Every finding on record at Blue Ridge Therapy Connection

Based on staff interview, clinical record, and facility document review, the facility staff failed to develop a comprehensive care plan for 6 of 33 current residents, Residents #1, #6, #126, #2, #12, and #17. The findings include. 1. For Resident (R) #1, the facility staff failed to develop a comprehensive care plan (CCP) that included their current code status. R1's clinical record included the diagnoses of toxic encephalopathy, unspecified abnormalities of gait and mobility, and muscle weakness. Section C (cognitive patterns) of R1's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] included a brief interview for mental status (BIMS) score of 11 out of a possible 15 points. Per the MDS manual an 11=moderately impaired in cognitive skills for daily decision making. R1's clinical record included a Do Not Resuscitate (DNR) order dated [DATE]. During a review of the clinical record the surveyor was unable to find information regarding R1's current code status included on the CCP. On [DATE] at 1:40 p.m., MDS nurse #1 was asked for information related to the care planning of R1's code status. On [DATE] at 2:35 p.m., MDS nurse #1 provided the surveyor with a copy of an updated CCP that now included R1's current code status. On [DATE] at 5:15 p.m. and again on [DATE] at 1:25 p.m., during meetings with the Administrator, Director of Nursing, Quality Assurance Nurse, Nurse Consultant #1 and #2, Assistant Director of Nursing, and Infection Preventionist the issue with the CCP not including information regarding this individual's code status was reviewed. The administrative staff provided the survey team with a copy of their policy titled, Care Planning-Comprehensive Person-Centered. This policy read in part, .The facility will develop and implement a comprehensive person-centered care plan for each resident. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident (R) #6, the facility staff failed to develop a comprehensive care plan (CCP) that included their current code status. R6's diagnoses included cognitive communication deficit, dysphagia, history of falling, and diabetes. Section C (cognitive patterns) of R6's significant change in status minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] was coded [DATE] indicating R6 had problems with long- and short-term memory and was severely impaired in cognitive skills for daily decision making. R6's clinical record included a Do Not Resuscitate (DNR) order dated [DATE]. During a review of the clinical record the surveyor was unable to find information regarding R6's current code status included on the CCP. On [DATE] at 2:35 p.m., MDS nurse #1 provided the surveyor with a copy of an updated CCP that now included R6's current code status. On [DATE] at 5:15 p.m. and again on [DATE] at 1:25 p.m., during meetings with the Administrator, Director of Nursing, Quality Assurance Nurse, Nurse Consultant #1 and #2, Assistant Director of Nursing, and Infection Preventionist the issue with the CCP not including information regarding this individual's code status was reviewed. The administrative staff provided the survey team with a copy of their policy titled, Care Planning-Comprehensive Person-Centered. This policy read in part, .The facility will develop and implement a comprehensive person-centered care plan for each resident. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident (R) #126, the facility staff failed to develop a comprehensive care plan (CCP) that included their current code status. R126's diagnoses included hemiplegia and hemiparesis following cerebral infarction, gastro esophageal reflux disease, and chronic respiratory failure. Section C (cognitive patterns) of R126's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE] was coded [DATE] to indicate this resident had problems with long- and short-term memory and was severely impaired in cognitive skills for daily decision making. R126's clinical record included a Do Not Resuscitate (DNR) order dated [DATE]. During a review of the clinical record the surveyor was unable to find information regarding R6's current code status included on the CCP. On [DATE] at 2:35 p.m., MDS nurse #1 provided the surveyor with a copy of an updated CCP that had been updated to include R126's current code status. On [DATE] at 5:15 p.m. and again on [DATE] at 1:25 p.m., during meetings with the Administrator, Director of Nursing, Quality Assurance Nurse, Nurse Consultant #1 and #2, Assistant Director of Nursing, and Infection Preventionist the issue with the CCP not including information regarding this individual's code status was reviewed. The administrative staff provided the survey team with a copy of their policy titled, Care Planning-Comprehensive Person-Centered. This policy read in part, .The facility will develop and implement a comprehensive person-centered care plan for each resident. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #2 the facility staff failed to develop and implement a comprehensive person-centered care plan to address trauma informed care related to a diagnosis of PTSD (post-traumatic stress disorder) and the facility staff failed to develop and implement a comprehensive person-centered care plan to address the resident's end-of-life care decisions and/or advance directive for DNR (do not resuscitate). Resident #2's diagnosis list indicated diagnoses that included but were not limited to Weakness, Rupture of Artery, Gastrointestinal Hemorrhage, Ruptured Infrarenal Abdominal Aortic Aneurysm, Post-Traumatic Stress Disorder, Malignant Neoplasm of Prostate, Depression, Atrial Fibrillation, Peripheral Vascular Disease, Chronic Kidney Disease-Stage 2, and Anxiety Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of [DATE], assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 for cognitive abilities, indicating the resident was cognitively intact. On [DATE] at 12:47 PM, surveyor spoke with Resident #2 and he informed surveyor he had served in the United States Army and had PTSD and has been seeing a therapist for years. A review of the person-centered comprehensive care plan did not reveal a focus, goal, and/or interventions for trauma informed care related to Resident #2's diagnosis of PTSD. On [DATE] at 2:03 PM, surveyor spoke with other staff #2 (OS#2) and he informed surveyor when residents are admitted he performs trauma screens and asks the residents about triggers and it should be care planned. Surveyor and OS#2 reviewed Resident #2's care plan and he agreed a PTSD (trauma-informed) care plan focus could not be located for the resident. A medical provider orders with a start date of [DATE] read in part, .Code Status: DNR. A review of a Durable Do Not Resuscitate Order dated [DATE] disclosed Resident #2's informed decision to have life-prolonging procedures withheld or withdrawn in the event of cardiac or respiratory arrest. A review of the person-centered comprehensive care plan did not reveal a focus, goal, and/or interventions to address Resident #2's end of life care decisions and/or advance directive for DNR. These concerns were discussed on [DATE] at 5:16 PM at the end of day meeting with the administrator, director of nursing, assistant director of nursing, regional nurse consultant, infection preventionist, and quality assurance nurse. Surveyor was provided with a care plan focus dated [DATE] which read in part, .The resident has advance directives in place. An intervention dated [DATE] read in part, .The resident has a DNR on file. Surveyor requested and received a facility policy titled, Care Planning-Comprehensive Person-Centered, which read in part, .2. The facility will develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified.13. The comprehensive care plan will.d. Be culturally competent and trauma informed as applicable.J. Reflect currently recognized standards of practice for problem areas and conditions. Surveyor requested and received a facility policy titled, Advance Directives which read in part, .10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.The plan of care will be reviewed periodically to ensure consistency with the resident's choice regarding Advanced {sic} Directive decisions. No further information regarding this issue was provided to the survey team prior to the exit on [DATE]. 5. For Resident #12 the facility staff failed to develop and implement a comprehensive person-centered care plan to address the resident's end of life care decisions and/or advance directive for DNR (do not resuscitate). Resident #12's diagnosis list indicated diagnoses that included, but were not limited to, PTSD (post-traumatic stress disorder), Anxiety Disorder, Schizoaffective Disorder-Bipolar Type, Parkinson's Disease, Depression, Mild Cognitive Impairment, Weakness, and Diabetes Mellitus Type 2. The most recent minimum data set (MDS) with an assessment reference date (ARD) of [DATE], 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 medical provider orders with a start date of [DATE] read in part, .Code Status: DNR. A review of a Durable Do Not Resuscitate Order dated [DATE] disclosed Resident #12's informed decision to have life-prolonging procedures withheld or withdrawn in the event of cardiac or respiratory arrest. A review of the person-centered comprehensive care plan did not reveal a focus, goal, and/or interventions to address Resident #12's end of life care decisions and/or advance directive for DNR. These concerns were discussed on [DATE] at 5:16 PM at the end of day meeting with the administrator, director of nursing, assistant director of nursing, regional nurse consultant, infection preventionist, and quality assurance nurse. Surveyor requested and received a facility policy titled, Advance Directives which read in part, .10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.The plan of care will be reviewed periodically to ensure consistency with the resident's choice regarding Advanced {sic} Directive decisions. No further information regarding this issue was provided to the survey team prior to the exit on [DATE]. 6. For Resident #17 the facility staff failed to develop and implement a comprehensive person-centered care plan to address the resident's end of life care decisions and/or advance directive for Full Code (medical definition means that in the event of a cardiac or respiratory arrest, healthcare providers will use all possible life-saving measures, including cardiopulmonary resuscitation (CPR), intubation, defibrillation, and other indicated interventions, without any limitations). Resident #17's diagnosis list indicated diagnoses that included, but were not limited to, Bipolar Disorder, Anxiety Disorder, Panic Disorder, Tremor, Legal Blindness, Heart Failure, Dermatitis, Chronic Pain Syndrome, Chronic Obstructive Pulmonary Disease, Depression, Schizoaffective Disorder, Epilepsy, and Torticollis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of [DATE], 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 medical provider orders with a start date of [DATE] read in part, .Full Code. A review of a Preferred Intensity of Care dated [DATE] disclosed Resident #17's informed decision to have life-prolonging procedures (CPR) to restore cardiovascular and respiratory functions in the event of cardiac or respiratory arrest. A review of the person-centered comprehensive care plan did not reveal a focus, goal, and/or interventions to address Resident #17's end of life care decisions and/or advance directive for CPR (full code). These concerns were discussed on [DATE] at 5:16 PM at the end of day meeting with the administrator, director of nursing, assistant director of nursing, regional nurse consultant, infection preventionist, and quality assurance nurse. Surveyor requested and received a facility policy titled, Advance Directives which read in part, .10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.The plan of care will be reviewed periodically to ensure consistency with the resident's choice regarding Advanced {sic} Directive decisions. No further information regarding this issue was provided to the survey team prior to the exit on [DATE].

Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to treat each resident with respect and dignity for one of 33 current residents in the survey sample, resident # 155 (R155).The findings included: R155's diagnoses included but were not limited to unspecified dementia without behavioral disturbance, major depressive disorder, anxiety disorder, heart failure, hypertension, and generalized weakness. The minimum data set (MDS) assessment with an assessment reference date of 7/22/2025 indicated that R155 has impaired short- and long-term memory as well as impaired decision-making capabilities and is dependent on staff for all activities of daily living (ADL) care. On 9/24/2025 at approximately 8:30 AM this surveyor was walking down the second-floor corridor toward the dining room and witnessed an Activity Assistant approach R155, who was sitting in a wheelchair by the door of their room. The Activity Assistant began to push R155 toward the dining room where staff were serving breakfast. This surveyor witnessed certified nursing assistant (CNA) # 4 yell out to the Activity Assistant, She's a feeder and you can't bring her in here right now! The Activity Assistant hesitated and asked, what? CNA #4 repeated, She's a feeder, don't bring her in here! The Activity Assistant parked R155 in the hall. This surveyor proceeded to the dining room and noted 5 staff members not including CNA #4 and approximately 20 residents in the room, all who witnessed this interaction. On 9/24/25 at 8:40 AM this surveyor interviewed CNA #4. When asked to repeat what was said regarding R155, they stated, I was telling her not to bring (R155 name omitted) in here because she is a feeder and we are ready for the feeders yet. This surveyor asked CNA #4 if they have ever had training on dignity and resident rights and they stated that they get monthly in-services that do include those topics both in person and on the computer. They stated, I guess that wasn't the right thing to say, was it? This surveyor requested and received a copy of the policy entitled, Dignity that read in part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy defined dignity as, Dignity is the right of a person to be valued and respected for their own sake, and to be treated ethically. Under number the heading, Specific Procedures the document read in part, When assisting with care, residents are supported in exercising their rights. For example, residents are e. Provided with a dignified dining experience .8. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labelling or referring to the resident by his or her room number, diagnosis, or care needs . 10. Staff protect confidential clinical information. Examples include the following: a. Verbal staff to staff communication (e.g., change of shift reports) are conducted outside the hearing range of residents and the public. On 9/25/25 at 1:25 PM the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing, Quality Assurance Nurse, Infection Preventionist and two regional consultants. This concern was discussed with them at this time. No further information 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 complete a Level II Preadmission Screening and Resident Review (PASARR) for 1 of 33 current sampled residents. (Resident #12)The findings included:For Resident #12, the facility staff failed to complete a level II PASARR (pre-admission screening and resident review). A PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Resident #12's diagnosis list indicated diagnoses that included, but were not limited to, PTSD (post-traumatic stress disorder), Anxiety Disorder, Schizoaffective Disorder-Bipolar Type, Parkinson's Disease, Depression, Mild Cognitive Impairment, Weakness, and Diabetes Mellitus Type 2. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 6/18/25, 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 clinical record revealed that Resident #12 had short term approval for a level II PASARR through 7/20/25. This concern was discussed on 9/24/25 at 5:16 PM at the end of day meeting with the administrator, director of nursing, assistant director of nursing, regional nurse consultant, infection preventionist, and quality assurance nurse. On 9/25/25 at 8:57 AM, the facility administrator informed this surveyor that a level II PASARR was not completed and she provided surveyor with a fax cover sheet indicating the request for a new level II PASARR was initiated on 9/24/25. Surveyor requested and received a facility policy titled, Long-Term Services and Supports (LTSS) Screening, Preadmission Screening and Resident Review (PASARR) which read in part, .4. Annual Review a. The state designated authority will review residents of the facility who have had a Level II evaluation at least once a year. No further information regarding this issue was provided to the survey team prior to the exit on 9/25/25.

Based on staff interview, clinical record review and facility document review, the facility staff failed to provide the resident or resident representative with a copy of the baseline care plan for one of 37 residents in the survey sample, resident #28 (R28). The findings included:For R28 the facility staff were unable to provide evidence that the baseline care plan had been provided to the resident, or the residents authorized representative.R28's diagnoses included but were not limited to cirrhosis of the liver, dementia, chronic obstructive pulmonary disease, chronic atrial fibrillation, chronic diastolic heart failure, anxiety, depression and panic disorder.The minimum data set (MDS) assessment with an assessment reference date of 9/7/25 stated that R28 is cognitively impaired with both short and long-term memory impairment and severely impaired decision-making ability.The demographic sheet listed multiple family members along with contact information for each.During a review of the clinical record, this surveyor was unable to locate evidence that a base line care plan had been provided to the resident, who was listed on the demographic sheet as their own responsible party, or to any family members. On 9/24/25 at 2:11 PM this surveyor interviewed the Director of Nursing (DON) and asked where the information regarding the baseline care plan be found. The DON stated, It should be on the admission Assessment but if it isn't, there should be a progress note about it. The admission assessment dated [DATE] was reviewed. Section I on page 16 of 16, was entitled, Baseline Care Plan and read in part, A. Baseline Care Plan Initiation of Baseline Care Plan 1. I have completed the care plan items included in this assessment that initiates the resident's baseline care plan. 2. Baseline care plan has been reviewed with resident and/or responsible party. 3. Copy of baseline care plan and copy of medications have been given to the resident and/or responsible party. The only box checked was number 1 stating the baseline care plan had been completed. Items number 2 and 3 had not been checked as done. The DON stated they checked the progress notes but was unable to locate a note to indicate the baseline care plan had been reviewed and/or printed for the resident or the family.The policy entitled Baseline Care Plans was reviewed and read in part, A baseline plan of care to meet the resident's immediate needs shall be developed within forty-eight (48) hours of admission. Under the heading, Specific Procedures/Guidance the document read in part, 4. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary.The survey team met with the Administrator, DON, Assistant DON, Quality Assurance Nurse, Infection Preventionist and two regional consultants on 9/25/25 at 2:11 PM. This concern was discussed with them at that time.No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of 33 current residents in the survey sample, resident # 155 (R155). The findings included:For R155, the facility staff failed to perform fingernail care.Diagnoses for R155 included but were not limited to unspecified dementia without behavioral disturbance, major depressive disorder, anxiety disorder, heart failure, hypertension, and generalized weakness.The minimum data set (MDS) assessment with an assessment reference date of 7/22/2025 indicated that R155 has impaired short- and long-term memory as well as impaired decision-making capabilities and is dependent on staff for all activities of daily living (ADL) care. On 9/23/25 at 1:10 PM during the initial tour of the facility, this surveyor observed R155 in their room. R155's fingernails were noted to be excessively long, jagged and there was a dark brown material noted under all fingernails of both hands. The resident was unable to answer the surveyor's questions. R155's care plan included a focus that read, Maintenance: (name omitted) is a long-term care resident and requires assistance with their ADL's related to advanced age, cognitive impairment, dementia. The goal read, Resident will have all ADL needs met through the review date. On 9/24/25 at approximately 8:30 AM this surveyor observed R155 on the unit. Resident was up and seated in a wheelchair. Fingernails were noted to be long, jagged and with dark brown material underneath each one. On 9/24/25 at 8:45 AM this surveyor interviewed certified nursing assistant (CNA) #4. When asked if they were familiar with R155, they stated they were. When asked if R155 was cooperative with care such as personal hygiene, and bathing they stated, Yes, I've never had a problem with her and haven't heard that anyone else has. On 9/24/25 at 8:55 AM this surveyor interviewed CNA # 1. When asked if they were familiar with R155 they stated they were. This surveyor asked if R155 was typically cooperative with ADL care such as bathing and personal hygiene. CNA #1 stated, Yes, she is. She has really had a decline and is on hospice now. This surveyor asked if the staff or hospice was providing daily care and they stated, It depends on the day, hospice comes sometimes and they bathe her, but on the days they don't come, we do all of her care. On 9/24/25 at 5:15 PM the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing, Quality Assurance nurse and two regional consultants. This concern was discussed with them at that time. This surveyor asked if R155 tended to be combative or refused care and the DON indicated that that the resident did not typically refuse care, but they would check for any notes regarding nail care. On 9/26/25 at 8:20 AM this surveyor observed resident and noted that nails were trimmed, clean and neat. The policy entitled, Fingernails/Toenails was provided and read in part, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Under the heading entitled General Guidelines the document read in part, 1. Routine nail care may be performed by nursing staff and/or qualified activity team members . 2.a. If the resident refuses nail care or desires to have nails maintained in a manner that may impair skin integrity or injury, the risk may be addressed in the resident's plan of care. 3. Nail care includes daily cleaning and regular trimming . Under the heading entitled, Documentation the document read in part, The following information should be included in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual who administered the nail care. 3. The condition of the resident's nails and nail bed . 4. Any difficulties cutting the resident's nails. 5. Any problems or complaints made by the resident with his/her hands or feet related to the procedure. 6. If the resident refuses the treatment, the reason(s) why and the intervention taken. 