronic respiratory failure with hypoxia, anoxic brain damage, heart failure, type 2 diabetes mellitus, persistent vegetative state, seizures, tracheostomy, gastrostomy, and osteomyelitis. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 12/25/25, Section C (Cognitive Patterns) was not coded due to resident being in a persistent vegetative state. A review of the current comprehensive person-centered activity care plan disclosed an initiated date of 4/30/25 for the focus. The goal associated with the focus had an initiated date of 4/30/25. Two interventions had an initiated date of 4/30/25 and one intervention had an initiated date of 4/30/25 with a revision date of 7/15/25. A review of the clinical record did not disclose any evidence of activity progress notes. Further review of the clinical record disclosed a Comprehensive Activity Evaluation dated 4/9/25 and an admission Activity Evaluation dated 10/1/25. A review of the completed MDS schedule revealed the following MDS assessments were completed on the following dates with no evidence of a completed activity assessment, activity care plan review, and/or activity progress note: 4/4/25-quarterly7/4/25-quarterly2/10/26-quarterly Requested evidence of activity progress notes, activity assessments, and/or care plan revisions for Resident #35. On 2/19/26 at 2:38 PM, the facility administrator stated quarterly activity progress notes had not been completed. On 2/19/26 at 3:10 PM, the activity director (AD) was interviewed. The AD stated the activity care plan is not changed unless the resident voices a change or if the resident gets a new interest. AD agreed the activity care plan is not reviewed or revised unless there is a significant change. When asked the process to document the effectiveness of activity care plan focus, goals, and/or interventions during MDS reviews, the AD agreed progress is not being documented for the residents as there is not a lot of change with resident activities. This concern was discussed on 2/19/26 at 4:15 PM during the end of day meeting with the administrator, director of nursing, regional director of clinical services, vice president of operations, and regional director of maintenance. Requested a facility policy for activity documentation and/or a facility policy for care plans and was informed by the facility administrator on 2/19/26 at 2:46 PM, that facility staff follow the regulations for care plan documentation and do not have these requested policies. No further information regarding this concern was presented to the survey team prior to the exit on 2/20/26.

Based on observation, resident interview, staff interview and clinical record review the facility staff failed to develop a comprehensive care plan related to hearing loss for one of 18 current residents in the survey sample, resident # 47. Findings include: Based on observation, resident interview, staff interview and clinical record review the facility staff failed to develop a comprehensive care plan related to hearing loss for one of 18 current residents in the survey sample, Resident # 47.The findings included:Review of the Electronic Medical Record (EMR) revealed that resident #47 (R47) was admitted to the facility on [DATE] with pertinent diagnoses including but not limited to bilateral hearing loss. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed section B (Hearing) documented minimal difficulty- difficulty in some environments (e.g., when person speaks softly or setting is noisy), no hearing devices used and a Brief Interview for Mental Status (BIMS) of 13 which indicated R47 was cognitively intact.During an observation and interview with R47 in their room on 2/18/2026 at 1:50 PM, the resident could not hear throughout most of the visit when spoken to despite speaking very loudly in his left ear (preferred ear). He was able to report having a bath earlier in the morning, and that he is from the area. After some time, R47 became upset and dismissive as he could not understand or hear well enough to answer any other questions and yelled, I can't hear you. R47 did not have any hearing aids or listening devices and was unable to answer questions about assistive devices. R47 did not want to answer questions with written notes. The visit ended due to the resident becoming upset and agitated. During an observation of a medication administration for R47 on 2/19/2026 at 8:34 AM, in order for R47 to understand, Licensed Practical Nurse (LPN) #3 had to lean down towards the resident's left ear and speak very loudly. The interaction was brief and R47 struggled to understand everything LPN #3 was saying, but understood he was to take his medication.During an observation on 2/19/2026 at 1:26 pm of R47 while in his room reading from a printed sheet, he observed this writer from the doorway. After entering the room and standing close to R47, the interaction was brief and R47 reports he is doing well but still cannot hear questions being asked. A review of the Baseline Care Plan on admission on [DATE], revealed a medical status of very hard hearing and needs hearing aids. Review of hearing test by audiologist dated 1/5/2026, revealed R47 is able to answer sentence but not audible words. Hearing loss noted on testing form and signed by audiologist. Review of revised Care Plan dated 1/9/2026, revealed that R47 has behaviors or history of behaviors of: refusing medications, refusing care, yelling at staff, refusing to have bedside table cleaned off. Care Plan did not address hearing loss or difficulty with communication leading to behaviors such as yelling, frustrations, and refusing medications and care. An interview with License Practical Nurse (LPN) #2 on 2/18/2026 at 9:15 am confirmed that R47 is self-sufficient and hard of hearing. It is reported he has become upset with LPN #2 but apologized for his outburst. R47 has anxiety and LPN #2 was unable to confirm if his hearing is why he was upset that day, but they did have communication issues. She thinks he may choose not to wear his hearing aids but is not positive. An interview with LPN #4 on 2/19/2026 at 1:25 pm, revealed that she is able to communicate with R47 if she stands in front of him and speaks loudly on his left side. She reports he reads lips well and that he has been able to let her know what his needs are, but he does get agitated and frustrated easily.An interview with Director of Nursing (DON) on 2/19/2026 at 3:40 pm regarding care plan for R47 revealed that the facility does not have a policy regarding care plans but follow the regulations. The DON was familiar with R47 and his hearing issues. The DON returned shortly with an update to the current care plan with new entry dated 2/19/2026, that included a focus of resident has limitations in how they are able to communicate related to, hearing deficit. Updated interventions include anticipating the residents needs as able; ask yes or no questions, when possible; face the resident and speak distinctly and follow up with audiology as needed. On 2/19/2026 at 4:15pm, the administrator and DON were informed of the concern regarding R47's comprehensive care plan failing to address hearing loss and difficulty with communication. No further information was provided prior to the exit conference on 2/20/26.