7. the signature and title of the person recording the data. Under the heading entitled, Reporting the document read in part, 2. Notify the licensed (there was a word omitted here in the policy that this surveyor is assuming was nurse if the resident refuses the care. No further information 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 ensure a complete and accurate clinical record for 1 of 37 residents, Resident (R) #1.The findings include. The facility staff failed to ensure R1's allergy list was up to date. Tylenol was listed as an allergy in R1's clinical record. R1 had current orders for Tylenol.R1's clinical record included the diagnoses of toxic encephalopathy, unspecified abnormalities of gait and mobility, and muscle weakness.Section C (cognitive patterns) of R1's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/19/25 included a brief interview for mental status (BIMS) score of 11 out of a possible 15 points. Per the MDS manual an 11=moderately impaired in cognitive skills for daily decision making.R1's care plan included the focus area of pain related to lower back pain.R1's allergy list included Tylenol their clinical record included 3 separate orders for Tylenol (acetaminophen).Acetaminophen 325 mg give 2 tablets by mouth every 4 hours as needed for pain. Order date 05/16/25.Tylenol 325 mg give 2 tablets by mouth every 4 hours as needed for temperature of 99.5 or greater. Order date 05/16/25.Tylenol 325 mg give 2 tablets by mouth two times a day for lower back pain. Order date 05/23/25.A review of R1's current medication administration records (September 2025) revealed R1 was currently receiving Tylenol twice a day at 9:00 a.m. and 5:00 p.m. There was no documentation to indicate R1 had received Tylenol per the as needed orders for pain and/or fever.On 09/24/2025 at approximately 9:00 a.m., the Director of Nursing (DON) and Quality Assurance (QA) Nurse were made aware that R1's was receiving Tylenol, and the clinical record included a current allergy to this medication.On 09/24/25, the administrative staff provided the surveyor with evidence that indicated the Family Nurse Practitioner had spoken with this resident on 08/28/25 and 06/16/25 regarding Tylenol and pain control.On 09/24/25 at 5:15 p.m., during an end of the day meeting with the Administrator, DON, QA Nurse, Nurse Consultant #1 and #2, Assistant Director of Nursing, and the Infection Preventionist the issue with R1 having current orders for Tylenol and it being listed as an allergy in the clinical record was reviewed.Licensed Practical Nurse (LPN) #2 documented on 09/24/25 that they had spoken with R1and their daughter regarding any allergy to Tylenol. LPN #2 documented R1 and the daughter both wished for the Tylenol to continue. On 09/25/25 at 9:30 a.m., the DON provided the survey team with a copy of their policy titled, Charting and Documentation. This policy read in part, .Documentation in the medical record will be.complete, and accurate.On 09/25/2025 at10:05 a.m., during an interview with R1 this resident stated they took Tylenol, they had not had any issues, and it helped with their pain. No further information regarding this issue was provided to the survey team prior to the exit conference on 09/25/25.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain an infection prevention and control program to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 33 current sampled residents, Resident #110. The findings included:For Resident #110, the facility staff failed to store the resident's nebulizer mask in a manner to prevent contamination. Resident #110's diagnosis list indicated diagnoses, which included, but not limited to chronic kidney disease and dementia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/26/25 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. Resident #110's current medical provider orders included an order dated 9/08/25 for Ipratropium-Albuterol Solution 0.5-2.5mg/3ml inhale orally via nebulizer every six (6) hours for congestion. On 9/23/25 at 2:10 PM, 9/24/25 at 11:18 AM, and 9/25/25 at 8:10 AM, surveyor observed Resident #110's nebulizer mask lying uncovered, directly on bedside table. Surveyor requested and received the facility policy titled Medicated Nebulizer Treatment with a revised date of 4/22/14 which read in part .16. Place Nebulizer mask or mouthpiece in a plastic ziplock bag when not in use.On 9/25/25 at 10:10 AM, surveyor spoke with the Infection Preventionist (IP) who stated after nebulizer use, the mask should be rinsed out, dried, and put back in a clean plastic bag and changed out weekly. On 9/25/25 at 1:25 PM, the survey team met with the facility administrative team including the administrator and discussed the concern of Resident #110's nebulizer mask observed uncovered. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/25/25.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide activities of daily living (ADL) care for 1 of 30 dependent care residents, Resident #45. The findings included: Resident #45 was observed to have long fingernails with debris observed under their nails. Resident #45's diagnoses included, but were not limited to, diabetes and muscle weakness. Section C (cognitive patterns) of resident #45's annual minimum data set assessment with an assessment reference date of 01/08/24 included a brief interview for mental status summary score of 3 out of a possible 15 points. Section GG (functional abilities and goals) was coded to indicate this resident was dependent in the area of personal hygiene. Resident #45's comprehensive care plan included the focus area of diabetes mellitus. Interventions included, but were not limited to, nails to be clipped by nurse or podiatrist as needed. On 02/27/24 during initial tour of the facility this resident was observed in the dining area. Resident #45's fingernails were observed to be long with debris present. On 02/28/24 at 8:30 a.m., Resident #45 was observed up in wheelchair, their fingernails were observed to be long with debris present. On 02/28/24 at 4:35 p.m., during an end of the day meeting with the Administrator, Director of Nursing, Quality Assurance Nurse, and Nurse Consultant the issue with Resident #45's fingernails were reviewed. On 02/29/24 at 9:25 a.m., Resident #45 was observed up in their wheelchair, their fingernails had been trimmed and cleaned. 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 the pneumococcal (pneumonia) vaccine for 1 of 5 residents reviewed for immunizations, Resident #66. The findings included: The facility staff failed to provide Resident #66 with the pneumococcal vaccine. Resident #66's Responsible Party (RP) had signed a consent giving permission for a pneumococcal vaccine on 03/20/19. The facility staff did not administer this vaccine. Resident #66's diagnoses included, but were not limited to, diabetes, vascular dementia, and depressive disorder. Section C (cognitive patterns) of Resident #66's quarterly minimum data set assessment with an assessment reference date of 12/27/23 was coded to indicate this resident had problems with long- and short-term memory and was severely impaired in cognitive skills for daily decision making. Section O (special treatments/procedures/programs) was coded to indicate this resident had been offered the pneumococcal vaccine and declined. Resident #66's clinical record included information to indicate this resident and/or RP had refused the pneumococcal vaccine. On 02/27/24 the surveyor requested documentation regarding the vaccine refusal. On 02/28/24 at 10:54 a.m., the Infection Preventionist (IP) provided the surveyor with a signed consent for the pneumococcal vaccine dated 03/20/19. Indicating the resident/RP had not refused the vaccine. The IP also provided the surveyor with a document dated 02/27/24 indicating the facility had contacted the RP via phone and obtained verbal consent to administer the pneumococcal vaccine. The vaccine was administered by the nursing staff on 02/27/24. On 02/28/24 at 2:00 p.m., the IP stated Resident #66 should have been administered the vaccine in 2019 when the original consent was obtained. The facility policy titled, Pneumococcal Vaccine read in part, .Consent for the administration of the pneumococcal vaccination will be obtained from the resident and/or resident's representative . On 02/28/24 at 4:35 p.m., during an end of the day meeting with the Administrator, Director of Nursing, Quality Assurance Nurse, and Nurse Consultant the issue with Resident #66's pneumococcal vaccine was reviewed. 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, facility staff failed to ensure the highest practicable well-being for 1 of 9 residents reviewed (Resident #6). This is past noncompliance. The findings: Facility staff failed to initiate emergency medical services and failed to provide cardiopulmonary resuscitation when Resident #6 was found unresponsive, cool to the touch, not breathing with no heartbeat. Resident #6's Admission Record listed diagnoses which included but were not limited to, burns involving less than 10% of body surface, chronic kidney disease, Type 2 Diabetes Mellitus with hyperglycemia, heart failure, cocaine abuse, pulmonary hypertension, other psychoactive substance dependence, and unspecified atrial fibrillation. On the Minimum Data Set document with an assessment reference date [DATE], the resident scored a 10 out of 15 on the brief interview for mental status in Section C (cognitive patterns). A facility reported incident read the resident was found unresponsive, unarousable, and cool to the touch on [DATE]. The resident had an order for a full code. The registered nurse (RN#1) assigned to Resident #6 called the medical doctor/medical director (MD) to report the clinical resident assessment. Due to the assessment findings and resident comorbidities, the MD called the resident's time of death via phone and gave an order for postmortem care and to notify the family and funeral home. Clinical record review revealed Resident #6's primary physician, also the facility's medical director, wrote an order for full code - CPR on [DATE]. The clinical record contained a care plan with a focus area that read the resident wished to be full code status. Interventions included, but were not limited to, CPR (cardiopulmonary resuscitation) certified staff would provide chest compressions when the residents' heart stops. The MD was interviewed via phone on [DATE] at 1:52 p.m. and 2:32 p.m. The physician acknowledged receiving RN #1's call about finding Resident #6 deceased and cold and had not been seen since going to bed that night. The MD stated since the resident was cold and stiff, it was clear the resident was dead, and CPR would not have changed the outcome. The MD reported that although a full code status resident should receive CPR when found unresponsive, in this specific case based on RN#1's assessment, the physician was comfortable with CPR not being initiated. He acknowledged providing the verbal order over the telephone for staff to provide postmortem care and to send the resident to the funeral home. The clinical record contained the MD's progress note dated [DATE] at 3:20 a.m. which read in part, Found dead in bed. This 56 YO man with heart [sic] failure, AF, hx of nonsustained ventricular tachycardia, and ejection fraction of ,d+[DATE]% was found dead and cold in bed. He had not been seen alive for several hours. Family had been contacted and gave preference of funeral home. Resuscitative efforts in this setting would [sic] have been futile. The doctor electronically signed this progress note on [DATE] at 7:52 a.m. Multiple facility staff were interviewed on [DATE] to include two licensed practical nurses (LPN#10 and LPN#11) and one registered nurse (RN#4) all who were working on the unit where Resident #6 had resided. The LPNs and RN were interviewed separately, and all acknowledged they received Code Blue training in recent days/weeks and consistently during their employment. They described the process of finding a resident unresponsive and verifying their code status in the computer. If the resident had a Full Code status, someone would call a code over the intercom in order to receive support from other staff, someone would call 911 while other staff started CPR. CPR would continue until 911 arrived. The nurses stated they would call a code and initiate CPR regardless of whether the resident was cold. LPN#10 stated there were circumstances when CPR would not be initiated such as a resident with a Do Not Resuscitate order or someone with symptoms of irreversible death for example, rigor mortis (body stiffening). When asked how staff would verify residents' code status if the computer system was down, all of the nurses reported a list was kept at the nurses' station. LPN#10 and RN#4 showed the surveyor two black binders with active residents' face sheets and code status documentation which was kept at the nurses' station. The director of nursing (DON) attempted to call RN#1 (assigned to Resident #6) multiple times on [DATE] without success therefore the nurse was not interviewed. The administrative team provided their investigation documentation which included a handwritten statement from RN#1. The nurse wrote she gave Resident #6 medications at approximately 8:15 p.m. at which time the resident reported not needing anything and was watching television. The resident, with a history of normally refusing medications, did agree to take medications but refused the treatment to his groin/legs. The certified nursing assistant (CNA) provided fresh water. RN#1 wrote around midnight, she spoke to Resident #6 from the door asking, you need anything, you good? and the resident threw his hand up however, his face and head was covered with a blanket. At approximately 2:15 a.m. on [DATE] a CNA#2 reported to RN#1 that Resident #6 was dead. The nurse and CNA went to the resident's room. RN#1 wrote the resident was unarousable, unresponsive, no pupil reaction, no audible heartbeat, no respirations, cool to the touch, flat on back, hands crossed (arms esp), rolled to side, noted cool backside as well. RN#1 called the physician and told him what she and the CNA had found, and she had just checked the code status and is Full Code. RN#1 wrote the MD said, Well time of death 0215 (2:15 a.m.), do the postmortem care, notify family, call the funeral home. RN#1 notified the responsible party (RP) and the family's choice of funeral homes. RN#1 wrote a progress note effective [DATE] at 2:15 a.m. which described events the same as her statement read. CNA#2, who found Resident #6 deceased , wrote a statement about working on the [NAME] Wing for night shift on [DATE] ([DATE] at midnight). The CNA was not available for interview during the survey. Her statement read the nursing assistant had a conversation with Resident #6 upon starting her shift and she put his oxygen back on which the resident would take off at times. The resident reported he was ok and he needed rest. CNA#2 wrote when she found him, he looked as if he was relaxed and sleeping. A second CNA's statement read she changed Resident #6's brief at approximately 12:00 a.m. The DON was interviewed along with the Administrator and Quality Assurance Director on [DATE] in the afternoon. The DON reported her expectation was the staff would verify residents' code status and progress accordingly. In Resident #6's case, according to the RN's observations there were signs of irreversible death which was explained to the MD. The DON provided a copy of RN#1's current American Heart Association's Basic Life Support card with an issue date of [DATE]. The administrative team (Administrator, DON, and Quality Director) provided evidence of their investigation and QAPI Action Plan. The plan, except for monthly Code Blue Drills, was competed on [DATE] if not earlier. The Quality Team determined RN#1 and all staff would be educated on how to identify code status and when to implement CPR. RN#1 was suspended during the investigation. The quality plan included educating licensed nurses on when not to initiate CPR and to notify Administrator or DON of any resident death or code initiated. An audit of 100% medical records to determine code status of residents to ensure the order matches the resident's desire on the Preferred Intensity of Care. The 100% audit of medical records included resident care plans to ensure they matched the physician orders for Code status and current with Preferred Intensity of Care. A 100% audit of resident demographic books at the nurse's station to ensure all residents' code statuses were included. CNAs were educated on where to find code status orders. Interdepartmental Team (IDT) meetings will discuss any changes in code status orders. And an audit of resident deaths for the past 30 days to ensure code blue was initiated as ordered. There had been three (3) deaths in the last 30 days (excluding Resident #6). All three residents had a Do Not Resuscitate order. The monitoring and reporting to Quality Assurance oversight will be done indefinitely. A surveyor reviewed other residents who had died in the facility. No concerns were identified. The DON provided a policy titled Cardiopulmonary Resuscitation (CPR) which read in part, The facility will provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care, prior to the arrival of emergency medical personnel, in accordance with physician orders, such as a DNR, and the resident's advance directives. During a summary meeting on [DATE], the Administrator, the DON, and Quality Director were notified the issue was to be considered past non-compliance with a correction plan completed.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to secure medications on 1 of 3 wings, [NAME] Wing. The findings included: The facility nursing staff left the nursing keys on top of the medication cart unattended, resulting in missing narcotics. 03/28/23, the facility staff reported to the Office of Licensure and Certification via a facility reported incident (FRI) that on 03/28/23 Licensed Practical Nurse (LPN) #1 left their medication keys on top of their medication cart. When LPN #1 completed a verification check of their narcotics prior to the end of their shift they noticed a total of nine (9) narcotic pain medications missing. Resident #1 missing one Hydrocodone/Acetaminophen 7.5/325 mg tablet. Resident #1's diagnoses included chronic pain syndrome. Section C (cognitive patterns) of Resident #1's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/29/23 included a BIMS score of 15. During an interview with Resident #1 on 04/17/23 at 2:20 p.m. they stated they had no issues with getting medications. Resident #2 missing one Hydrocodone/Acetaminophen 7.5/325 mg tablet. Resident #2's diagnoses included wedge compression fracture of the second lumbar vertebra. Section C of Resident #2's quarterly MDS assessment with an ARD of 03/03/23 included a BIMS score of 5 out of a possible 15 points. The surveyor was unable to interview this resident. Resident #3 missing two Oxycodone/Acetaminophen 5/325 mg tablets. Resident #3's diagnoses included peripheral vascular disease and cervicalgia (neck pain). Section C of Resident #3's quarterly MDS assessment with an ARD of 04/03/23 included a BIMS score of 15. Resident #3 was complimentary of the facility staff and stated they had no issues regarding medications. Resident #4 missing two Oxycodone 5 mg tablets. Resident #4's diagnoses included unilateral primary osteoarthritis right knee. Resident #4's admission MDS assessment with an ARD of 03/21/23 included a BIMS score of 15. This resident had been discharged . Resident #5 missing one Hydrocodone/Acetaminophen 7.5/325 mg tablet. Resident #5's diagnoses included chronic pain syndrome. Section C of Resident #5's admission MDS assessment with an ARD of 03/08/23 included a BIMS score of 15. Resident #5 had no complaints regarding their medications. Resident #6 missing two Oxycodone 5 mg tablets. Resident #6's diagnoses included, burns involving less than 10% of body surface. Section C of Resident #6's admission MDS assessment with an ARD of 03/28/23 included a BIMS score of 10 out of a possible 15 points. Resident #6 was no longer at the facility. A review of the above residents medication administration records revealed that the medications had been given per the providers orders on the night the medications went missing. The facility staff provided the surveyor with the results of their investigation which indicated they had completed drug screens on LPN #1 and Certified Nursing Assistant (CNA) #1. LPN #1's drug screen was negative CNA #1's drug screen was Presumptive Positive for Benzodiazepines, Buprenorphine, Opiates, and Oxycodone/Oxymorphone. CNA #1 had been terminated due to the positive drug screen and the fact that they did not follow up with the laboratory when the lab services provider attempted to reach out to them regarding their positive drug screen. 04/17/23 3:07 p.m., when asked about the missing narcotics CNA #1 stated they really didn't know what had happened. LPN #1 had asked them if they had observed anyone around their medication cart and they stated they had not. CNA #1 stated they were no longer employed at the facility they had been terminated and they knew they had failed a drug test, they had bought the medications off the street, and they were trying to get help. The facility provided the surveyor with statements from CNA's #3 and #4. Date of statement 03/28/23. CNA #3 stated the nurse approached them and wanted to know if they had saw anyone around their medication cart to which they replied, they had not. CNA #3 stated CNA #1 was acting strange, vanished several times during the night, and stated they had Xanax in their system. Date of statement 03/28/23. CNA #4 stated they had not seen anyone around the medication cart being unusual. Everyone seemed to be doing their usual duties. CNA #4 stated their coworker (CNA #1) did not seem to be available as much as normal. CNA #4 stated they went to lunch around 4:07 a.m. and CNA #1 was left on the hall by themselves. 04/18/23 10:56 a.m., LPN #1 stated they had more than one medication cart the night of the incident. They had hidden the medication cart keys under the narcotic book. LPN #1 stated they hated to admit it, but they typically left their medication keys on top of the medication cart. One CNA (CNA #1) was acting odd, they got fidgety and nervous but denied taking any medications. They had acted funny all night, the staff were having a hard time finding them, and they kept going out to their vehicle. When the Sheriff department came to the facility, they asked the staff if they could search their vehicles. CNA #1 went to their car after being asked not to leave the floor. LPN #1 stated the Sheriff did not find anything when they searched the staff's vehicle. LPN #1 stated they had been told to keep their keys on them, no one on the floor knew they kept their keys on their medication cart, someone must have been watching, and it would never happen again. LPN #1 provided the facility with a written statement on 03/28/23 stating they were working [NAME] Wing on third shift on 03/27/23-03/28/23 at approximately 8:45 p.m. they had completed their medication pass on A cart and set the key on the back corner of A cart covered with the narcotic book. After passing B cart medication this nurse got keys back off A cart and placed back in pocket. After final medication pass at approximately 6:40 a.m. this nurse was rechecking narcotic drawer to ensure all narcotic this nurse gave was signed out at this time this nurse noticed several narcotics were missing from A cart drawer. 