Based on interviews and the and facility document review, the facility staff failed to ensure eleven (11) of 47 residents were provided the opportunity to to vote: Resident #1, Resident #2, Resident #10, Resident #18, Resident #21, Resident #24, Resident #36, Resident #37, Resident #38, Resident #43, and Resident #48. The findings include: The following information was found as part of the facility's Operational Policy Manual: Activity Programs . Intellectual activities are encouraged and are designed to stimulate the resident's mind. Intellectual activities include participation in discussion groups, clubs, and committees; voting; book reviews; and music appreciation. On the afternoon of 11/10/21, a group interview with five (5) residents was completed. During this interview, it was reported that residents at the facility were not able to vote in the November 2021 elections. The group reported the absentee ballots were not obtained and the van was not available for residents to go to the polling place on Election Day. On 11/10/21 at 3:20 p.m., the Administrator was asked about resident's voting. The Administrator reported they thought the residents voted on Election Day using the van. The Activities Director (AD) was interviewed about resident voting on 11/10/21 at 3:32 p.m. The AD provided a list of 11 resident names who wanted to vote via absentee ballot. The AD reported they had missed the deadline to obtain the absentee ballots. The AD reported that two (2) residents (Resident #18 and Resident #43) wanted to vote in-person on Election Day but the polls had closed prior to the AD being able to use the transport van to take the two (2) residents to vote. On 11/10/21 at 3:41 p.m., the facility's Administrator, Director of Nursing (DON), and Chief Nursing Officer (CNO) confirmed the aforementioned residents had been unable to vote for the November 2021 election.

Based on staff interview, clinical record review, facility document 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 three (3) errors in 33 opportunities for a medication error rate of 9.09%. These medication errors affected Resident #4 and #35. The findings included: 1. Resident #4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent admission MDS (minimum data set) with an ARD (assessment reference date) of 8/06/21 assigned the resident a BIMS (brief interview for mental status) score of 8 out of 15 in section C, Cognitive Patterns. Resident #4's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/10/21 at 8:16 am, LPN (licensed practical nurse) #1 was observed preparing and administering Resident #4's medications. LPN #1 administered a [MEDICATION(S)] 120 mg tablet to Resident #4. LPN #1 did not obtain a blood pressure prior to administration. At 12:03 pm, LPN #1 was interviewed and stated Resident #4 did not have a blood pressure check this morning but they would check the blood pressure now. LPN #1 provded a list of residents who had a blood pressure check that morning and Resident #4's name was not on the list. LPN #1 stated the MAR (medication administrator record) should provide a prompt for the blood pressure and stated I'll fix that right now. During the medication pass and pour observation on 11/10/21 at 8:16 am, LPN #1did not administer administer Culturelle to Resident #4; however, LPN #1 signed Resident #4's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . At approximately 1:30 pm, LPN #1was interviewed concerning the administration of Culturelle and LPN #1 pulled a box of Culturelle from the medication cart and stated they think it was given. LPN #1 was unable to provide verification of Culturelle administration. On 11/10/21 at 5:02 pm during a meeting with the administrator, director of nursing, and the chief nursing officer, concerns were discussed about Resident #4 not receiving Culturelle as ordered and [MEDICATION(S)] being administered prior to a blood pressure check on 11/10/21. The facility policy for medication administration entitled General Dose Preparation and Medication Administration which states in part: 4. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 4.1 Facility staff should: 4.1.5 If necessary, obtain vital signs No further information regarding this concern was presented to the survey team prior to the exit conference on 11/12/21. 2. Resident #35's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 10/12/21 assigned the resident a BIMS (brief interview for mental status) score of 14 out of 15 in section C, Cognitive Patterns. Resident #35's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/10/21 at 8:40 am, LPN #1 was observed removing one [MEDICATION(S)] 20 mg tablet from a blister pack card and placing it in a medication cup with the other oral medications, and administering the medications to Resident #35. After reviewing Resident #35's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 stated I just don't know. LPN #1 pulled Resident #35's blister pack of [MEDICATION(S)] from the medication cart, the medication pack was labeled [MEDICATION(S)] 20 mg, give 40 mg and there was one tablet in each blister bubble. The facility policy for medication administration entitled General Dose Preparation and Medication Administration stated in part verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. On 11/10/21 at 5:02 pm during a meeting with the administrator, director of nursing, and the chief nursing officer, the concern of Resident #35 receiving the incorrect dosage of [MEDICATION(S)] was discussed. No further information regarding this concern was presented to the survey team prior to the exit conference on 11/12/21.