04/17/23, the facility staff provided the surveyor with their policy titled, Medication Storage. This policy read in part, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .nursing staff shall be responsible for maintaining medication storage .Only persons authorized to prepare and administer medications shall have access to the medication room, including keys . 04/17/23, the facility staff provided the surveyor with a copy of Notice of Disciplinary Action dated 03/28/23. This document named LPN #1 and stated they had been suspended as they had .left keys on the medication cart resulting in multiple narcotic medication card missing . The facility staff provided the survey team with a copy of their QAPI (quality assurance performance improvement) ACTION PLAN dated 03/28/23. Issue/Concern Medication Keys were not left in nurses possession. Goals/Objectives/Expected Outcome Licensed nurses will keep medication cart keys in their possession. Correction: Medication cart narcotic counts reconciled on all floors in facility. Responsible person(s) Director of Nursing/Quality Assurance (QA) or designee. Projected completion date 03/28/23. System Changes: Education provided to licensed nurses to ensure keys remain in their possession and medication carts are locked at all times when nurse is not present with cart. Responsible person(s) Staff development coordinator or designee. Projected completion date 03/29/23. Monitoring/QA oversight: Medication carts will be audited for compliance with locking and securing keys weekly X 4, biweekly X 2, and monthly X 2. Responsible person(s) Unit manager or designee. Projected completion date 07/21/23. The Director of Nursing and QA nurse provided the surveyor with documentation to indicate all narcotic count sheets and medication cards were reconciled on all floors on 03/28/23. Education had been provided to licensed nurses on 03/28 and 03/29/23. Audits were being completed in the medication rooms/cart/resident rooms. 04/18/23 8:55 a.m. LPN #2 (agency nurse) stated they kept their medication keys in their pocket. The surveyor and LPN #2 compared the narcotic medication cards against the narcotic books for Resident #1's Hydrocodone, Resident #2's Hydrocodone, and Resident #5's Hydrocodone and no issues were identified. 04/18/23 9:00 a.m., LPN #6 stated they kept their medication cart key in their pocket and denied ever seeing medication cart keys on top of a medication cart. 04/18/23 11:05 a.m. RN #2 stated they knew to always keep their medication keys on them. 04/18/23, interviews were completed onsite with LPN #2, LPN #4, LPN #5, LPN #6, LPN #7, LPN #8, LPN #9, and Registered Nurse (RN) #2. All these nurses stated they had been inserviced regarding where to keep their medication cart keys. 04/18/23 9:10 a.m., interview with Resident Council President who stated there were no issues with medications. Throughout the course of the survey no keys were observed to be left unattended on the medication carts. 04/18/23 4:10 p.m., during a meeting with the Administrator, DON, and QA Nurse the issue with the missing and unsecured medications was reviewed. A plan of correction was in place at the time of the survey this citation is past non-compliance.

Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to maintain a clean, comfortable home-like environment for 1 of 3 units (2nd Floor) and 5 of 27 residents in the survey sample, Resident #18, #106, #58, #41, and #55. The findings included: 1. The facility staff failed to maintain a clean, sanitary resident shared shower chair and failed to maintain a window in good repair on the 2nd Floor. On 10/19/22 at 1:15 pm, surveyor and the 2nd Floor Unit Manager (UM) entered the unit shower room and observed the shower chair. At the request of the surveyor, the UM turned the shower chair over revealing a black, damp appearing substance with strands of hair intertwined on the lower section of the chair legs and around the wheels. A light tan dried substance was visible on the upper section of the chair legs and underneath the seat where the seat was attached to the chair. The UM stated That's pretty awful ain't it and they would put in a housekeeping ticket. UM stated one resident had used the shower room earlier in the day. On 10/19/22 at 1:20 pm, the Director of Nursing (DON) and the Quality Assurance (QA) Coordinator entered the 2nd Floor shower room and observed the shower chair and the QA Coordinator removed the shower chair and said it would be taken out of service. At 1:34 pm, the QA Coordinator stated shower chairs were cleaned between each resident use. On 10/19/22 at 1:11 pm, surveyor observed the window at the end of the hall on 2nd Floor and noted five (5) linear cracks. The cracks were not sharp to the touch and no starburst patterns were present. At 1:32 pm, surveyor notified the administrator of the window cracks. At 3:27 pm, the administrator returned and stated the facility felt the window was stable with the inner window wire but would need to be replaced. On 10/19/22 at 3:13 pm, the survey team met with the Administrator, DON, and QA Coordinator and discussed the concern of the soiled shower chair and the broken window. No further information regarding this concern was presented to the survey team prior to the exit conference on 10/19/22. 2. For Resident #18, the facility staff failed to maintain a clean, sanitary wheelchair. Resident #18's diagnosis list indicated diagnoses, which included, but not limited to Severe Dementia with Other Behavioral Disturbance, Parkinson's Disease, Sequelae of Cerebral Infarction, and Mood Disorder. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 7/29/22 assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 indicating the resident was severely cognitively impaired. Resident #18 was coded as requiring extensive assistance with transfers, locomotion on unit, eating and being totally dependent on staff for personal hygiene. On 10/18/22 at 11:10 am, surveyor observed Resident #18 sitting in a wheelchair in the 2nd Floor dining room/common area. The resident's wheelchair cushion had a large amount of a dried white substance on the left side and a small amount on the right side with crumbs and debris around the edges of the cushion. The wheelchair spokes and wheels had a large amount of dust and debris present. On 10/18/22 at 11:30 am, surveyor spoke with the Administrator, Director of Nursing (DON) and the Quality Assurance (QA) Coordinator who stated there was no policy or schedule for the cleaning of wheelchairs and they were cleaned on an as needed basis by housekeeping. Surveyor requested the last time Resident #18's wheelchair was cleaned. On 10/18/22 at 11:42 am, surveyor spoke with the Housekeeping Assistant Supervisor (HAS) who stated the previous housekeeping supervisor had a wheelchair cleaning schedule but does not know what happened to the schedule when they left. HAS stated there was no current wheelchair cleaning schedule. HAS stated when a wheelchair needed cleaning, staff will verbally notify housekeeping as they pass by. HAS stated they pressure washed Resident #18's wheelchair last week or the week before. On 10/19/22 at 3:13 pm, the survey team met with the Administrator, DON, and QA Coordinator and discussed the concern of Resident #18's soiled wheelchair. No further information regarding this concern was presented to the survey team prior to the exit conference on 10/19/22. 3. For Resident #106, the facility staff failed to maintain a clean, sanitary bathroom and privacy curtain. Resident #106's diagnosis list indicated diagnoses, which included, but not limited to Severe Dementia with Other Behavioral Disturbance, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, History of Traumatic Brain Injury, and Unspecified Mood Disorder. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 9/20/22 coded the resident as being severely impaired in cognitive skills for daily decision making with short-term and long-term memory problems. Resident #106 was coded as requiring limited assistance with transfers, walking, personal hygiene and extensive assistance with toilet use. On 10/19/22 at 12:57 pm, surveyor observed Resident #106's bathroom and noted six (6) separate areas of a dark brown dried substance on the right side of the inner doorframe. Surveyor also observed an area of a dark brown dried substance on each side of the resident's privacy curtain nearest the bathroom along with multiple light brown stains on the outer side of the privacy curtain. On 10/19/22 at 3:13 pm, the survey team met with the Administrator, DON, and QA Coordinator and discussed the concern of Resident #106's soiled bathroom and privacy curtain. No further information regarding this concern was presented to the survey team prior to the exit conference on 10/19/22. 47299 4. For resident #58, the facility staff failed to ensure the wheel chair the resident was sitting in was clean. Resident #58's diagnosis list includes, but is not limited to, the following: unspecified dementia, major depressive disorder, anxiety disorder, cognitive communication deficit, dysphagia, debility, and protein-calorie malnutrition. Resident #58's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 8-8-2022, assigned the resident a BIMS (brief interview for mental status) summary score of 0 out of 15 in section C, cognitive patterns, indicating the resident was severely cognitively impaired. On 10/18/2022 at 11:00 A.M., surveyor observed resident #58 in the dining room and noted that the wheel chair the resident was sitting in was dirty. There was a thick, dry brown substance noted on each of the pedals of the chair, as well as the left inside panel of the chair. There were white flakes and dried white splatters of an unknown substance on the foot pedals as well as on both arm rests. There were dried food particles noted in the seat and the cushion of the chair. Surveyor met with the Administrator and Director of Nursing (D.O.N.) on 10/18/2022 at 11:30 A.M. and asked for a copy of the wheel chair cleaning schedule. The Administrator stated, There is no definitive schedule for cleaning chairs she went on to say that chairs are cleaned by housekeeping on an as needed basis. Surveyor met with the assistant housekeeping director at 11:43 A.M. who concurred that there was no schedule for cleaning chairs because the previous housekeeping director took the document when employment ended. He stated that the Certified Nursing Assistants will generally stop him and let him know when they notice a chair needs cleaning. On 10/19/22 at 3:13 P.M. Surveyor met with the Administrator, D.O.N. and QA nurse to review the concern of the soiled wheel chair for resident #58. No further information regarding this concern was provided to the survey team prior to the exit conference. 