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to obtain physician ordered medications for 2 of 20 residents in the survey sample, Resident #25 and #45. The findings included: 1. Resident #25's diagnosis list indicated diagnosis, which included, but not limited to Unspecified Dementia with Behavioral Disturbance, Anxiety Disorder, Cognitive Communication Deficit, Essential Hypertension, and [CONDITION(S)]. The most recent significant change MDS (minimum data set) with an ARD (assessment reference date) of 9/29/21 coded the resident as being moderately impaired in cognitive skills for daily decision making with short term and long term memory problems. Resident #25's current physician's orders included an active order dated 2/10/21 for [MEDICATION(S)] tablet 0.5 mg, give 0.25 mg by mouth at bedtime related to anxiety disorder. A review of the resident's October 2021 MAR (medication administration record) revealed [MEDICATION(S)] was not administered as ordered on 10/15/21, 10/16/21, 10/17/21, and 10/18/21. According to Resident #25's nursing progress notes, [MEDICATION(S)] was not administered for the following documented reasons: 10/15/21 11:20 pm - Medication unavailable. Awaiting pharmacy. MD aware 10/16/21 10:49 pm - Medication unavailable. Awaiting pharmacy. MD aware 10/17/21 10:20 pm - Medication unavailable. Awaiting pharmacy. MD aware 10/18/21 9:55 pm - On hold. NP (nurse practitioner) aware. RP (responsible party) notified The DON (director of nursing) provided physician's orders to hold the 2100 (9:00 pm) dose of [MEDICATION(S)] for 10/15/21, 10/16/21, 10/17/21, and 10/18/21. On 11/12/21 at 11:29 am, the pharmacy manager with the facility's contract pharmacy was interviewed concerning Resident #25's [MEDICATION(S)] unavailability from 10/15/21 through 10/18/21. The pharmacy manager stated a 14 day supply of [MEDICATION(S)] was dispensed on 9/30/21 for Resident #25. A refill request was sent in to the pharmacy on 10/10/21; however, the pharmacy was unable to fill the request due to a pharmacy billing error made on 9/30/21. The facility sent in another refill request on 10/18/21 and the [MEDICATION(S)] supply was dispensed on 10/19/21. The pharmacy manager stated there was no record of the facility requesting removal of [MEDICATION(S)] from the stat box or any additional communication concerning Resident #25's [MEDICATION(S)] between 10/10/21 and 10/18/21 when the second refill request was submitted on 10/18/21. The facility policy entitled Medication Shortages/Unavailable Medications documented in part: 3. If a medication shortage is discovered after normal pharmacy hours: 3.1 A licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery; or 3.2.2 Use of an emergency (back-up) pharmacy The facility narcotic stat box listing was reviewed and included a supply of four (4) [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg tablets. On 11/12/21 at 4:26 pm, a meeting was held with the administrator, director of nursing, and the chief nursing officer and the concern of Resident #25 not receiving [MEDICATION(S)] as ordered was discussed. No further information regarding this concern was presented to the survey team prior to the exit conference on 11/12/21. 2. Resident #45's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/26/21, was completed on 11/2/21. Resident #45 was assessed as able to understand others and as able to make self understood. Resident #45's Brief Interview for Mental Status (BIMS) summary score was a 15 out of 15 (indicating intact/borderline cognition). Resident #45 was documented a being totally depended on others for bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. Resident #45's diagnoses included, but were not limited to: [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)], depression, post traumatic stress disorder, and borderline personality disorder. During an interview on the morning of 11/9/21, Resident #45 reported having dental pain. Resident #45 reported the medical provider had ordered a different pain medication for them. Resident #45 stated the newly ordered pain medication had yet to arrive at the facility but stated that the facility staff were providing other interventions to address their dental pain. Resident #45's clinical record included an order for [MEDICATION(S)] 5mg/acetaminophen 325mg one (1) tablet to be given as needed every twelve (12) hours, dated 11/8/21 at 11:22 a.m. This medication was not documented as being received at the facility until 11/11/21 at 1:07 a.m. Resident #45 was first documented as being provided this medication on 11/10/21 at 3:50 p.m. (the documentation did not specifically address whether or not this medication had been obtained via the facility STAT medication process). Resident #45's plan of care included the focus of risk for pain . This care plan included the following interventions: (a) administer medications as ordered and (b) refer to dentist as needed. On 11/10/21 at 5:02 p.m., a meeting was conducted with the facility's Administrator, Director of Nursing (DON), and Chief Nursing Officer (CNO). During this meeting, the delay in the availability of Resident #45's provider ordered pain medications was discussed. It was reported the pharmacy had not received the prescription and it had to be resent. The possibility of the medication being available at the facility using the facility's STAT medication process was discussed. The survey team was informed the pharmacy would have had to provide a code for the facility staff to access the medication via the facility's STAT medication process. (STAT is a medical abbreviation used to indicate urgent or rushed.)

Based on observation and facility staff interviews, the facility staff failed to follow infection control guidelines in regards to a contract staff member being observed to be sitting on the side of a resident's bed while performing a doppler study on his lower extremity. (Resident in room [ROOM NUMBER]). The findings included: The facility staff failed to follow infection control guidelines in regards to a contract staff member being observed sitting on the side of a resident's bed while performing a doppler study on the residemmt's lower extremity. This staff member did not have gown on during this observation, only a face mask and gloves were being used as personal protective equipment (PPE). The resident involved was in room [ROOM NUMBER] at the bed beside of the window. The surveyor made this observation on 6/22/2020 at 11:25 am while making rounds with the director of nursing (DON) on the 300 hallway. The surveyor asked the DON was the person observed sitting on the side of the resident's bed was a family member. The DON stated, No, that person is from ______ (name of imaging company). The surveyor asked the DON what PPE should be worn while performing a doppler study on this resident. The DON stated, They should have a gown on and not be sitting on the resident's bed. The surveyor notified the administrator of the above documented findings. The administrator stated, That person should not had been sitting on the resident's bed and should of had a gown on with the other PPE that was being used by the staff member of the contracted mobile imaging company. No further information was provided to the surveyor prior to the exit conference on 6/29/2020.

Based on resident interview and staff interview, the facility staff failed to promote the rights of the residents by allowing the facility residents to exercise their voting rights as citizens for six residents who participated in the group meeting. The findings included: The facility staff failed to provide the facility residents with the opportunity to vote. On 11/14/19 at 9:03 am, a resident group meeting was held with six alert and oriented residents. The surveyor asked the residents if the facility staff had provided them with the opportunity to vote. All six residents in the group meeting reported to the surveyor that they have not been provided the opportunity to vote. On 11/14/19 11:28 at am, the surveyor interviewed the facility activity/social services director. The surveyor informed the activity/social services director that the residents in the group meeting had expressed concerns about not being allowed the opportunity to vote in the most recent election. The activity/social services director informed the surveyor that the residents were offered the opportunity to vote and that no one signed up to vote on the signup sheet. The activity/social service director stated that a few residents stated that they wanted to vote but once they found out that there was not a presidential election being held, they declined to vote. The surveyor asked the activity/social service director if there was any documentation that the residents were offered the opportunity to vote. The activity/social service director stated, No I'm sorry. On 11/14/19 at 3:15 pm, the administrator and director of nursing were 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 11/14/19.