22218 5. For Resident #41 facility staff failed to clean the floor of the bedroom and bathroom, leaving blood on the floor of the bathroom for 3 days. Resident #41 was admitted to the facility with diagnoses including cardiopulmonary disease exacerbation, chronic respiratory failure, pulmonary fibrosis, difficulty walking, opioid dependence, ataxia, type 2 diabetes mellitus, hypertension, chronic pain, anxiety, and depression. On the Minimum Data Set quarterly assessment with assessment reference date 8/15/22, the resident scored 12/15 on the brief interview for mental status and was assed as not exhibiting signs of delirium, psychosis, or behaviors affecting care. During initial tour on 10/17/2022 at approximately 2 PM, the resident stated that the floors were not kept clean. The floors were dirty under and around the resident beds and the resident had cut her leg the day before and no one had yet cleaned up the blood on the bathroom floor. The surveyor observed food and paper debris in the floor around both beds. There was a discarded dressing with bloody (rust-colored,dry) gauze and tape on the floor near the door to the hall. On the bathroom floor, the surveyor observed red spots dime to dollar coin size on the bathroom floor. On 10/18/22 at 10:24 AM, the surveyor noted there was still debris on the bedroom floor, including dust and debris around the resident's chair and under the bed. There appeared to be some partially mashed beans on the floor by the room mate's bed. The floor in the bathroom appeared to have been partially cleaned, but one dollar coin size and several small blood-colored spots remained. The administrator and director of nursing were notified of the concern during a daily summary meeting on 10/18/2022. On 10/19/2022 at 3 PM the surveyor noted there was still one blood-colored spot on the bathroom floor between the leg of a bedside commode frame and the toilet base. 28567 6. For Resident #55, the facility staff failed to ensure the residents wheelchair was clean. The wheelchair was observed to have dried debris present on the wheels, cushions, and arm rests. Resident #55's clinical record included the diagnoses, diabetes and post-traumatic stress disorder. Section C (cognitive patterns) of Resident #55's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/06/22 included a brief interview for mental status (BIMS) summary score of 00 out of a possible 15 points. Indicating the resident had severe impairment in cognitive skills. Section G (functional status) was coded to indicate Resident #55 used a wheelchair for mobility. 10/18/22 9:50 a.m., the surveyor and Registered Nurse (RN) #1 observed Resident #55 in their wheelchair. The wheelchair was observed to have dried debris on the wheels, cushions, and arm rests. RN #1 stated housekeeping cleaned the wheelchairs in the evenings and acknowledged the wheelchair needed cleaning. 10/18/22 11:42 a.m., housekeeping staff #1 stated the previous housekeeping director had a cleaning schedule but lately the certified nursing assistants (CNA's) asked them to clean the wheelchairs as they passed by. 10/18/22 3:45 p.m., the Administrator, Director of Nursing (DON), and Quality Assurance Coordinator were made aware of the issue with Resident #55's wheelchair during an end of the day meeting. No further information regarding this issue was provided to the survey team prior to the exit conference. 7. The facility failed to maintain a temperature range between 71-81 Fahrenheit (F) on the second floor on the B hall. During initial tour of the facility Resident #94 stated they did not know how to control the heat in their room. Maintenance and LPN (licensed practical nurse) #1 were made aware of the residents concern. Resident #94 diagnoses included chronic obstructive pulmonary disease, asthma, and diabetes. Section C of Resident #94's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 09/17/22 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. Indicating the resident was alert and orientated. 10/18/22 11:51 a.m., the surveyor observed several windows with plastic covering the inside. The Administrator and Director of Nursing (DON) stated the plastic was in place to cut down on drafts and they had a plan to replace the windows. The building appeared to be currently under construction. The Administrator stated it was a holiday and the construction crew was off the entire week. 10/19/22 10:45 a.m., the surveyor observed the hallway on unit 2/floor 2, hall B to be cold. No residents were observed in the hallway. Random temperature checks were completed on the hallway with the Maintenance Director (MD) with readings of 68, 68.5 and 69 degrees F being obtained. The MD obtained these temperatures using what they identified as an infrared thermometer. 10/19/22 11:00 a.m., MD checked temperature in Resident #94's room. Temperatures obtained were 63.5 F and 64.5 F. Resident #94 denied being cold and was observed to be fully dressed in street clothes and a sweater. The bathroom temperature registered 57 F. The MD stated they were going to obtain a different type of thermometer and left the unit/floor. 10/19/22 11:03 a.m., Resident #122 stated they were cold. The thermometer on the wall in the Resident #122's room read 65 degrees. Resident #122's diagnoses included, but were not limited to, dementia, depression, anxiety, and peripheral vascular disease. Section C of the resident #122's quarterly MDS assessment with an ARD of 09/22/22 included BIMS summary score of 10 out of a possible 15 points. 10/19/22 11:05 a.m., the MD returned to the unit with what they identified as an ambient heat thermometer, checked Resident #122's room temperature, and obtained a temperature reading of 67 F. The MD checked the heater and stated the fan was not working. The Administrator was on the floor and was aware of the issues regarding the temperature(s). 10/19/22, the MD checked the temperature outside of the elevator on the B hall and obtained a temperature reading of 69.4 F rechecked and obtained a temperature reading of 69.6 F. Rechecked Resident #94's room with the ambient thermometer and received a reading of 70 F in room [ROOM NUMBER] F in the bathroom. 10/19/22 11:17 a.m., Certified Nursing Assistant (CNA) #2 stated the hall was usually burning up but it was chilly in some spots. CNA #2 identified Resident's #37 and #95 as stating it was cold. Both of these residents denied being cold when asked by the surveyor. 10/19/22 11:19 a.m., LPN #3 stated they were comfortable and no resident had complained of being cold. 10/19/22 11:23 a.m., Licensed Practical Nurse (LPN) #5 (hall nurse) stated no resident had complained of being cold. 10/19/22 11:23 a.m., CNA #3 stated no residents complained of being cold. However, the residents were elderly and always stated they were cold. 10/19/22 11:44 a.m., the MD stated they had spoken with the Fire Marshall and they obtained information on what kind of heaters were approved for use and they were going out of the facility to obtain these type of heaters. The MD also stated they had another heating system on the hall and they were in the process of getting it turned on. 10/19/22 12:10 p.m., Quality Assurance (QA) coordinator stated they offered Resident #122 a room change but they had refused and the MD had went out to purchase Fire Marshall approved heaters. 10/19/22 12:44 p.m., the QA coordinator and Director of Nursing (DON) provided the surveyor with a progress note transcribed by the social service department that read, SS (social service) offered resident a room change d/t (due to) heat currently not working in room. Resident stated ____ does not want to move. 10/19/22 1:45 p.m., Resident #122 stated they did not want to move out of their room. The surveyor observed silver tape on the window sills in room. Thermostat in room at doorway read 65 F. The surveyor identified 7 rooms on the B hall with plastic covering the windows. Resident #131 stated they liked to of froze last night. Resident #131's diagnoses included Alzheimer's, ataxia, and anxiety. Section C of their quarterly MDS assessment with an ARD of 09/28/22 included a BIMS score of 15 out of a possible 15 points. Resident #72 observed resting on bed in room, stated they were warm. Diagnoses included, hypertension and diabetes. Section C of their quarterly MDS assessment with an ARD of 09/14/22 included a BIMS score of 14 out of a possible 15 points. The facility policy titled, Homelike Environment read in part, .comfortable and safe temperatures (71 F-81 F) . 10/19/22 3:15 p.m., during a meeting with the Administrator, DON, and QA coordinator the issue with the resident room(s) heat and temperature(s) on the B hall was reviewed. The Administrator stated the MD had not returned to the facility as of yet, this time of the year is the change of season, it is the coldest weather we have had this year, we do have some residents complain of being cold, and it's hard to keep everyone happy. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain essential equipment for 1 of 27 resident (Resident #122) and for 3 of 3 facility elevators. The findings include: 1. For Resident #122, the facility staff failed to ensure the residents heater was in working order. Resident #122's diagnoses included, but were not limited to, dementia, depression, anxiety, and peripheral vascular disease. Section C (cognitive patterns) of the resident #122's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 09/22/22 included a brief interview for mental status (BIMS) summary score of 10 out of a possible 15 points. 10/19/22 10:45 a.m., the surveyor observed the hallway on unit 2/floor 2, hall B to be cold. 10/19/22 11:03 a.m., Resident #122 stated they were cold. The thermometer on the wall in the Resident #122's room read 65 degrees Fahrenheit (F). 10/19/22 11:05 a.m., Maintenance Director (MD) checked the room temperature using an ambient heat thermometer. Temperature read 67 F. The MD checked the heater and stated the fan was not working. The Administrator was on the floor and was aware of the issues regarding the temperature(s). 10/19/22 11:17 a.m., Certified Nursing Assistant (CNA) #2 stated the hall was usually burning up but it was chilly in some spots. 10/19/22 11:23 a.m., Licensed Practical Nurse (LPN) #5 (hall nurse) stated no resident had complained of being cold. 10/19/22 12:10 p.m., Quality Assurance (QA) coordinator stated they offered Resident #122 a room change but they had refused and the MD had went out to purchase Fire Marshall approved heaters. 10/19/22 12:44 p.m., the QA coordinator and Director of Nursing (DON) provided the surveyor with a progress note transcribed by the social service department that read, SS (social service) offered resident a room change d/t (due to) heat currently not working in room. Resident stated ____ does not want to move. 10/19/22 1:45 p.m., Resident #122 stated they did not want to move out of their room. The surveyor observed silver tape on the window sills in room. Thermostat in room at doorway read 65 F. The facility policy titled, Homelike Environment read in part, .comfortable and safe temperatures (71 F-81 F) . 10/19/22 3:15 p.m., during a meeting with the Administrator, DON, and QA coordinator the issue with the heat/temperatures was reviewed. The Administrator stated the MD had not returned to the facility as of yet, this time of the year is the change of season, it is the coldest weather we have had this year, we do have some residents complain of being cold, and it's hard to keep everyone happy. No further information regarding this issue was provided to the survey team prior to the exit conference. 22218 2. On 10/19/22 at 02:57 PM the West wing and Main elevator certificates show every 6 month inspections with the last inspection date on both certificates was 8/2021. The West wing elevator certificate holder had been partially pulled from the wall with a sharp corner sticking out and the floor indicator assembly was broken with an opening exposing a circuit board and broken edges of plastic. The administrator was informed of the concern. The administrator was not aware the elevators had not been inspected for over a year. Code of Virginia S 36-105.01. Elevator inspections - requires annual inspections of elevators. On 10/19/22 at 03:23 PM the administrator provided an email dated 10/19/2022 from the elevator inspection company stating that the company only has 1 inspector in Virginia, so it has been unable to keep up with the inspections every 6 months. The company did not offer a prospective inspection date for the facility's three elevators.