Based on clinical record review and staff interview, the facility staff failed to ensure the resident's right to formulate an advanced directive by failing to ensure the advanced directive in the resident's record was complete for 1 of 14 residents in the survey sample (Resident #15). The findings included: For Resident #15 the facility staff failed to accurately complete the resident's DDNR (Durable Do Not Resuscitate Order). All boxes on this form were left unchecked. This DDNR form was part of the resident's clinical record and was located in the electronic health record. Resident #15's [DIAGNOSES REDACTED]. The most recent significant change MDS (minimum data set) with an ARD (assessment reference date) of 9/18/19 assigned the resident a BIMS (brief interview for mental status) score of 12 out of 15 in section C, cognitive patterns. Resident #15's clinical record included a physician's orders [REDACTED]. The clinical record also included a DDNR from the Virginia Department of Health dated 9/07/18 that was signed by the physician and the resident's daughter. This DDNR read in part Under section 1 I 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 were left blank. The concern of Resident #15's incomplete DDNR was discussed with the administrative staff (director of nursing and administrator) during a meeting on 11/13/19 at 4:25 pm. On 11/14/19 at approximately 8:00 am, the surveyor was provided with a copy of the revised DDNR dated 9/07/18 with box #2 checked in section 1 and box C checked in section 2. The surveyor also received a copy of a progress note dated 11/13/19 19:19 stating the resident's guardian was called and notified of the incomplete DDNR and the guardian choose box 2 in section 1 and box C in section 2. No further information was provided prior to exit conference on 11/14/19.

Based on clinical record review and staff interview, the facility staff failed to review and revise the plan of care for one of 15 residents in the survey sample, Resident # 19. The findings included: The facility staff failed to review and revise the plan of care for Resident # 19 to indicate the correct size suprapubic Foley catheter. Resident # 19 was originally admitted to the facility on [DATE], and had a facility readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 19 was reviewed on 11/14/19 at 8:41 am. The most recent MDS (minimum data set) assessment for Resident # 19 was an admission assessment with an ARD (assessment reference date) of 9/24/19. Section C of the MDS assesses cognitive patterns. In Section C1000, the facility staff documented that Resident # 19's cognitive status was severely impaired. Section H of the MDS assesses bladder and bowel. In Section H0100, the facility staff documented that Resident # 19 had an indwelling catheter. Resident # 19 had orders that included but were not limited to, Change suprapubic Foley catheter using 16fr (French) 10 cc (cubic centimeter) balloon, which was initiated by the physician on 10/28/19. The plan of care for Resident # 19 was reviewed and revised on 10/28/19. The facility staff documented a focus area for Resident # 19 as, Resident requires suprapubic catheter for urinary output related to: [MEDICAL CONDITION] 18 FR with 10 cc balloon. On 11/14/19 at 1:21 pm, the surveyor interviewed MDS coordinator # 1. The surveyor and MDS coordinator # 1 reviewed the plan of care for Resident # 19 and the surveyor pointed out the discrepancy in Resident # 19's order for 16 Fr catheter and 18 Fr catheter that was written on the plan of care for Resident # 19. MDS coordinator # 1 informed the surveyor that she would look into the discrepancy and find out what the issue was. On 11/14/19 at 1:31 pm, MDS coordinator # 1 informed the surveyor that Resident # 19 did have an 18 FR Foley catheter when he initially came in and that Resident # 19 went out and returned to the facility with a 16FR Foley catheter. MDS coordinator # 1 informed the surveyor that the care plan for Resident # 19 would be revised. On 11/14/19 at 3:15 pm, the administrator and director of nursing were 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 11/14/19.

Based on observation, staff interview and clinical record review, the facility staff failed to ensure that residents receive treatment and care in accordance with physician orders [REDACTED].#17). The findings included: For Resident #17 the facility staff failed to administer a laxative, Polyethylene [MEDICATION NAME], through the route ordered by the physician. Resident #17's [DIAGNOSES REDACTED]. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/19/19 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. Resident #17 was also coded as having a feeding tube in section K, Swallowing/Nutritional Status. On 11/14/19 at approximately 8:40am, the surveyor observed RN #1 mix polyethylene [MEDICATION NAME] 17 grams in 30 ml of Pro-stat and administer to Resident #17 by peg tube. RN #1 stated the resident prefers the Pro-stat and the polyethylene [MEDICATION NAME] to be given by peg tube due to the taste. Review of the clinical record revealed an order for [REDACTED]. On 11/14/19 at approximately 3:15pm, the administrative team consisting of the administrator and director of nursing were made aware of RN #1 not administering the Polyethylene [MEDICATION NAME] by the appropriate route as ordered by the physician. No further information regarding this issue was presented to the survey team prior to the exit conference on 11/14/19.

Based on observation, clinical record review, resident interview, and staff interview, the facility staff failed to provide respiratory care consistent with the comprehensive plan of care to one of 15 residents in the survey sample, Resident # 22. The findings included: The facility staff failed to deliver oxygen to Resident # 22 at the physician ordered rate. Resident # 22 was originally admitted to the facility on [DATE]. Resident # 22 had a readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 22 was reviewed on 11/13/19 at 2:35 pm. The most recent MDS (minimum data set) assessment for Resident # 22 was a quarterly assessment with an ARD (assessment reference date) of 8/14/19. Section C of the MDs assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 22 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident # 22 was cognitively intact. Section O of the MDS assesses special treatments and programs. In Section O0100, the facility staff documented that Resident # 22 had received oxygen within the last 14 days of the 8/14/19 look back period. Resident # 22 had orders that included but were not limited to, O2 (oxygen) at 3L (liters) via NC (nasal cannula) continuous, that was initiated by the physician on 11/6/19. The plan of care for Resident # 22 was reviewed and revised on 10/8/19. The facility staff documented a focus area for Resident # 22 as, Altered respiratory status, difficulty breathing d/t (due to) sleep apnea, hospitalized for [REDACTED]. Interventions included but were not limited to, Elevate HOB (head of bed) as tolerated. O2 continuously, and Administer medication and respiratory treatments as ordered. Monitor for effectiveness and side effects. On 11/13/19 at 2:10 pm, the surveyor was in Resident # 22's room conducting a resident interview. The surveyor observed that the oxygen concentrator was set to deliver 4 liters of oxygen. Resident # 22 observed the surveyor looking at the oxygen concentrator and stated, I am supposed to get 3 liters. On 11/13/19 at 3:05 pm, the surveyor and LPN # 1 entered Resident # 22's room and observed her oxygen concentrator. The surveyor asked LPN # 2 how many liters of oxygen was being delivered to Resident # 22. LPN # 1 stated, She's getting 4 liters. and looked at oxygen. On 11/13/19 at 4:30 pm, the administrator and director of nursing were 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 of 11/14/19.

Based on observation, clinical record review, staff interview, and facility document review, the facility staff failed to maintain an infection prevention and control program by failing to utilize personal protective equipment and failing to utilize appropriate handwashing on one of three halls in the facility. The findings included: A facility staff member failed to wear gloves and failed to wash hands after exiting a contact isolation room. On 11/14/19 at 8:33 am, the surveyor observed an isolation cart in the hallway outside of room [ROOM NUMBER]. The surveyor observed signage on the door that stated, See nurse before entering room. The surveyor observed CNA #1 (certified nursing assistant) put on a yellow gown and enter room [ROOM NUMBER]. The surveyor observed that CNA # 1 did not put on gloves. The surveyor observed CNA # 1 remove a burgundy covered food plate from room [ROOM NUMBER] and placed it on top of the tray cart. The surveyor observed that CNA # 1 did not wash her hands. The surveyor asked CNA #1 if she had been wearing gloves on when she entered the room [ROOM NUMBER]. CNA # 1 stated, No, I didn't even think about it. I just got her tray. The surveyor observed CNA # 1 knock and enter room [ROOM NUMBER] without washing her hands. The surveyor called CNA # 1 from the room and informed her of the observation of her entering a contact isolation room without gloves and failing to wash her hands after exiting and prior to entering another resident's room. On 11/14/19 at 9:14 am, the surveyor reviewed the clinical record for the resident that CNA # 1 was observed handling the food plate without wearing gloves. Resident # S1 (unsampled). Resident # S1 was a [AGE] year-old-female that was originally admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident # S1 had orders that included but were not limited to, Contact isolation precautions d/t (due to)[MEDICAL CONDITION] to L (left) wrist, which was initiated by the physician on 11/13/19. The facility Infection Prevention and Control Program contained documentation that included but was not limited to, .Outbreak Management a. Outbreak management is a process that consists of: (3) preventing the spread to other residents. On 11/14/19 at 10:18 am, the administrator and director of nursing were 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 11/14/19.

Based on staff interview and clinical record review, the facility staff failed to ensure 5 of 12 residents were free of an unnecessary medication (Resident #18, Resident #48, Resident #3, Resident #23, and Resident #29). The findings included: 1. The facility staff failed to provide behavior monitoring for the [MEDICAL CONDITION] medication [MEDICATION NAME] for Resident #18. Resident #18 was admitted to the facility 4/5/16 with [DIAGNOSES REDACTED]. The OBRA minimum data set (MDS) with an assessment reference date (ARD) of 5/19/18 assessed the resident with a BIMS (brief interview for mental status) as 15 out of 15. No signs of [MEDICAL CONDITION] or [MEDICAL CONDITION]. Mood was described as feeling down, depressed or hopeless and feels tired with little energy. Total severity score =3. Resident #18's current comprehensive care plan initiated 4/6/16 for use of [MEDICAL CONDITION] medications and revised 3/15/2018 identified interventions to be evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs per pharmacy review. Observe for adverse effects related to [MEDICAL CONDITION]. Resident #18 has orders for [MEDICATION NAME] 20 mg (milligrams) every day. According to the Physician's Desk Reference, [MEDICATION NAME] is an antidepressant used for the treatment of [REDACTED]. The surveyor reviewed the behavior monitoring and side effects flow sheets for (MONTH) (YEAR). The April (YEAR) side effect monthly flow sheet did not identify what side effect was being monitored. The (MONTH) (YEAR) Behavior Monthly Flow Sheet did not have evidence that the behavior for Resident #18 was monitored on the day shift 5/1/18 through 5/17/18 and on the following evening/night shift: 5/1/18 through 5/3/18, 5/6/18, 5/11/18, 5/14/18, 5/17/18, and 5/18/18. The (MONTH) (YEAR) Side Effects Monthly Flow Sheet did not have evidence of monitoring on the day shift 5/1/18 through 5/31/18 and the evening/night shift 5/1/18 through 5/3/18, 5/6/18, 5/11/18, 5/13/18, and 5/17/18. The surveyor was unable to locate the (MONTH) (YEAR) Behavior Monthly Flow Sheet or the Side Effects Monthly Flow Sheet. The surveyor informed the assistant director of nursing of the above concern on 7/12/18 at 9:06 a.m. The ADON confirmed the incomplete monitoring for (MONTH) (YEAR) and (MONTH) (YEAR). The DON stated the facility was unable to locate the (MONTH) (YEAR) Behavior Monthly Flow Sheets and the (MONTH) Side Effects Flow Sheet. The (MONTH) (YEAR) medication regimen review was reviewed. On the note, the contracting pharmacist had documented Resident #18's behavior monitoring documentation appears not to be maintained completely; that is, it is missing the following items: 1. Behavior monitoring for (MONTH) for [MEDICATION NAME] and [MEDICATION NAME]. The surveyor informed the administrator, the director of nursing, the assistant director of nursing and the rehab manager on 7/12/18 at 1:15 p.m. No further information was provided prior to the exit conference on 7/12/18. 2. The facility staff failed to provide behavior monitoring for Resident #48's [MEDICAL CONDITION] medication [MEDICATION NAME] and [MEDICATION NAME]. The clinical record of Resident #48 was reviewed 7/9/18 through 7/12/18. Resident #48 was admitted to the facility 5/15/18 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #48's 14 day minimum data set (MDS) with an ARD (assessment reference date) of 6/27/18 assessed the resident with a BIMS (brief interview for mental status) of 15 out of 15. Resident #48 did not have any signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]; the resident did reject care 4-6 days during the week. Mood interview identified feeling down, depressed or hopeless and feeling bad about yourself. Total severity score=6. Resident #48's current comprehensive care plan initiated 6/1/18 identified the resident was at risk for adverse effects related to [MEDICAL CONDITION] medications secondary to dx (diagnosis) of anxiety. Resident #48 had physician orders [REDACTED]. According to the Physician's Desk reference, [MEDICATION NAME] ([MEDICATION NAME]) is an antidepressant in a group of drugs called selective serotonin reuptake inhibitors (SSRIs). According to the Physician's Desk Reference, Klonopin is an Oral long-acting benzodiazepine,noticeable efficacy in the treatment of [REDACTED]. Also used for panic disorder and restless leg syndrome. The surveyor reviewed the clinical record for the (MONTH) (YEAR) Behavior Monitoring Flow Sheets and the Side Effects Flow Sheet. The surveyor was unable to locate any behavior monitoring for (MONTH) (YEAR). The surveyor informed the medical records staff (MR#1) on 7/12/18 at 11:07 a.m. The surveyor reviewed the (MONTH) (YEAR) Behavior Monitoring Flow Sheets and the Side Effects Flow Sheet. The Behavior Monitoring Flow Sheets and the Side Effects Flow Sheet had not been completed upon Resident #48's readmission to the facility 6/13/18. Medical records #1 stated he was unable to locate (MONTH) or (MONTH) (YEAR) behavior monitoring sheets. The surveyor informed the administrator, the director of nursing, the assistant director of nursing and the rehab manager on 7/12/18 at 1:15 p.m. No further information was provided prior to the exit conference on 7/12/18. 3. The facility staff failed to provide behavior monitoring for Resident #3's [MEDICAL CONDITION] medications [MEDICATION NAME] SR, and [MEDICATION NAME]. The clinical record of Resident #3 was reviewed 7/9/18 through 7/12/18. Resident #3 was admitted to the facility 7/27/15 with [DIAGNOSES REDACTED]. Resident #3's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/28/18 assessed the resident with a BIMS (brief interview for mental status) as 15 out of 15. No signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]. Mood interview revealed the resident was feeling down, depressed or hopeless, had trouble falling or staying asleep, and feeling tired or having little energy. Current comprehensive care plan initiated 7/27/15 and reviewed 7/10/18 identified Resident #3 required use of [MEDICAL CONDITION] medications with potential for adverse reactions related to depression and anxiety. Resident #3 is on [MEDICATION NAME] and [MEDICATION NAME]. Resident #3 had physician orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) is an antidepressant medication used to treat major [MEDICAL CONDITION] and seasonal affective disorder. [MEDICATION NAME] ([MEDICATION NAME]) belongs to a group of drugs called benzodiazepines . [MEDICATION NAME] affects chemicals in the brain that may be unbalanced in people with anxiety. [MEDICATION NAME] is used to treat anxiety disorders. The surveyor reviewed the (MONTH) (YEAR) behavior monthly flow sheet and found no monitoring completed on 5/15/18 evening/night shift for [MEDICATION NAME] and [MEDICATION NAME]. The (MONTH) (YEAR) Side Effects Flow Sheet did not specify the side effect staff were to monitor and failed to document on 5/15/18 evening/night shift. The surveyor reviewed the (MONTH) (YEAR) behavior monthly flow sheet and found no monitoring completed on 6/19/18 evening/night shift for [MEDICATION NAME] and [MEDICATION NAME]. The surveyor informed the assistant director of nursing on 7/12/18 at 11:31 a.m. After reviewing, the ADON stated, it was a night shift nurse. The surveyor informed the administrator, the director of nursing, the assistant director of nursing, and the rehab manager on 7/12/18 at 1:15 p.m. No further information was provided prior to the exit conference on 7/12/18. 4. The facility staff failed to provide behavior monitoring for the [MEDICAL CONDITION] medication [MEDICATION NAME] for Resident #23. The clinical record of Resident #23 was reviewed 7/9/18 through 7/12/18. Resident #23 was admitted to the facility 1/19/18. The resident has had multiple hospitalization s since admission the most recent re-admission being 6/25/18. Resident #23 [DIAGNOSES REDACTED]. Resident #23's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 5/24/18 assessed the resident with a BIMS (brief interview for mental status) of 12 out of 15. There were no signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]. Mood interview revealed Resident #23 had feelings of being down, depressed or hopeless and feeling tired or having little energy. Resident #23's current comprehensive care plan initiated 1/31/18 and revised 3/5/18 read that the resident had behaviors of becoming easily agitated, crying, refusing showers or therapy and making negative statements. Resident #23 also was at risk for adverse consequences related to use of [MEDICAL CONDITION] medications secondary to [DIAGNOSES REDACTED]. Interventions included evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs per pharmacy recommendation. Monitor behaviors related to antipsychotic use. Resident #23's physician's orders [REDACTED]. According to the Physician's Desk Reference, [MEDICATION NAME] is a medicine called a selective serotonin reuptake inhibitor (SSRI). It is used to treat major [MEDICAL CONDITIONS], panic disorder, post-traumatic stress disorder, premenstrual dysphoric disorder, and social anxiety disorder. According to the Physician's Desk Reference, Klonopin is an Oral long-acting benzodiazepine,noticeable efficacy in the treatment of [REDACTED]. Also used for panic disorder and restless leg syndrome. The surveyor reviewed the (MONTH) (YEAR) Behavior Monitoring Flow Sheets and the (MONTH) (YEAR) Side Effects Flow Sheets. The surveyor was unable to locate any (MONTH) (YEAR) flow sheets for [MEDICATION NAME] and Klonopin after the resident was readmitted to the facility 6/25/18. The surveyor informed the administrator, the director of nursing, the assistant director of nursing, and the rehab manager on 7/12/18 at 1:15 p.m. No further information was provided prior to the exit conference on 7/12/18. 