Based on staff interview and clinical record review, the facility staff failed to accurately code a discharge minimum data set (MDS) assessment for 1 of 3 closed record reviews, Resident #139. The findings include: The facility staff coded the residents discharge MDS assessment as if the resident was discharged to an acute care hospital. Resident #139 was discharged home. The clinical record included the diagnoses, chronic kidney disease, fracture of other parts of pelvis, and difficulty walking. Section A (identification information) of the residents discharge MDS assessment with an assessment reference date (ARD) of 07/30/22 had been coded to indicate Resident #139 was discharged to an acute care hospital. Section C (cognitive patterns) was coded to indicate the resident had short term memory problems and required modified independence for cognitive skills for daily decision making. Resident #139's clinical record included a progress note dated 07/30/22 that read, Pt discharged home. 10/19/22 8:24 a.m., Registered Nurse (RN) #2/MDS coordinator reviewed the clinical record with the surveyor and acknowledged the MDS had been coded incorrectly. 10/19/22 3:15 p.m., the Administrator, Director of Nursing, and Quality Assurance Coordinator were notified of the inaccurate MDS assessment. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain an infection control program designed to identify and prevent the transmission of COVID-19. The facility staff failed to follow the manufacturer guidelines when obtaining a rapid COVID-19 test for one of one employee. Employee #1. The findings included: The facility staff failed to obtain a COVID-19 rapid test sample per the manufactures instructions. The facility staff only obtained a sample from one nostril when the instructions stated to use the same swab for both nostrils. The facility was using the BinaxNOW COVID-19 Ag Card test system. 09/14/2021 9:38 a.m., the surveyor observed (RN) registered nurse #1 obtain a COVID-19 sample from employee #1. RN #1 swabbed employee #1's right nostril and placed the swab into the test card for processing. After this observation, the surveyor asked for the manufacturer's instructions. Page two of these instructions read in part, .To collect a nasal swab sample, Firmly sample the nasal wall by rotating the swab in a circular path against the nasal wall .Using the same swab, repeat sample collection in the other nostril . RN #1 confirmed that they only used one nostril when obtaining the sample and stated they were instructed to use one nostril. RN #1 stated I will do both from now on. 09/15/2021 The (IP) infection preventionist provided the surveyor with a signed consent from employee #1 and stated this employee was retested and was negative. The IP also provided the surveyor with a skill check off regarding the BinaxNow COVID-19 Ag Card testing. This skill check off was signed by RN #1. Number 5 on this form read in part, .Using the same swab repeat the collection procedure with the second nostril . 09/15/2021 9:40 a.m., the IP stated RN #1 should have sampled both nostrils. No further information regarding this issue was provided to the surveyor prior to the exit conference.

Based on observations, clinical record review, staff interview, facility documentation review, and in the course of a COVID-19 focused survey, it was determined the facility staff failed to consistently implement infection control plans/practices designed to attempt to prevent the development and/or transmission of COVID-19 in the facility as evidenced by failing to implement face coverings and social distancing guidelines. The findings included: On 6/16/20 at 10:10 am, the surveyor toured the facility's secured dementia unit. The surveyor observed four residents sitting side by side in chairs along a wall directly across from the nurse's station, and five residents sitting side by side in chairs along another wall directly across from the nurse's station. The surveyor observed that none of the nine residents that were sitting along the walls across from the nurse's station were wearing face coverings, and none of the residents were seated at least six feet apart. The surveyor observed that no staff member attempted to offer face coverings to the residents nor did any staff member attempt to implement interventions to maintain social distance at that time. On 6/16/20 at 10:15 am, the surveyor interviewed CNA#1 (certified nursing assistant). The surveyor asked CNA#1 if the residents wore facemasks. CNA#1 stated, They have the option to wear them. We try to put them on the resident's but they take them off. The surveyor asked CNA#1 how they maintain social distancing guidelines. CNA#1 stated, A lot of residents stay in their room. We try to keep them apart, but it's hard on the Alzheimer's unit. The surveyor asked CNA#1 to observe the nine residents sitting side by side across from the nurse's station. CNA#1 agreed that the nine residents were not distanced at least 6 feet apart. On 6/17/20 at 2:30 PM, the surveyor reviewed the clinical records for three of the nine residents that had been observed on 6/16/20 at 10:10 am, sitting across from the nurse's station side by side without face coverings. Resident # 2 had [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment for Resident # 2 was a quarterly assessment with an ARD (assessment reference date) of 4/8/20. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 2 had a BIMS (brief interview for mental status) score of 3 out of 15, which indicated that Resident # 2's cognitive status was severely impaired. The most recent plan of care for Resident # 2 was reviewed and revised on 3/17/20. The facility staff documented a focus area for Resident # 2 as, Resident # 2 is at risk for exposure to and or transmission of COVID-19. Interventions included but were not limited to, Provide face mask if resident must leave the room for medically necessary transfer out of the facility. The surveyor reviewed the entire plan of care for Resident # 2 and did not observe documentation that Resident # 2 refused to wear facemask, and the surveyor did not observe documentation of interventions utilized for Resident # 2 to promote social distancing. The surveyor reviewed the nurse's notes for Resident # 2 and did not observe documentation that facility staff had attempted to provide face coverings to Resident # 2 and there was no documentation of Resident # 2 refusing to wear face coverings. The surveyor also did not locate documentation in the nurse's notes of attempted social distancing interventions utilized for Resident # 2 and documentation of compliance or noncompliance of social distancing interventions. Resident # 3 had [DIAGNOSES REDACTED]. The most recent MDS assessment for Resident # 3 was a quarterly assessment with an ARD of 4/29/20. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 3 had a BIMS score of 4 out of 15, which indicated that Resident # 3's cognitive status was severely impaired. The most recent plan of care for Resident # 3 was reviewed and revised on 3/17/20. The facility staff documented a focus area for Resident # 3 as, Resident is at risk for exposure to and or transmission of COVID-19. Interventions included but were not limited to, Educate resident on social distancing with no handshakes, hugging, communal dining, and group activities. The surveyor reviewed the entire plan of care for Resident # 3 and did not observe documentation that Resident # 3 refused to wear facemask, and the surveyor did not observe documentation of interventions utilized for Resident # 3 to promote social distancing. The surveyor reviewed the nurse's notes for Resident # 3 and did not observe documentation that facility staff had attempted to provide face coverings to Resident # 3 and there was no documentation of Resident # 3 refusing to wear face coverings. The surveyor also did not locate documentation in the nurse's notes of attempted social distancing interventions utilized for Resident # 3 and documentation of compliance or noncompliance of social distancing interventions. Resident # 4 had [DIAGNOSES REDACTED]. The most recent MDS assessment for Resident # 4 was a quarterly assessment with an ARD of 5/11/20. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 4 had a BIMS score of 3 out of 15, which indicated that Resident # 4's cognitive status was severely impaired. The most recent plan of care for Resident # 4 was reviewed and revised on 3/17/20. The facility staff documented a focus area for Resident # 4 as, Resident # 4 is at risk for exposure to and or transmission of COVID-19. Interventions included but were not limited to, Provide face mask if resident must leave the room for medically necessary transfer out of the facility. The surveyor reviewed the entire plan of care for Resident # 4 and did not observe documentation that Resident # 4 refused to wear facemask, and the surveyor did not observe documentation of interventions utilized for Resident # 4 to promote social distancing. The surveyor reviewed the nurse's notes for Resident # 4 and did not observe documentation that facility staff had attempted to provide face coverings to Resident # 4 and there was no documentation of Resident # 4 refusing to wear face coverings. The surveyor also did not locate documentation in the nurse's notes of attempted social distancing interventions utilized for Resident # 4 and documentation of compliance or noncompliance of social distancing interventions. The facility provided documentation of a Family Update that was dated 5/13/20. The documentation included but was not limited to, .We are asking any resident who is out of room to have a mask on, we have cloth masks that have been donated that residents are wearing. On 6/17/20 at 3:28 PM, the surveyor informed the administrator, director of nursing, and the infection control nurse of the findings as stated above. The director of nursing requested time to review the clinical records to attempt to locate documentation of interventions and compliance or noncompliance related to face coverings and social distancing. On 6/17/20 at 4:32 PM, the director of nursing informed the survey team that he/she did not locate any additional documentation in the clinical records for Resident # 2, Resident # 3 and Resident # 4 related to face coverings and social distancing. No further information regarding this issue was presented to the survey team prior to the exit conference on 6/17/20.