5. The facility staff failed to monitor a [MEDICAL CONDITION] medication, [MEDICATION NAME], for Resident #29. Resident #29 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/23/18 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #29 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. The surveyor performed a review of Resident #29's clinical record on 7/12/18. During this review, the surveyor noted a physician order [REDACTED]. The surveyor also reviewed the behavioral monitoring sheets for Resident #29. For the month of (MONTH) (YEAR), the surveyor noted documentation for the dates of 6/1, 6/2, 6/3 and 6/4. The rest of the behavioral monitoring sheet for (MONTH) was blank with no documentation noted. The surveyor notified the administrative team of the above documented findings on 7/12/18 at 1:14 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 7/12/18.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow physician orders [REDACTED].#10 and Resident #48). The findings included: 1. The facility staff failed to follow physician's orders [REDACTED].#10's blood pressure in regards to administering the resident's blood pressure medication. Resident #10 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/4/18 coded the resident as having a BIMS (Brief Interview for Mental Status) of 14 out of a possible score of 15. Resident #10 was also coded as being totally dependent on 2 or more staff members for dressing, personal hygiene and bathing. The surveyor performed a review of Resident #10's clinical record on 7/10/18. During this review, the surveyor noted a physician order [REDACTED].[MEDICATION NAME] .0.1 mg (milligram) Give 1 tablet every 6 hours as needed for increased BP (blood pressure) Systolic >190 and Dias. (diastolic) >90 . This order was written on 5/13/18. The surveyor reviewed the resident's MAR for the months of May, (MONTH) and (MONTH) (YEAR). There was no blood pressures documented on the MAR during these months. In the vital signs section of the clinical record for Resident #10, the surveyor noted blood pressure documented for 6/1/18, 6/11/18, and 6/13/18. On 7/10/18 at 2:16 pm, the surveyor notified the director of nursing (DON) of the above documented findings. The DON stated, The NP only meant to take the BP if the patient was complaining of her BP being up, then we were to take it and if the BP fell along these perimeters then we are to give the medication. The surveyor notified the administrative team of the above documented findings on 7/10/18 at 4:50 pm. No further information was provided to the surveyor prior to the exit conference on 7/12/18. 2. The facility staff failed to follow physician orders [REDACTED].#48. The staff failed to administer ASA 81 mg (milligrams), Klonopin 0.5 mg, [MEDICATION NAME] 40 mg subc (subcutaneous), [MEDICATION NAME] 500 mg, Lactobacillus,[MEDICATION NAME] mg, [MEDICATION NAME] 300 mg, and [MEDICATION NAME] 10 mg. The clinical record of Resident #48 was reviewed 7/9/18 through 7/12/18. Resident #48 was admitted to the facility 5/15/18 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #48's 14 day minimum data set (MDS) with an ARD (assessment reference date) of 6/27/18 assessed the resident with a BIMS (brief interview for mental status) of 15 out of 15. Resident #48 did not have any signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION]; the resident did reject care 4-6 days during the week. The surveyor reviewed Resident #48's progress notes from admission through 7/12/18. The progress note written 6/14/18 at 17:00 (5:00 p.m.) read in part, Medications ordered from pharmacy. The next progress note written 6/14/18 at 1:29 a.m. read in part Spoke with on-call pharmacy. Re-faxed medication orders as per their request. A third progress note dated 6/14/18 at 7:45 a.m. read in part Called on-call pharmacy. Spoke with _____ (name omitted). He stated he will notify ______( contracting pharmacy name omitted) to send residents medications STAT that it will be quicker than requesting from back-up pharmacy since _____ (contracting pharmacy) is opening soon for the day. This nurse explained to him that we requested several times and faxed orders and still hadn't received resident's medications. The surveyor reviewed the 6/13/18 discharge summary and the readmission physician's orders [REDACTED]. [MEDICATION NAME] 500 mg (milligram) 1 tablet p.o. (by mouth) every other day for 5 more tablets-Start 6/14/18 [MEDICATION NAME] 0.5 mg inhalation every 12 hours [MEDICATION NAME] nebulizers 3 ml (milliliter) inhalation 3 times per day [MEDICATION NAME] 20 mg 1 tablet po bid (twice a day)-start 6/14/18 [MEDICATION NAME] 100 mg po q (every) 6 hours p.r.n. (whenever necessary) Aspirin 81 mg 1 tablet po daily-start 6/14/18 [MEDICATION NAME] 12.5 mg po bid-start 6/14/18 [MEDICATION NAME] 10 mg 1 tablet po daily-start 6/14/18 [MEDICATION NAME] 300 mg 1 tablet po daily-start 6/14/18 Lactobacillus 1 capsule po daily-start 6/14/18 [MEDICATION NAME] 20 mg 1 tablet po at bedtime-start 6/14/18 [MEDICATION NAME] 40 mg subcu (subcutaneous) 24 hours-start 6/14/18 Pepto-Bismol po bid prn [MEDICATION NAME] 500 mg tablet po bid-start 6/14/18 [MEDICATION NAME] 600 mg po bid-start 6/14/18 [MEDICATION NAME] mg 1 tablet po 3 times a day-start 6/13/18 Tylenol 650 mg po q6 hours prn for pain [MEDICATION NAME] 2 mg po tid (three times a day) for diarrhea [MEDICATION NAME] 15 ml po q 8 hours prn for GERD Milk of magnesia 30 ml po daily prn for constipation [MEDICATION NAME] 5/325 mg 1 tablet po q 8 hours prn for pain-start 6/13/18 [MEDICATION NAME] spray prn Klonopin 0.5 mg q 6 hours-start date 6/13/18 The surveyor reviewed the (MONTH) (YEAR) medication administration records. Klonopin 0.5 mg ordered q 6 hours was not given as ordered 6/13/18 at 2200 (10:00 p.m.), 6/14/18 at 0500, 1200, 5:00 p.m. or 10:00 p.m.) and 6/15/18 at 0500, 1200, 5:00 p.m. and 10:00 p.m. In each box for the administration time, there was an x. Resident #48 was not administered 9 doses of physician ordered Klonopin. Lactobacillus was ordered to start 6/14/18. Review of the (MONTH) (YEAR) had an x marked on 6/14/18. The medication was not administered. [MEDICATION NAME] 500 mg was ordered every other day. The (MONTH) (YEAR) MAR had an x documented on 6/14/18 and the entry on the MAR read one time a day for pneumonia until 6/19/18. Resident #48 received [MEDICATION NAME] every day for 7 doses not every other day for 5 doses as ordered. Resident #48 did not receive [MEDICATION NAME] beginning 6/14/18. The first dose of [MEDICATION NAME] administered was documented on 6/15/18. [MEDICATION NAME] 40 mg subcutaneous was ordered every 24 hours. The start date was 6/14/18. In the box for 6/14/18 an x had been placed. Resident #48 did not receive [MEDICATION NAME] as ordered every 24 hours. Aspirin 81 mg ordered once a day to start 6/14/18, [MEDICATION NAME] 10 mg ordered once a day to start 6/14/18, and [MEDICATION NAME] 300 mg ordered once a day to start 6/14/18 all had an x in the boxes for 6/14/18. The medications were not administered as ordered. The surveyor was unable to locate the (MONTH) (YEAR) medication administration record [MEDICATION NAME] mg ordered tid. The surveyor interviewed both the director of nursing (DON) and the assistant director of nursing (ADON) on 7/12/18 at 10:46 a.m. The DON stated that medications couldn't be ordered from the pharmacy until the resident was physically in the building. The DON reviewed the discharge summary from the hospital and stated dots beside the medications indicated they had been placed on the MAR. The DON and surveyor reviewed the (MONTH) (YEAR) MARs together. She stated Aspirin 81 mg and Lactobacillus were over the counter medications and [MEDICATION NAME] 500 mg was in the stat box and did not know why those medications were not administered. The DON stated the ordered dose of [MEDICATION NAME] (40mg) was not in the stat box. The DON stated she was unable to locate page 1 of the (MONTH) (YEAR) scheduled medications and page 1 of the (MONTH) prn medications. The DON was unable to provide evidence the facility staff [MEDICATION NAME] mg tid beginning 6/13/18. The DON stated the missing MAR was probably the page containing [MEDICATION NAME]. The surveyor informed the administrator, the director of nursing, the assistant director of nursing, and the rehab manager of the above issues with medications not administered to Resident #48 as ordered on [DATE] at 1:15 p.m. No further information was provided prior to the exit on 7/12/18.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure 1 of 12 current residents (Resident #23) was assessed by the registered dietician (RD) for weight loss. Resident #23 had continuous tube feeding. The findings included: The facility RD failed to assess Resident #23 when the resident had a significant weight change in 30 days of 6.14%, which is 9.6 pounds from 4/26/18 to 5/24/18. Resident #23's weight dropped from 166 to 156.4 pounds in 1 month. Resident #23 is NPO (nothing by mouth) and was fed by a PEG (percutaneous endoscopic gastrostomy) tube continuously. The clinical record of Resident #23 was reviewed 7/9/18 through 7/12/18. Resident #23 was admitted to the facility 1/19/18. The resident has had multiple hospitalization s since admission the most recent re-admission being 6/25/18. Resident #23 [DIAGNOSES REDACTED]. Resident #23's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 5/24/18 assessed the resident with a BIMS (brief interview for mental status) of 12 out of 15. Section K. Swallowing/Nutritional Status and specifically Section K0510 Nutritional Approaches was marked for Feeding Tube only. K0710. Percent Taken by Artificial Route was marked that Resident #23 received 51% or more of total calories through [MEDICATION NAME] or tube feeding during the 7 day look back period and 501 cc(cubic centimeters) day or more of fluid intake per day by IV or tube feeding. Current comprehensive care plan dated 3/5/18 identified the resident was peg tube dependent and interventions included NPO status and RD (registered dietician) review. The surveyor observed Resident #23 on 7/9/18 at 5:15 p.m. The resident was in bed with the head of the bed elevated and receiving Glucerna 1.2 at 55 cc/hr via pump. The surveyor reviewed Resident #23's weights since admission. 1/20/18=160 2/11/18=166.1 2/13/18=162.6 2/22/18=166.4 3/1/18=161.2 3/5/18=161.8 3/22/18=165 3/29/18=168 4/5/18=166 4/26/18=166 5/24/18=156.4 6/19/18=151.2 6/26/18=153 7/5/18=150.6 7/10/18=150.8 The dietary note dated 5/24/18 4:37 p.m. read Quarterly note: Resident #23 continues vent/trach dependent. She is NPO. She receives her nutrition and hydration via PEG tube. Her current weight (2-13-18) is 156.4 lbs. (pounds), ht (height) 65 inches, IBWR (ideal body weight range) is 113-137 lbs., BMI (body mass index) is 25.96. She has had a significant weight change in 30 days of 6.14% which is 9.6 lbs. Referring her to the RD due to weight loss. Her skin is intact. She is receiving diuretic therapy. She receives supplements of lactobacillus, potassium chloride, and a multivitamin. The surveyor informed the assistant director of nursing of the weight loss concerns, the RD recommendation by the dietary manager, and the inability to locate the RD recommendations in the clinical record on 7/12/18 at 11:00 a.m. The assistant director of nursing informed the surveyor 7/12/18 at 12:12 p.m. that an RD consult was not completed. The surveyor was unable to locate the RD assessment and recommendations in the clinical record and interviewed the director of culinary services on 7/12/18 at 1:00 p.m. The surveyor asked the director of culinary services the process for informing the RD of a concern. The DCS stated the RD came to the facility 2x/week. The DCS stated she writes up her findings and gives the RD the information and texts the RD to tell her that there is information for the RD to review. The surveyor informed the administrator, the director of nursing, the assistant director of nursing, and the rehab manager of the above concern in the end of the survey meeting on 7/12/18 at 1:15 p.m. No further information was provided prior to the exit conference on 7/12/18.