Based on staff interview and clinical record review, the facility staff failed to ensure the right to formulate an advanced directive as evidenced by the advanced directive on resident record was not completed accurately for one of 34 residents, Resident #131. The findings: The facility staff failed to accurately complete Resident #131's Durable Do Not Resuscitate (DDNR) Order. Section 2 of the order had two boxes checked instead of one. Resident #131's clinical record was reviewed on 1[DATE] and revealed the resident's [DIAGNOSES REDACTED]. Section C of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of [DATE] included a BI[CONDITION] (brief interview for mental status) summary score of 15 out of 15 points. Resident #131's clinical recorded contained a scanned form; a Durable Do Not Resuscitate (DDNR) Order from Virginia Department of Health dated 01/28/15. The DDNR had two sections that required a check beside which option was selected: · Section 1 read in part, I further certify (must check 1 or 2): The check was present beside #2 which read in part: The patient is INCAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment. · Section 2 read in part, If you checked 2 above, check A, B, or C below: There were checks beside both A and C. The A response read in part, While capable of making an informed decision, the patient has executed a written advanced directive. while the C response read in part, The patient has not executed a written advanced directive. On [DATE] in the afternoon, the facility's director of nursing (DON) with this surveyor observed a printed copy of Resident #131's DDNR. The DON acknowledged the DDNR had not been filled out correctly and said there should only be one of the letters (A, B, or C) in Section 2 checked. The DON stated there was no other DDNR found in Resident #131's clinical record. The above concern was discussed with the facility's administrator, DON, and regional director of clinical services on [DATE] at approximately 12:10 p.m. No further information regarding the DDNR was provided prior to exit.

Based on clinical record review, staff interview, facility document review, the facility staff failed to ensure that one of 34 residents in the survey sample received care and treatment in accordance with the plan of care as evidenced by failure to follow physician's orders [REDACTED]. The findings included: Resident #309 was admitted to the nursing facility after a hospitalization in which a discharge [DIAGNOSES REDACTED]. In the nursing documentation dated and timed for 12/14/19 at 22:15 (10:15 pm) read in part, .Resident readmitted to the facility at 16:00 (4 pm) .Has positive attitude upon entering unit. Cooperative with staff. A/O (Alert and Oriented) X4 with clear speech. No confusion noted at this time. Resident OOB (out of bed) and transfers from stretcher to bed via (by) x2 assist. Is ambulatory x 2 .Afebrile . And on 12/14/19 at 22:23 (10:23 pm) the nurses note read in part, .Resident is DX (diagnosis) to have ESBL in urine .Single lumen left arm PICC in place . The surveyor reviewed the clinical record of Resident #308 on [DATE] and noted that on the discharge summary from the hospital was dated 12/14/19 and noted a physician order [REDACTED]. The surveyor also reviewed the December 2019 MAR (Medication Administration Record) for Resident #308. The following documentation was noted by the surveyor: 12/14 1[AGE]0 (4:00PM) this box was blank for this date and time 12/15 0000 (12:00 am) this box had the initials of the nurse that administrated this medication 12/15 0[AGE]0 (8:00 am) this box had a 9 and the initials of the nurse. According to the 9 it represents Other. The surveyor reviewed the nurses' notes for 12/15/19 at 09:17 am and the documentation was noted which read in part, .called pharmacy about order, it's not here yet and no available in either medicine machines . The following dates had documentation that reflected that the nurses administered this medication was 12/15 at 0000 and 1[AGE]0. All three doses of medication received on [DATE] and then on 1[DATE], the medication was administrated at 0000 and 0[AGE]0. The physician wrote an order to discontinue this medication on 1[DATE] at 1454 (2:54 pm). The surveyor requested and received the content page of the medication that are available in the medication machines for after-hours use. This antibiotic was not on the list that could had been obtained from these machines. The surveyor notified the administrator, DON (director of nursing) and regional nurse of the above information on [DATE] at approximately 5 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on [DATE].

Based on observation, staff interview, facility document, and drug manufacturers' instructions for use review, the facility staff failed to label and store medications as indicated per manufacturer's guidelines on one of six medication carts in the facility as evidenced by failure to date medications and failure to store medications appropriately. The findings: 1. The facility staff failed to label medications with the opened date and therefore were unable to determine when the opened, multi-dose medications would expire. On [DATE] at 11:52 a.m. one surveyor observed medication storage and labeling with a facility employee (LPN #1) on a medication cart referred to as 1st Floor Cart B. Three multi-dose medications were found without dates indicating when the medications were opened which would effect when those medications would expire: a. [MEDICATION NAME] Respimat (inhaler), for unsampled Resident #153, had no date indicating when it was opened. b. [MEDICATION NAME] Nasal Spray, for unsampled Resident #141, had no date indicating when it was opened. c. [MEDICATION NAME] 250mg/5ml solution, for unsampled Resident #[AGE], had no date indicating when it was opened. LPN #1 was asked to look for open dates on the medications and acknowledged the date they were opened was not found on the medications. LPN #1 stated, I don't know why there isn't an open date on everything. And when asked how to determine when these medications expired, the LPN stated, No way to know when it expires if you don't know when it was opened. On the afternoon of [DATE], the DON (director of nursing) provided the facility's list of medications' special storage and expiration dates and the facility's medication storage policy. This list included the three medications identified above: a. [MEDICATION NAME] Respimat - Discard 90 days after insertion of cartridge. b. Fluticason - Discard 50mcg after 6 weeks; discard 100mcg and 250mcg after 8 weeks. c. [MEDICATION NAME] Oral Solution - Store refrigerated at all times; see label on bottle for expiration date. The manufacturer's instructions for use regarding [MEDICATION NAME] Respimat was reviewed and read, in part, Three months after insertion of cartridge, throw away the [MEDICATION NAME] RESPIMAT even if it has not been used, or when the inhaler is locked, or when it expires, whichever comes first. The facility's policy from Section 3.7 Medications and Medication Labels on page 3 of 4, read in part, 2. Nursing staff should document the date opened on multi-dose vials on the attached auxiliary label. 2. The facility staff failed to store medications labeled refrigerate in the refrigerator. On [DATE] at 11:52 a.m. one surveyor observed medication storage and labeling with the facility employee (LPN #1) on a medication cart referred to as 1st Floor Cart B. Within the locked narcotics' drawer, a bottle of [MEDICATION NAME] 250mg/5ml solution for unsampled Resident #[AGE] was found. On the front of the bottle was a pre-printed sticker that read, Refrigerate. When asked why the medication was not refrigerated, LPN #1 stated they had not noticed the refrigerator label on it and that when that LPN had given [MEDICATION NAME] liquid at other facilities (in other jobs), the medication had not been refrigerated. On the afternoon of [DATE], the DON (director of nursing) provided the facility's list of medications' special storage and expiration dates and the facility's medication storage policy. The special storage and expiration list included [MEDICATION NAME] Oral Solution with instructions to Store refrigerated at all times; see label on bottle for expiration date. The DON said that after speaking with their pharmacist, the pharmacist indicated liquid [MEDICATION NAME] should be refrigerated. The DON stated the unrefrigerated bottle had been destroyed. During a meeting with the administrator, DON, and regional director of clinical services on [DATE] at approximately 12:10 p.m., the above concerns were discussed. No additional information was provided prior to exit conference.

Based on observation and staff interview, the facility staff failed to provide privacy in a manner that maintained or enhanced the dignity of the Resident's during a group meeting. The findings included: The facility failed to post a notice of the group meeting outside the meeting room. This resulted in one staff member entering the group meeting. On 10/10/18 beginning at 1:45 p.m., a group meeting was held with thirteen alert and orientated Residents of the facility. During this meeting, one staff person (dietary) entered the room disturbing the group meeting. At the conclusion of this meeting, the surveyor checked the outside door of the meeting room for a sign that would have announced a private meeting was being conducted. No sign had been posted. The surveyor was able to observe a sign at the nurse's station, which was located in the middle of two hallways that announced the meeting time and place. The administrative team were notified of the above issue during a meeting with the survey team on 10/10/18 at 3:38 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference.