Every finding on record at Davis and McDaniel Veterans Care Center

Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the Office of the Long-term Care Ombudsman of resident transfers and/or discharges to higher levels of care and the facility staff failed to ensure the appropriate information was provided to the receiving healthcare institution(s) and/or resident(s) and resident representative(s) for 2 of 35 residents, Residents #6 and #125. The findings included:1.For the facility, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman of resident transfers/discharges to higher levels of care. This surveyor requested evidence that the Office of the State Long-Term Care Ombudsman received notification of resident transfers/discharges to higher levels of care. On 1/8/26 at 8:38 AM, other staff #7 (OS#7) informed this surveyor that she agreed the notifications of resident transfers/discharges were not sent to the ombudsman and that she was never educated or informed to send notifications to the ombudsman when a resident is transferred/discharged to the hospital/higher level of care. She informed this surveyor that she does send notifications to the ombudsman if a resident expires at the facility, expires at the hospital, or is discharged home and provided this surveyor with evidence of those ombudsman notifications. This concern was discussed at the pre-exit meeting on 1/8/26 at 11:33 AM with the administrator, director of nursing, assistant director of nursing, administrator-in-training, and assistant administrator. Surveyor requested a facility policy on emergency discharges/transfers and/or a change in condition policy and was informed by registered nurse #2 (RN#2) the facility did not have either of these policies. No other information was provided to the survey team prior to exit on 1/8/26. 2. For Resident #6, the facility staff failed to ensure the appropriate information was provided to the receiving healthcare institution for a transfer/discharge on [DATE] and 11/26/25, and the facility staff failed to provide written notification of the reason(s) for a transfer/discharge to the resident and resident representative for a transfer/discharge on [DATE]. Resident #6's diagnosis list indicated diagnoses that included, but were not limited to, end stage renal disease, ulcerative proctitis, type 2 diabetes mellitus, and dependence on renal dialysis. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 12/2/25, assigned the resident a brief interview for mental status (BIMS) summary score of 8 out of 15 for cognitive abilities, indicating the resident was moderately impaired in cognition. A review of the clinical record indicated Resident #6 was transferred to the hospital on [DATE] and on 11/25/25. No evidence that appropriate information was provided to the receiving healthcare institution for the transfer/discharge on [DATE] and 11/25/25 could be located and no evidence of a written notice of the reason(s) for the transfer/discharge being provided to the resident and the resident's representative could be located for the discharge on [DATE]. This surveyor requested evidence that appropriate information was provided to the receiving healthcare institution for the transfer/discharge on [DATE] and 11/25/25. This surveyor also requested evidence that written notification was provided to the resident and resident representative for the reason(s) of transfer/discharge for 11/25/25. On 1/7/26 at 3:12 PM, the assistant director of nursing (ADON) provided this surveyor evidence of written notification for the reason(s) of transfer/discharge provided to the resident and the resident's representative for the transfer/discharges on 10/02/25 and 11/16/25. Evidence of written notification of the reason(s) for the transfer/discharge for 11/25/25 was not provided to this surveyor. The ADON agreed a Resident Transfer Form could not be located for the 10/2/25 transfer/discharge and the ADON informed this surveyor a Resident Transfer Form was not needed for the transfer/discharge on [DATE] because the resident returned to the facility on [DATE]. This concern was discussed at the end of day meeting on 1/7/26 at 4:15 PM with the administrator, director of nursing, assistant director of nursing, administrator-in-training, and assistant administrator. Surveyor requested a facility policy on emergency discharges/transfers and/or a change in condition policy and was informed by registered nurse #2 (RN#2) the facility did not have either of these policies. No other information was provided to the survey team prior to exit on 1/8/26. 3. For Resident #125, the facility staff failed to provide evidence to the survey team that the appropriate information was communicated to the receiving health care institution when the resident was transferred to a higher level of care on 11/26/25 and failed to provide written notice of transfer and a bed hold to the resident and/or resident representative until 12/01/25. Resident #125's diagnoses included adult failure to thrive, malignant neoplasm of colon, hypertension, diabetes, and heart failure. Section C (cognitive patterns) of Resident #125's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/08/25 included a brief interview for mental status (BIMS) score of 15 indicating Resident #125 was cognitively intact. Resident #125's clinical record included a nursing progress note that indicated this resident was transferred and admitted to a higher level of care on 11/26/25 for hypoxia and hypotension. On 12/01/25 at 9:09 a.m., Social Worker #1 documented that a temporary transfer notice was mailed to the responsible party/daughter of Resident #125. On 01/08/26 at 9:00 a.m., during an interview with Registered Nurse (RN) #2 this staff stated the date the resident was transferred (11/26/25) was a state holiday and 12/01/25 would have been the next business day. On 01/08/26 at 11:30 a.m., during a meeting with the Administrator, Assistant Administrator, Administrator in Training, Director of Nursing, and Assistant Director of Nursing the above issues were reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to review and revise the residents comprehensive care plan (CCP) to include the residents current code status for 1 of 35 current residents, Resident #9.The findings included:The facility staff failed to include Resident #9's code status on their CCP when the care plan was reviewed and revised on 12/05/25. Resident #9's diagnoses included myocardial infarction, peripheral vascular disease, and post-traumatic stress disorder.Section C (cognitive patterns) of Resident #9's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/24/25 included a brief interview for mental status (BIMS) score of 14 out of a possible 15 points indicating Resident #9 was cognitively intact.Resident #9s clinical record included provider orders dated 02/26/24 indicating this resident was a full code.During a review of Resident #9's CCP the surveyor was unable to locate any information related to this resident's code status.On 01/06/26 at 4:40 p.m., during an end of the day meeting with the Administrator, Assistant Administrator, Director of Nursing, Administrator in Training, and Assistant Director of Nursing the issue with Resident #9's code status not being included on the CCP was reviewed.On 01/07/26 at 11:41 a.m., during an interview with Registered Nurse (RN) #4 this nurse stated the Social Worker had revised/updated the CCP on 12/05/25 and failed to put Resident #9's code status back on the CCP.No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, resident interview, clinical record review and facility document review, the facility staff failed to follow physician orders for 1 of 35 current residents, Resident #1. The findings included:For Resident #1 the facility staff failed to follow physician's orders for sliding scale insulin protocol.Resident #1's clinical record listed diagnoses which included but not limited to type 2 diabetes mellitus and chronic kidney disease.Resident #1's most recent minimum data set with an assessment reference date of 10/15/25 assigned the resident a brief interview for mental status score of 15 out of 15 in section C, cognitive patterns. This indicates that the resident is cognitively intact. Section N, medications, coded the resident as receiving insulin injections for 7 out of 7 days in the look back period. Resident #1's comprehensive care plan contained a plan for . has Diabetes Mellitus with neuropathy, episodes of hyper/hypoglycemia; refuses insulin at times . Interventions for this care plan included diabetes medication as ordered by doctor ., Monitor blood sugar as indicated by MD orders for s/s (signs/symptoms) of hypo/hyperglycemia. Administer insulin and S/S (sliding scale) insulin as indicated by MD orders, and Monitor/document/report to MD PRN (as needed) for s/sx (signs/symptoms) of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, .Resident #1's clinical record was reviewed and contained a physician's order summary which read in part, Accuchecks prn notify MD if above 400. If below 60 follow standing order for Hypoglycemia and notify MD ** as needed for b/s (blood sugar) checks. Notify MD if below 60 or above 400, and Novolin R Solution 100 unit/m; (Insulin Regular Human). Inject as per sliding scale: if 300-350 = 6; 351-400 = 8; 401 + = 10, subcutaneously before meals and at bedtime for Diabetes Mellitus. If reading is 60 or below refer to hypoglycemia standing orders.Resident #1's electronic medication administration record (eMAR) for the month of December 2025 was reviewed and contained entries which read in part, Accuchecks prn notify MD if above 400. If below 60 follow standing order for Hypoglycemia and notify MD ** as needed for b/s (blood sugar) checks. Notify MD if below 60 or above 400, and Novolin R Solution 100 unit/m; (Insulin Regular Human). Inject as per sliding scale: if 300-350 = 6; 351-400 = 8; 401 + = 10, subcutaneously before meals and at bedtime for Diabetes Mellitus. If reading is 60 or below refer to hypoglycemia standing orders. Resident #1's blood sugar was recorded as 410 on 12/06/25 at 9 pm, 493 on 12/12/25 at 4:30 pm, and 497 on 12/12/25 at 9 pm. These entries were also coded 2 on the eMAR. eMAR code 2 is equivalent to drug refused. Surveyor spoke with Resident #1 on 01/07/26 at 2:45 pm. Surveyor asked resident if they every refused their insulin, and resident stated, Sometimes I refuse it at night. Even if my sugar is high, if I take the insulin, my sugar will drop way down. I don't like for it to drop like that.Surveyor spoke with registered nurse (RN) #8 on 01/07/26 at 2:30 pm. Surveyor asked RN #8 what the protocol is when a resident refuses to take their medication, and RN #8 stated, I would find out why they were refusing, document the refusal in an eMAR note and health status note. Surveyor asked RN #8 specifically about residents who refuse insulin, and RN #8 stated, depends on their blood sugar, but I would notify the physician. RN #8 went on to say, without being asked, that Resident #1 will refuse his insulin, even if his blood sugar is within parameters to get it. Surveyor asked RN #8 what the protocol is if a resident's blood sugar is greater than 400, and RN #8 stated, Make a note and contact the physician.Surveyor reviewed Resident #1's nursing progress notes and could not locate any evidence that the physician had been notified on the days that Resident #1 had refused his insulin, and his blood sugar was greater than 400.Surveyor requested and was provided with a facility policy entitled Recommended Order for Sliding Scale Insulin/ Applies to all Nursing Home Residents which read in part, For blood sugar greater than 400, give 10 units of Regular insulin subcutaneously and notify the MD.The concern of not notifying the physician of resident's blood sugars being greater than 400 was discussed with the administrator, assistant administrator, administrator-in-training, director of nursing and assistant director of nursing on 01/07/26 at 4:15 pmNo further information was provided prior to exit.

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to administer the physician ordered vitamin [MEDICATION(S)] senior for 1 of 33 residents, Resident #44. The findings included: For Resident #44, the facility staff failed to administer the physician ordered vitamin [MEDICATION(S)] senior per the physicians order. Resident #44's clinical record included the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44's annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/17/21 included a BIMS (brief interview for mental status) summary score of 3 of 15. 01/26/22 7:43 a.m., the surveyor observed LPN (licensed practical nurse) #1 prepare and administer Resident #44's morning medications. After this observation, the surveyor reconciled Resident #44's medications using the clinical record. Resident #44's clinical record included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor did not observe this medication being prepared or administered. 01/26/22 8:04 a.m., LPN #1 stated the [MEDICATION(S)] was house stock and they had forgotten to administer it. LPN #1 pulled the bottle of [MEDICATION(S)] from the medication drawer, placed it into a clear medication cup, and stated they would administer it to Resident #44. 01/26/22 4:00 p.m., the administrator, DON (director of nursing), assistant administrator, and ADON (assistant director of nursing) were made aware of the issue regarding Resident #44's [MEDICATION(S)]. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observations, staff interviews, clinical records reviews, and facility document reviews, the facility failed to maintain an infection prevention program for preventing and controlling infection and communicable diseases during an identified outbreak of COVID-19 on one of four units, 1 West/VACU. At the time of the survey, there was a cumulative total of 50 COVID-19 positive residents with two deaths. The findings included: Facility staff failed to ensure social distancing and the use of facial coverings for three (3) COVID-19 exposed residents residing on unit 1 West/VACU, which is considered a Warm Unit. On 10/06/20 at 1:04pm, surveyor, accompanied by the DON (director of nursing) and the assistant administrator, observed three residents (Resident #1, #2, and #3) in the 1 West/VACU solarium sitting within three feet of one another without facial coverings in place. Resident #2 was sitting in a wheelchair at a square table facing the window and Resident #1 sitting in a wheelchair to the right of Resident #2 with a separation of approximately three feet. Resident #1 and #2 were working on a jigsaw puzzle together. Resident #3 was also sitting in a wheelchair within approximately three feet of Resident #1 and #2 facing away from the windows watching television. Surveyor did not observe any staff members intervening to remind or encourage the residents to maintain social distancing or wear a facial covering. The DON stated all three residents were on contact precautions due to each being exposed to a COVID-19 positive staff member. Surveyor discussed the concern of Residents #1, #2, and #3 not being socially distanced from one another and not wearing facial coverings with the assistant administrator and the DON. The DON stated it is their home. Resident #1's [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date) of 9/02/20 assigned Resident #1 a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. Resident #1 is also coded as requiring supervision only for transfers and locomotion on and off the unit. Resident #1 has an active physician's orders [REDACTED]. Resident #2's [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 9/09/29 assigned Resident #2 a BIMS score of 15 out of 15 in section C, Cognitive Patterns. Resident #2 is also coded as requiring supervision only for transfers and locomotion on unit and off unit. Resident #2 has an active physician's orders [REDACTED]. Resident #3's [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 7/29/20 assigned Resident #3 a BIMS score of 15 out of 15 in section C, Cognitive Patterns. Resident #3 is also coded as requiring extensive assistance for transfers and supervision only for locomotion on unit and off unit. Resident #3 has an active physician's orders [REDACTED]. On 10/08/20 at 11:36am, surveyor spoke with the UM (unit manager) for 1 West/VACU concerning the observation of Resident #1, #2, and #3. The UM stated residents are offered a mask every morning, some will accept them and some will not, these three residents usually do not accept a mask. UM stated staff educate the residents and they are told to stay in their rooms. UM stated that they know they need to keep the residents apart. UM further stated these three residents stayed together on their unit before being moved to the warm unit and they need to socialize. UM stated Resident #1, #2, and #3 moved themselves to the solarium. Surveyor requested and received the facility's policy for COVID-19 entitled, COVID-19 Outbreak Management which states in part: b. Monitoring vii. Residents who have recently tested negative but were exposed to a positive COVID resident will be treated as though they are positive and considered WARM. These residents will be placed on Contact Precautions and monitored for symptoms. Another COVID-19 test will be administered. They may stay in a single room, or if conditions allow, moved to a WARM section of the COVID unit. WARM residents must wear a mask when outside of their room and practice social distancing. If the resident becomes symptomatic, they will be moved to the COVID unit and retested . After a negative COVID-19 test result and by remaining symptom free for 72 hours, the resident may come off of Contact Precautions or be transferred back to their unit. On 10/13/20, surveyor received an email from the assistant administrator stating in part, All three residents are cognitively intact (each have a BIMS of 15), they are aware of their isolation, have been offered opportunity to wear face coverings, and have made independent choices for mask use and social distancing based upon this information and their resident rights. On 10/13/20, surveyor was provided with a copy of a form entitled, Face Mask (VACU) 1 West for the date of 10/06/20 indicating Resident #1 accepted a mask, Resident #2 accepted a mask, and Resident #3 refused a mask. No further information regarding this issue was presented to the surveyor prior to the exit conference on 10/13/20.

Based on observations, staff interviews, clinical record review, facility documentation review, and during 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 involving 2 out of 7 residents in the survey sample as evidence by failure to implement face coverings for a resident with known exposure to COVID while seated with a group of residents; failure to implement transmission based precautions for residents with known exposure to COVID-19; failure to have PPE readily accessible for staff caring for residents with COVID-19; and failure to appropriately handle linen from a COVID positive room. The findings included: 1. The facility staff failed to implement interventions of face coverings for Resident # 3 who had been exposed to COVID-19, and was observed seated in the day room with a group of residents. On 6/25/20 at 10:45 am, an entrance conference was conducted with the assistant administrator, director of nursing (DON), assistant director of nursing (ADON), and the QI (quality improvement)/regulatory nurse. During this entrance conference, the assistant administrator informed the survey team that the facility staff had tested 178 residents and 239 facility staff members, and that the facility staff had been made aware via telephone that morning (6/25/20), that 8 facility residents and 6 facility staff members had tested positive for COVID-19. The assistant administrator had also informed the survey team there were 6 COVID-19 test results that were still pending and that the identity of the 6 pending test results were unknown. Therefore, the pending COVID-19 test results could belong to any resident or facility staff member. Resident # 3 has [DIAGNOSES REDACTED]. Resident # 3's roommate tested positive for COVID-19 on 6/25/20, therefore Resident # 3 had been exposed to COVID-19. The most recent MDS (minimum data set) assessment for Resident # 3 was a quarterly assessment with and ARD (assessment reference date) of 6/16/20. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 3 had a BIMS (brief interview for mental status) score of 5 out of 15, which indicated that Resident # 3's cognitive status was severely impaired. Section G of the MDS assesses functional status. In Section G0110, the facility staff documented that Resident # 3 was totally dependent of staff, requiring the assistance of one person for locomotion on the unit. The plan of care for Resident # 3 was reviewed and revised on 3/18/20. The facility staff documented a focus area for Resident # 3 as, Risk of exposure/transmission COVID-19. Interventions included but were not limited to, Educate resident on social distancing with no handshakes, hugging, communal dining, and group activities, and Provide facemask if the resident must leave the room for medically necessary transfer out of the facility. On 6/25/20 at 11:30 am, the surveyor conducted observations on the 2-west unit. The surveyor observed a group of 11 residents seated out in the day room area around the television. The surveyor observed that none of the residents were wearing face coverings or facemasks. The surveyor noted Resident # 3 to be one of the 11 residents in the group in the day room area around the television. Resident # 3 was seated in a broada chair, and did not have a face covering or face mask. The surveyor also observed 2 residents ambulate independently and one resident self propel via wheelchair independently without face coverings, and the 3 residents observed were within 6 feet of Resident # 3. The surveyor did not observe a staff member attempt to offer a facemask or face covering to any of the residents seated in a group in the day room area. The surveyor also did not observe any staff member attempt to provide interventions to promote social distancing when residents were within 6 feet of Resident # 3. The facility Outbreak Management plan contained documentation that included but was not limited to, .C. Restrictions vii. Limit group activities and outings, if so directed by the administrator (or designee). The facility policy on Transmission Based Precautions contained documentation that included but was not limited to, .4. Specific precaution advise n. Droplet Precautions - Resident MUST wear a mask when out of room or during transportation to outside appointments. The facility Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID19 contained documentation that included but was not limited to, .Elements to be assessed If residents leave their rooms, they should wear a cloth face covering or facemask (if tolerated), perform hand hygiene, limit movement in the facility, and perform social distancing. The surveyor observed a handwritten check mark next to Yes for Assessment in this area. In the Notes/Areas for Improvement block in this area, the surveyor observed handwritten documentation that stated Except for those who will not tolerate mask, and those on memory care unit. On 6/26/20 at 1:32 pm, the surveyor made the administrator and director of nursing aware of the findings as stated above. The surveyor asked the administrator and the director of nursing if it was acceptable for a resident that had been exposed to COVID-19 to be seated in an area with a group of other residents without a face covering. The administrator stated, We constantly ask residents to wear masks. They refuse. There is nothing in the regulations require us to force them to wear a mask. We had no positive results until the recent test and they were all asymptomatic. On 6/29/20 at 8:00 am, the surveyor reviewed the clinical record for Resident # 3. The surveyor did not observe documentation in the clinical record for Resident # 3 that indicated that facility staff had attempted to provide face coverings to Resident # 3 and there was no documentation observed in the clinical record that Resident # 3 had refused to wear face coverings. On 6/30/20 at 2:47 pm, the survey team spoke with the administrator and director of nursing. The survey team informed the director of nursing and the administrator that the clinical record for Resident # 3 was reviewed and that the surveyor did not observe documentation that the facility staff attempted to provide a face mask or face covering to Resident # 3, nor did the clinical record show documentation that Resident # 3 refused to wear a face mask. The surveyor asked the administrator and the director of nursing why Resident # 3, a resident with known exposure to COVID-19 did not droplet precautions initiated, and was allowed to be seated in an area with a group of residents with no face covering since at the time of the observation, the facility still had 6 pending COVID-19 test results outstanding and the identity of those with pending results was unknown. The administrator stated to the survey team, Up until now, I felt we were doing everything right. I am not disagreeing with you, and we will definitely do some things differently moving forward. No further information regarding this issue was presented to the survey team prior to the exit conference on 7/1/20. 2. The facility staff failed to implement appropriate transmission based precautions for 2 of 7 residents in the survey sample that had been exposed to COVID-19 Resident # 3 and Resident # 4. Resident # 3 had [DIAGNOSES REDACTED]. Resident # 3's roommate tested positive for COVID-19 on 6/25/20, therefore Resident # 3 had been exposed to COVID-19. The most recent MDS assessment for Resident # 3 was a quarterly assessment with and ARD of 6/16/20. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 3 had a BIMS score of 5 out of 15, which indicated that Resident # 3's cognitive status was severely impaired. The current plan of care for Resident # 3 was reviewed and revised on 3/18/20. Facility staff documented a focus area for Resident # 3 as, Risk for exposure/transmission COVID-19. Interventions included but were not limited to, Implement standard, contact, and droplet precautions for symptoms/undiagnosed respiratory infections; follow facility policy. Resident # 4 had [DIAGNOSES REDACTED]. Resident # 4's roommate tested positive for COVID-19 on 6/25/20, therefore Resident # 4 had been exposed to COVID-19. The most recent MDS for Resident # 4 was a significant change 5-day Medicare assessment with an ARD of 6/11/20. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 4 had a BIMS score of 13 out of 15, which indicated that Resident # 4 was cognitively intact. The current plan of care for Resident # 4 was reviewed and revised on 3/18/20. Facility staff documented a focus area for Resident # 4 as, Risk for exposure/transmission COVID-19. Interventions included but were not limited to, Implement standard, contact, and droplet precautions for symptoms/undiagnosed respiratory infections; follow facility policy. On 6/26/20 at 11:51 am, the surveyor observed Resident # 3 sitting in a broada chair in his/her room. The surveyor did not observe any signage on Resident # 3's door or personal protective equipment (PPE) that indicated that Resident # 3 was on any type of transmission based precautions. On 6/26/20 at 11:53 am, the surveyor observed Resident # 4 sitting in a wheelchair in his/her room. The surveyor did not observe any signage on Resident # 4's door or PPE that indicated that Resident # 4 was on any type of transmission-based precautions. On 6/26/20 at 12:06 pm, the surveyor conducted an interview with CNA #1 (certified nursing assistant). The surveyor asked CNA #1 what type of monitoring was being done for residents exposed to COVID-19. CNA # 1 informed the surveyor that residents were kept in their room unless they needed special attention, and then they would be placed up front in the day area and distanced apart. CNA # 1 informed the surveyor that residents' temperatures were checked twice a shift. Once when they came on shift, and again before the shift was over. The surveyor asked CNA # 1 if he/she wore any additional PPE other than masks and gloves when caring for residents that had been exposed to COVID-19. CNA #1 informed the surveyor that he/she did not wear additional PPE other than mask and gloves when caring for residents that had been exposed to COVID-19 because their tests had come back negative. The surveyor asked CNA #1 how he/she know that the test had come back negative. CNA #1 stated that he/she did not know for sure but assumed that the test had been negative because all of the positive people had been moved to the first floor. The surveyor asked CNA # 1 if he/she was aware that there were COVID-19 test results that were still pending, and that those results could belong to any resident or staff member in the building. CNA # 1 stated that he/she was not aware that there were COVID-19 test results that were still pending. On 6/26/20 at 1:32 pm, the surveyor made the administrator and director of nursing aware of the findings as stated above. The surveyor asked the administrator and the director of nursing why transmission based precautions had not been implemented for Resident # 3 and Resident # 4 since they had been exposed to COVID-19 when their roommates tested positive, and there were still 6 pending COVID-19 tests results. The identity of those pending results were unknown, therefore any of the facility residents or staff could return with a positive result. The director of nursing informed the surveyor that the facility staff was completing full assessments every shift and assessing vital signs on the residents. On 6/29/20 at 8:10 am, the surveyor reviewed the clinical records for Resident # 3 and Resident # 4. The surveyor did not observe any current or discontinued orders for transmission based precautions for Resident # 3 and Resident # 4. The facility policy on Transmission Based Precautions contained documentation that included but was not limited to, .Suspected COVID-19 residents will be moved to a private isolation room and placed on Droplet Precautions until cleared or confirmed. On 6/30/20 at 2:47 pm, the administrator and director of nursing were made aware of the findings as stated above. The administrator stated to the survey team, Up until now, I felt we were doing everything right. I am not disagreeing with you, and we will definitely do some things differently moving forward. No further information regarding this issue was presented to the survey team prior to the exit conference on 7/1/20. 3. The facility staff filed to have PPE readily accessible and failed to wear appropriate PPE into a room of a COVID positive resident. On 6/25/20 at 11:37 am, the surveyor was conducting observations on the 2-west unit. The surveyor observed signage for Contact Precautions and Droplet Precautions on the door of room of Resident # 4. The surveyor did dot observe any type of isolation cart containing PPE near the room. On 6/25/20 at 11:40 am, the surveyor observed signage for Contact Precautions and Droplet Precautions on the door of room of Resident # 3. The surveyor did dot observe any type of isolation cart containing PPE near the room. The surveyor interviewed the assistant director of nursing (ADON). The surveyor asked the ADON if the resident in room [ROOM NUMBER] was on isolation precautions. The ADON stated, Yes, we are in the process of taking the residents down to the COVID unit. The surveyor sked the ADON where the PPE was for staff to utilize when caring for the resident. The ADON stated, We will have to go down to central supply to get PPE. The surveyor asked the ADON, If your residents need assistance prior to being transferred to the COVID unit, they will have to wait for someone to go to central supply to get PPE before they can be assisted? The ADON stated, Yes. The surveyor observed the ADON leave the unit at that time. On 6/25/20 at 11:43 am, the surveyor observed the 2-west unit manager leave the unit. On 6/25/20 at 11:46 am, the surveyor observed the 2-west unit manager return to the unit with disposable gowns in hand. On 6/25/20 at 11:47 am, the surveyor observed 2-west unit manager and LPN #1 (licensed practical nurse) don disposable gowns and gloves. 2-west unit manager and LPN # 1 already had facemask on. The surveyor did not observe 2-west unit manager and LPN # 1 apply a face shield or goggles prior to entering Resident # 4's room. On 6/25/20 at 2:31 pm, the survey team interviewed the facility infection preventionist. The surveyor asked the infection preventionist if facility staff were expected to wear goggles or a face shield when caring for residents with a [DIAGNOSES REDACTED]. The facility policy on Transmission Based Precautions contained documentation that included but was not limited to, .2. Implementation e. All licensed nurses are responsible for ensuring that Transmission-Based Precautions are correctly implemented and that supplies are in place as required. The facility staff provided the survey team with educational material that had been reviewed with facility staff dated 2/27/20. The educational materials contained documentation that included but was not limited to, .WHO NEEDS PPE: Healthcare personnel should adhere to Standard, Contact, and Airborne Precautions including the use of eye protection (e.g., googles or a face shield) when caring for patients with [DIAGNOSES REDACTED]-Co V-2 infection. On 6/26/20 at 1:32 pm, the surveyor made the administrator and director of nursing aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 7/1/20. 4. The facility staff failed to appropriately handle linen from a COVID positive resident. On 6/25/20 at 1:29 pm, the surveyor observed CNA # 3 enter Resident # 3's room wearing a gown, mask, and gloves. The facility staff had recently transferred the Resident # 3's roommate to the COVID positive unit on the first floor. The surveyor observed CNA # 3 strip Resident # 3's roommate's bed and place the linen in a red biohazard bag following the instruction of the 2 west unit manager. The facility policy for Laundry COVID 19 contained documentation that included but was not limited to, .Procedure 4 COVID-19 positive laundry will be placed in the wash in the yellow laundry bags, inverted without touching the contents. On 6/26/20 at 1:32 pm, the surveyor made the administrator and director of nursing aware of the findings as stated above. The administrator and director of nursing agreed that COVID positive linens should have been placed in a yellow bag. No further information regarding this issue was presented to the survey team prior to the exit conference on 7/1/20.

Based on observation, staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs by ensuring that residents' call cords were within reach for 2 of 8 residents (Resident #2 and Resident #3). The findings included: 1. The facility staff failed to ensure Resident #2's call cord was accessible. Resident #2's call cord was observed lying on the floor between the wall and the head of the bed-out of reach and not accessible to the resident. The clinical record of Resident #2 was reviewed 7/30/19 through 8/2/19. Resident #2 was admitted to the facility 8/4/16 with diagnoses, that included but not limited to myelodysplasti[DIAGNOSES REDACTED], [MEDICAL CONDITION], [MEDICATION NAME] degeneration, [DIAGNOSES REDACTED], testicular hypofunction, dementia, major [MEDICAL CONDITIONS], and hypertension. Resident #2's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 4/25/19 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #2's current comprehensive care plan initiated the focus area for communication on 8/10/16 with a revision on 8/1/18. Interventions: Ensure/provide a safe environment: Call light in reach. The surveyor observed Resident #2 during the initial tour on 7/30/19 at 6:10 p.m. Resident #2 was observed in bed. The call cord was observed lying on the left side of the bed on the floor between the wall and the headboard. Resident #2 stated he was taking it easy. The call cord was out of reach and not accessible to Resident #2. The surveyor observed Resident #2 on 7/31/19 at 8:34 a.m. Resident #2 was in bed. The call cord was on the floor on the left side of the bed between the wall and the headboard. The call cord was out of Resident #2's reach and not accessible. The surveyor observed Resident #2 on 7/31/19 at 8:59 a.m. Resident #2 was still in bed and had not yet received the breakfast tray. The surveyor informed the unit manager registered nurse #1 that Resident #2 did not have a breakfast tray. The call cord was on the floor on the left side of the bed between the wall and the headboard. The call cord was out of Resident #2's reach and not accessible. Resident #2 received the breakfast tray at 9:05 a.m. on 7/31/19. Certified nursing assistant #1 delivered the tray to both Resident #2 and the roommate. The unit manager registered nurse #1 was also present in the room. C.N.[NAME] #1 turned on the roommate's over the bed light and prepared the breakfast tray and then pulled the privacy curtain back towards the wall to turn on Resident #2's light. The call cord was lying on the floor. Neither C.N.[NAME] #1 nor the unit manager R.N. #1 observed the call cord lying on the floor and out of Resident #2's reach. The surveyor observed Resident #2 again at 9:46 a.m. eating breakfast in bed. The call cord remained on the floor and out of Resident #2's reach. The surveyor observed Resident #2 again on 7/31/19 at 11:08 a.m. The resident was observed coming out of the bathroom. The call cord was still on the floor. The surveyor asked the unit manager to accompany her to Resident #2's room at this time and showed the unit manager the call bell. The unit manager R.N. #1 stated the call cord should be in the resident's reach. R.N. #1 stated education was needed. The surveyor informed the assistant administrator of the above issue on 7/31/19 at 11:59 a.m. The assistant administrator stated the call cords should be accessible to all residents even those who had dementia. The surveyor conducted a resident council meeting on 7/30/19 at 4:16 p.m. Fourteen alert and oriented residents of the facility attended. The surveyor asked the council about the use of call cords. The majority of the council stated at times the call cords are out of reach. They drop down beside the bed and you can't reach them. Some staff tie them to the bulletin board so you can't reach them. One resident stated sometimes the staff take a while to answer the call lights. One resident stated the call cords need to be in a specific location that easily reached so they don't get dropped to the floor. The surveyor also informed the director of nursing of the concern with the call cord out of Resident #2's reach on 7/31/19 at 12:00 p.m. The surveyor requested the facility policy on call cords. The director of nursing informed the surveyor on 7/31/19 at 1:30 p.m. that the facility did not have a policy on call cords but stated they should be within reach. The surveyor informed the administrator on 8/2/19 at 2:45 p.m. of the above concern. No further information was provided prior to the exit conference on 8/2/19. This is a complaint deficiency. 2. The facility staff failed to ensure Resident #3's call cord was accessible. Resident #3's call cord was clipped on the resident's privacy curtain and out of reach. The clinical record of Resident #3 was reviewed 7/30/19 through 8/2/19. Resident #3 was admitted to the facility 5/4/18 with diagnoses, that included but not limited to traumatic subdural hemorrhage, [MEDICAL CONDITION], major [MEDICAL CONDITION], cardiac pacemaker, [MEDICAL CONDITION], dementia, anxiety, and [MEDICAL CONDITION] reflux disease. Resident #3's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/6/19 assessed the resident with a BIMS (brief interview for mental status) as 00/15. Resident #3's current comprehensive care plan initiated 5/4/18 and revised 12/10/18 identified a focus area that read Resident #3 has a communication problem r/t (related to) dementia and hearing deficit. Residents wife took hearing aids home. Interventions: Ensure/provide a safe environment: Call light in reach. The surveyor observed Resident #3 during the initial tour on 7/30/19 at 6:15 p.m. Resident #3 was observed in bed, eyes closed. The call cord was clipped to the privacy curtain that separated Resident #3 from the roommate. The call cord was out of Resident #3's reach and inaccessible to the resident. The privacy curtain was approximately 2 feet from Resident #3's bed and clipped on the curtain approximately 5 feet from the floor. The surveyor observed Resident #3 on 7/31/19 at 8:41 a.m. Resident #3 was in bed, eyes closed. Call cord clipped in the same location as on 7/30/19-to the privacy curtain. The call cord was out of reach and not accessible to Resident #3. On 7/31/19 at 8:44 a.m., certified nursing assistant #2 entered Resident #3's room with the breakfast tray. At 8:46 a.m., Resident #3 was uncooperative in moving up in the bed. C.N.[NAME] #2 walked to the curtain and rang for assistance. At 8:48 a.m., licensed practical nurse #1 entered room and assisted certified nursing assistant #2 to position the resident in bed for the meal. [MI]P.N. #1 was on the right side of the bed near the privacy curtain. No attempts by [MI]P.N. #1 to move the call cord closer to Resident #3 were made. At 9:00 a.m. on 7/31/19, C.N.[NAME] #2 raised the head of Resident #3's bed and positioned herself on the right side of the bed to help the resident with breakfast. At 9:20 a.m., C.N.[NAME] #2 left Resident #3's room. The call cord remained clipped to the privacy curtain-out of reach and inaccessible to Resident #3. The surveyor observed Resident #3 on 7/31/19 at 9:47 a.m. Resident #3 was in bed. The call cord remained clipped to the privacy curtain-out of reach of Resident #3 and inaccessible. The surveyor observed Resident #3 on 7/31/19 at 11:09 a.m. Resident #3was in bed. The call cord was clipped to the privacy curtain. The call cord was out of the reach of Resident #3 and in accessible for use. The surveyor asked the unit manager registered nurse #1 to come to Resident #3's room on 7/31/19 at 11:35 a.m. The surveyor showed the unit manager registered nurse #1 the call cord clipped to the privacy curtain. The surveyor informed the unit manager of the different observation times and with each observation the location of the call cord. The unit manager registered nurse #1 stated some education was needed. The surveyor informed the assistant administrator of the above issue on 7/31/19 at 11:59 a.m. The assistant administrator stated the call cords should be accessible to all residents even those who had dementia. The surveyor conducted a resident council meeting on 7/30/19 at 4:16 p.m. Fourteen alert and oriented residents of the facility attended. The surveyor asked the council about the use of call cords. The majority of the council stated at times the call cords are out of reach. They drop down beside the bed and you can't reach them. Some staff tie them to the bulletin board so you can't reach them. One resident stated sometimes the staff take a while to answer the call lights. One resident stated the call cords need to be in a specific location that easily reached so they don't get dropped to the floor. The surveyor also informed the director of nursing of the concern with the call cord out of Resident #3's reach on 7/31/19 at 12:00 p.m. The surveyor requested the facility policy on call cords. The director of nursing informed the surveyor on 7/31/19 at 1:30 p.m. that the facility did not have a policy on call cords but stated they should be within reach. The surveyor informed the administrator on 8/2/19 at 2:45 p.m. of the above concern. No further information was provided prior to the exit conference on 8/2/19. Ths is a complaint deficiency.

Based on observation the facility staff failed to provide a private uninterrupted space for council meeting. The findings included On 5/22/19 at 10:47 am, the surveyor was conducting a group meeting with the Resident council. The surveyor observed a facility staff member come into the room where the group meeting was being conducted. The surveyor observed the staff member place a tray on a tray cart and then removed the entire tray cart from the room. On 5/22/19 at 3:45 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/22/19.

Based on observation, Resident interview, and clinical record review, the facility staff failed to ensure that 1 of 37 Residents in the survey sample was free of restraints, Resident # 55. The findings included The facility staff had fall mats and bed and chair alarms in place for Resident # 55, which restricted Resident # 55 from moving and transferring. Resident # 55 was a [AGE] year-old-male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 55 was reviewed on 5/21/19 at 4:05 pm. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 3/15/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 55 had a BIMS (brief interview for mental status) score of 12 out of 15, which indicated that Resident # 55 was cognitively intact. On 5/21/19 at 3:07 pm, the surveyor was in the hallway outside of Resident # 55's room and heard an alarm sounding. The surveyor knocked and was invited into the room by Resident # 55. The surveyor entered the room to observe Resident #55 sitting in his wheelchair with a bed alarm in his hand attempting to stick his finger in a hole on the bottom of the bed alarm. Resident # 55 stated, I'm trying to get my finger in here to turn this thing off. I hate this thing; it makes you scared to move because this thing goes beep, beep, beep every time you move. Resident # 55 then stated, They keep putting those mats down and they get in the way of embarking and disembarking. They restrict me every chance they get when they put those pads down. Resident # 55 pointed at fall mats that were down on the floor next to his roommate's bed and fall mats that were observed against the wall on Resident # 55's side of the room. The surveyor observed that the fall mat that was down next to Resident # 55's roommate's bed extended to Resident # 55's side of the room and was positioned against the wheels on Resident # 55's wheelchair. On 5/22/19 at 8:16 am, the surveyor reviewed the clinical record for Resident # 55. The surveyor observed a telephone order that was written on 5/3/19. The telephone order was documented as, D/C (discontinue) bed/chair alarms & low beds with mats d/t (due to) not attempting to get up unassisted. On 5/22/19 at 3:45 am, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 5/23/19.

Based on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to follow standards of professional practice for 1 of 37 Residents, Resident #16. The findings included: The facility staff failed to obtain the resident's apical pulse prior to administering the medication [MEDICATION NAME]. The clinical record review revealed that Resident #16 had been admitted to the facility 10/21/10. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/13/19 included a BIMS (brief interview for mental status) summary score of 4 out of a possible 15 points. The resident's comprehensive care plan included the following focus areas-has altered cardiovascular status related to [MEDICAL CONDITION] and [MEDICAL CONDITION] and is on [MEDICATION NAME] therapy. Interventions included, but were not limited to, vital signs as ordered and report to physician if pulse falls below 60 or rises above 110 or if you detect skipped beats or other changes in rhythm. On 05/22/19 at 8:24 a.m., the surveyor observed LPN (licensed practical nurse) #3 prepare and administer Resident #16's morning medications to include the medication [MEDICATION NAME] 125 mg. Prior to administering the resident's medications LPN #3 obtained the resident's blood pressure (124/58) and pulse (77) using an electronic blood pressure machine. After this medication observation, the surveyor used the resident's clinical record to reconcile the resident's medications. The resident's clinical record included the order [MEDICATION NAME] 125 mcg one time a day related to [MEDICAL CONDITION] hold for apical pulse less than 60 beats per minute. After this reconciliation, the surveyor interviewed LPN #3. LPN #3 was asked how she had obtained the resident's pulse. LPN #3 replied, I should have used my stethoscope. The unit included a Mosby's Nursing Drug Reference book that included the following information regarding the medication [MEDICATION NAME] .NURSING CONSIDERATIONS Assess: Apical pulse for 1 min (minute) before giving product, if pulse < (less than) 60 in adult take again in 1 hr (hour) .Cardiac Status: apical pulse, character, rate, rhythm . The facility was notified of the above issue during a meeting with the survey team on 05/22/19 at 3:00 p.m. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure 1 of 37 Residents were free of accident hazards (Resident #96). The findings included: Resident #96 had a physician order [REDACTED]. The clinical record review revealed that Resident #96 had been admitted to the facility 07/31/18. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 04/02/19 included a BIMS (brief interview for mental status) summary score of 4 out of a possible 15 points. Section G (functional status) had been coded to indicate the Resident required extensive assistance of one person for bed mobility. The Residents clinical record included a physicians order dated 07/18/18 for padded side rails and gerisleeves to bilateral arms at all times for protection. The Residents comprehensive care plan included the focus areas of has [MEDICAL CONDITION], activities of daily living/self-care deficit, limited physical mobility, high risk for falls, potential for pressure ulcer related to immobility/incontinence. Interventions included, but were not limited to, adaptive devices as recommended by therapy, geri-sleeves as ordered and padded siderails. The facility staff provided the surveyor with a copy of the tasks for this Resident these included Safety .padded siderails .Resident Care .Geri-sleeves per order . The Resident was observed on 05/22/19 at 9:40 a.m. and again at 10:39 a.m. with no geri sleeves in place and no padding to the Residents side rails. On 05/22/19 at 10:45 a.m., LPN (licensed practical nurse) #4 (agency nurse) was asked how she knew what care to provide to this Resident. LPN #4 stated she asked one of the regular CNA's (certified nursing assistants). LPN #4 and the surveyor then proceeded to the Residents room and checked the Resident and again this Resident was observed without their physician ordered geri sleeves and padding on the side rails. The facility was notified of the above issue during a meeting with the survey team on 05/22/19 at 3:00 p.m. No further information was provided to the survey team prior to the exit conference.

Based on clinical record review, Resident interview, and staff interview, the facility staff failed to ensure 1 of 37 residents in the survey sample had orders for Foley catheter, Resident # 55. The findings included: The facility staff failed to ensure that Resident # 55 had orders for Foley catheter that included catheter and bulb size. Resident # 55 was a [AGE] year-old-male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 55 was reviewed on 5/21/19 at 4:05 pm. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 3/15/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 55 had a BIMS (brief interview for mental status) score of 12 out of 15, which indicated that Resident # 55 was cognitively intact. Section H of the MDS assesses bladder and bowel. In Section H0100, the facility staff documented that Resident # 55 had an indwelling catheter. The plan of care for Resident # 55 was reviewed and revised on 3/28/19. The facility staff documented a focus area for Resident # 55 as, Resident # 55 has indwelling catheter: He is unable to void after removal. Interventions included but were not limited to; Change catheter per order/facility protocol. The surveyor reviewed the current orders for Resident # 55 and did not locate any orders for a Foley catheter that included a catheter and bulb size. On 5/21/19 at 3:21 pm, the surveyor was in Resident # 55's room conducting a Resident interview. The surveyor asked Resident # 55 if he had a catheter. Resident # 55 stated, I have a leg catheter. On 5/22/19 at 9:15 am, the surveyor interviewed unit manager RN # 1 (registered nurse). The surveyor asked RV # 1 if Resident # 55 had a Foley catheter. RN # 1 stated, Yes he does. The surveyor asked RN # 1 if she could show the surveyor an order for [REDACTED].# 1 stated, I see an order for [REDACTED].# 1 agreed that Resident # 55 did not have an order for [REDACTED]. On 5/22/19 at 3:45 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/22/19.

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure 1 of 37 residents (Resident #16) was free of a significant medication error. The findings included: The facility staff failed to obtain the resident's apical pulse prior to administering the medication [MEDICATION NAME]. The clinical record review revealed that Resident #16 had been admitted to the facility 10/21/10. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/13/19 included a BIMS (brief interview for mental status) summary score of 4 out of a possible 15 points. The resident's comprehensive care plan included the focus areas altered cardiovascular status related to [MEDICAL CONDITION] and [MEDICAL CONDITION] and is on [MEDICATION NAME] therapy. Interventions included, but were not limited to, vital signs as ordered and report to physician if pulse falls below 60 or rises above 110 or if you detect skipped beats or other changes in rhythm. On 05/22/19 at 8:24 a.m., the surveyor observed LPN (licensed practical nurse) #3 prepare and administer Resident #16's morning medications to include the medication [MEDICATION NAME] 125 mg. Prior to administering the resident's medications LPN #3 obtained the resident's blood pressure (124/58) and pulse (77) using an electronic blood pressure machine. After this medication observation, the surveyor used the resident's clinical record to reconcile the resident's medications. The resident's clinical record included the order [MEDICATION NAME] 125 mcg one time a day related to [MEDICAL CONDITION] hold for apical pulse less than 60 beats per minute. After this reconciliation, the surveyor interviewed LPN #3. LPN #3 was asked how she had obtained the resident's pulse. LPN #3 replied, I should have used my stethoscope. The facility was notified of the above issue during a meeting with the survey team on 05/22/19 at 3:00 p.m. No further information was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to report irregularities to the facility's medical director for 4 of 35 residents (Resident #41, Resident #74, Resident #86 and Resident #117). The findings included: 1. The facility staff failed to report irregularities identified on Resident #86's (MONTH) 28, (YEAR) monthly drug regimen review to the medical director. The clinical record of Resident #86 was reviewed 3/20/18 through 3/22/18. Resident #86 was admitted to the facility 3/28/17 with [DIAGNOSES REDACTED]. Resident #86's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/1/18 was assessed with [REDACTED]. Resident #86 was assessed to have inattention, disorganized thinking, physical behaviors directed at others, and rejection of care. No [MEDICAL CONDITION] present. During the clinical record review, Resident #86 had a monthly drug regimen review dated 2/28/18 with the following written: [MEDICAL CONDITION] Drug Use Review Antipsychotic Please note that this resident has taken their current dose of antipsychotic medication [MEDICATION NAME] 25 mg (milligrams) qhs (at bedtime) since 9/17. Federal guidelines recommend periodic dose reduction for [MEDICAL CONDITION] medications unless several previous attempts have failed or it is clinically contraindicated as documented by the physician in the resident's medical record. Consider a trial dose reduction or please document the need to continue current dose. Signed by consultant pharmacist. Physician Response (select one): Comment noted; no action desired. No change resident cont (continues) with paranoia & resistance to care. Signed by physician assistant (PA). There was no evidence the medical director had been informed of the irregularities identified in the (MONTH) (YEAR) MRR (monthly regimen review). The surveyor informed the unit manager licensed practical nurse #1 of the concern on 3/20/18 at 1:44 p.m. L.P.N. #1 stated the physician assistant reviews the monthly drug reviews and stated she puts them in her box. The surveyor informed the director of nursing on 3/21/18 about the lack of medical director review of the irregularities in the (MONTH) 28, (YEAR) monthly drug regimen review for Resident #86. The director of nursing informed the surveyor that the PA reviews them for Resident #86's attending physician and that there was no indication the medical director had been informed. The DON identified the PA's signature only on the monthly review. The surveyor informed the administrator, the director of nursing, and the QAPI (quality assurance/performance improvement) nurse of the above identified concern in the end of the day meeting on 3/21/18 at 4:36 p.m. No further information was provided prior to the exit conference on 3/22/18. 2. The facility staff failed to ensure the medical director was informed of irregularities from Resident #74's (MONTH) 30, (YEAR) monthly drug regimen review. The clinical record of Resident #74 was reviewed 3/20/18 through 3/22/18. Resident #74 was admitted to the facility 7/28/17 with [DIAGNOSES REDACTED]. Resident #74's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/25/18 assessed the resident with long term memory problems, short term memory problems, and severely impaired cognitive skills for daily decision making. Resident #74 was assessed with [REDACTED]. During the clinical record review, Resident #74 had a monthly drug regimen review dated 1/30/18 with the following written: [MEDICAL CONDITION] Drug Use Review Antipsychotic Please note that this resident has taken their current dose of antipsychotic medication [MEDICATION NAME] 25 mg (milligrams) q8 hours [MEDICAL CONDITION] (every 8 hours) since 7/17. Federal guidelines recommend periodic dose reduction for [MEDICAL CONDITION] medications unless several previous attempts have failed or it is clinically contraindicated as documented by the physician in the resident's medical record. Consider a trial dose reduction or please document the need to continue current dose. Signed by consultant pharmacist. Physician Response (select one): Accept above recommendation. Signed by physician assistant (PA). A telephone order dated 2/6/18 read in part Decrease am (morning) [MEDICATION NAME] to 12.5 mg qam (every morning). There was no evidence the medical director had been informed of the irregularities identified in the (MONTH) 30 (YEAR) MRR (monthly regimen review). The surveyor informed the director of nursing on 3/21/18 at 10:22 a.m. about the lack of medical director review of the irregularities in the (MONTH) 30, (YEAR) monthly drug regimen review for Resident #74. The director of nursing informed the surveyor that the PA reviews them for Resident #74's attending physician and that there was no indication the medical director had been informed. The DON identified the PA's signature only on the monthly review. The surveyor informed the administrator, the director of nursing, and the QAPI (quality assurance/performance improvement) nurse of the above identified concern in the end of the day meeting on 3/21/18 at 4:36 p.m. No further information was provided prior to the exit conference on 3/22/18. 3. The facility staff failed to ensure the medical director was informed of irregularities from Resident #117's (MONTH) 31, (YEAR) monthly drug regimen review. The clinical record of Resident #117 was reviewed 3/20/18 through 3/22/18. Resident #117 was admitted to the facility 2/20/15 with [DIAGNOSES REDACTED]. On the quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/15/18, the resident scored 14/15 on the brief interview for mental status and was without signs of [MEDICAL CONDITIONS] or behaviors affecting others. During the clinical record review, Resident #117 had a monthly drug regimen review dated 12/31/17 with the following written: [MEDICAL CONDITION] Drug Use Review Antipsychotic Please note that this resident has taken their current dose of antipsychotic medication Quetiapine 12.5 mg (milligrams) bid (twice a day) since 6/17. Federal guidelines recommend periodic dose reduction for [MEDICAL CONDITION] medications unless several previous attempts have failed or it is clinically contraindicated as documented by the physician in the resident's medical record. Consider a trial dose reduction or please document the need to continue current dose. Signed by consultant pharmacist. Physician Response (select one): Accept above recommendation. Signed by physician assistant (PA). A telephone order dated 1/5/18 read Per pharm (pharmacy) rec (recommendations) attempt dose reduction [MEDICATION NAME]-DC (discontinue) am (morning) dose [MEDICATION NAME] 12.5 mg & cont (continue) evening dose. Document s/sx (signs/symptoms) [MEDICAL CONDITION]. There was no evidence the medical director had been informed of the irregularities identified in the (MONTH) 30, (YEAR) MRR (monthly regimen review). The only signature on the page was that of the PA. The surveyor informed the administrator, the director of nursing, and the QAPI (quality assurance/performance improvement) nurse of the above identified concern in the end of the day meeting on 3/22/18 at 1:45 p.m. No further information was provided prior to the exit conference on 3/22/18. 4. For Resident #41, the facility failed to ensure a monthly drug regimen review with recommendations to decrease [MEDICATION NAME] was reported to the medical director. The record review revealed that Resident #41 had been admitted to the facility 09/17/14. [DIAGNOSES REDACTED]., hypertension, and [MEDICAL CONDITION]. Section C (cognitive patterns) of the Residents annual MDS (minimum data set) assessment with an ARD of 01/04/18 included a BIMS (brief interview for mental status) summary score of four out of a possible 15. The clinical record included a monthly drug regimen review dated 01/30/18. The pharmacist had recommended a trial dose reduction of the antipsychotic medication [MEDICATION NAME]. This drug regimen review had been signed by the attending but had not be signed by the medical director to indicate they had reviewed the recommendation. On 03/22/18 at approximately 10:25 a.m. the unit manager was asked about the medical director reviewing the drug regimen recommendation. The unit manager verbalized to the surveyor that the drug regimen review/recommendation had not been signed or reviewed by the medical director. The unit manager did add that new interventions were to be implemented. The administrative staff were notified of the above during a meeting with the survey team on 03/22/18 at approximately 1:45 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, it was determined that the facility staff failed to ensure that 2 of 35 Residents in the sample survey were free from unnecessary medications, Resident #46 and Resident #156. The facility staff failed to monitor for the use of [MEDICAL CONDITION] drug ([MEDICATION NAME]) use to include specific behaviors, nursing interventions, side effects and effectiveness for both Resident #46 and Resident #156. The Findings Included: 1. For Resident #46 the facility staff failed to monitor for [MEDICATION NAME], a [MEDICAL CONDITION], drug use to include specific behaviors, nursing interventions and effectiveness Resident #46 was a [AGE] year old male who was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 1/9/18. The facility staff coded that Resident #46 had a Cognitive Summary Score of 7. The facility staff also coded that Resident #46 required extensive (3/3) to total nursing assistance (4/3) with Activities of Daily Living (ADL's). In Section N.0410 Medications, the facility staff documented that Resident #46 had received 7 days of a [MEDICAL CONDITION] medication. On (MONTH) 22, (YEAR) at 10:49 a.m., the surveyor reviewed the clinical record. Review of the clinical record produced physician orders. Physician orders [REDACTED].= no side effects; 2=sedation; 3= headache; 5= dizziness; 8= dry mouth. (sic) The order for the [MEDICATION NAME] initiated on 9/22/17. Continued review of the clinical record produced the (MONTH) (YEAR) Medication Administration Records (MAR's). The (MONTH) (YEAR) MAR's documented that the staff were administering the [MEDICATION NAME] every day at 2 p.m. The facility staff were also documenting on the (MONTH) (YEAR) MAR's 0 indicating that Resident #46 did not have any side effects from the use of the [MEDICATION NAME]. Further review of the clinical record failed to document Resident #46's specific behaviors, nursing interventions or effectiveness of the use of the [MEDICAL CONDITION] medication ([MEDICATION NAME]). Additional review of the clinical record produced the Comprehensive Care Plan (CCP). The CCP identified the following Focus and Interventions. Focus (name of Resident withheld) presents with potential for fluctuations in mood state and behavior pattern r/t (related to) hx (history) and Dx (diagnosis) dementia with behavioral disturbances, GAD (general anxiety disorder), and MDD (major [MEDICAL CONDITION]), Mood state and behavioral pattern have been stable over the long term. Interventions Practice active listening and offer a supportive presence during times of interaction and prn (as needed) in effort to develop rapport with (name of resident withheld). Recognize and report possible triggers of possible triggers of behavioral disturbances or fluctuation in mood state, work to meet any unmet needs and/or address triggers if possible. If unable to reduce or eliminate triggers, work with resident towards developing coping mechanisms (appropriate for cognitive function). (sic) CCP initiated on 10/31/16. The surveyor observed two Licensed Practical Nurses (LPN's) sitting at the nurses' station. The surveyor asked the LPN's why Resident #46 was receiving the [MEDICATION NAME]. The LPN's were unable to tell the surveyor why Resident #46 was receiving the [MEDICATION NAME]. The surveyor asked the LPN's what Resident #46's specific behavior was. The LPN's could not tell the surveyor what Resident #46's behavior (s) were. The surveyor reviewed Resident #46's clinical record with the two LPN's. The surveyor reviewed the physician orders [REDACTED]. The two LPN's reviewed the clinical record and were unable to locate a [DIAGNOSES REDACTED].#46 was receiving the [MEDICATION NAME]. One of the LPN's stated she would contact the Director of Nursing (DON) to help the surveyor. Within a few moments, the DON approached the surveyor. The surveyor notified the DON that Resident #46 was receiving [MEDICATION NAME]. The surveyor notified the DON that the surveyor could not locate a [DIAGNOSES REDACTED]. The surveyor also notified the DON that specific behaviors regarding the use of the [MEDICAL CONDITION] medication ([MEDICATION NAME]) could not be located in the clinical record. The surveyor additionally notified the DON that review of the clinical record failed to document effectiveness and nursing interventions that had been provided other than administering the [MEDICAL CONDITION] drug to Resident #46. The DON stated that this surveyor had sited her for the same issue last year and that she, the DON, thought she had fixed the problem. The surveyor and DON reviewed Resident #46's clinical record. The DON was unable to locate any documentation regarding Resident #46's specific behavior/diagnoses, nursing interventions and/or effectiveness in the use of the [MEDICATION NAME]. The DON stated she was going to call the Quality Assurance and Performance Improvement (QAPI) nurse. Within a few minutes, the QAPI nurse approached the surveyor and DON. The surveyor and DON explained to the QAPI nurse that Resident #46 was receiving [MEDICATION NAME]. The surveyor notified the QAPI nurse that specific behaviors, nursing interventions and effectiveness of the use of the [MEDICATION NAME] could not be located in the clinical record. The QAPI nurse and DON reviewed the clinical record. The DON stated that she had seen a document in the clinical record that stated prior to Resident #46's admission into the facility that Resident #46 yelled. The surveyor notified the DON and QAPI Nurse that Resident #46 had been on the [MEDICATION NAME] since 9/23/17 and that no specific behaviors that were being monitored, nursing interventions other than administering the [MEDICATION NAME] had been documented nor had the effectiveness of the [MEDICATION NAME] been documented. On (MONTH) 22, (YEAR) at 2:45 p.m., the surveyor notified the Administrator (Adm), DON and QAPI Nurse that Resident #46 was receiving [MEDICATION NAME], a [MEDICAL CONDITION] drug. The surveyor notified the Administrative Team (AT) that the facility staff were not monitoring Resident #46 for the use of the [MEDICAL CONDITION] drug to include specific behaviors, nursing interventions and effectiveness. No further information was provided to the team prior to exiting the facility as to why the staff failed to ensure that Resident #46 was free from unnecessary medications. The facility staff failed to monitor for the use of a [MEDICAL CONDITION] Drug ([MEDICATION NAME]) to include specific behaviors, nursing interventions and effectiveness. 2. The facility staff failed to identify and monitor target behaviors associated with the use of [MEDICATION NAME] for Resident # 156. Resident # 156 is a [AGE] year-old male that was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 156 was reviewed on 3/22/18 at 9:38 am. The most recent MDS (minimum data set) assessment was an annual assessment with an ARD (assessment reference date) of 3/1/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 156 had a BIMS (brief interview for mental status) score of 3/15, which indicated severe cognitive impairment. The current plan of care for Resident # 156 was reviewed and revised on 3/8/18. The current plan of care has documentation that states, Resident # 156 uses [MEDICAL CONDITION] medications related to behavior management. Interventions included but were not limited to: Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor /record occurrence of target behavior symptoms. The physician signed the most recent physician's orders [REDACTED]. Resident # 156 has current orders for Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) Tablet 25 mg (milligrams) Give 1 tablet by mouth one time a day related to unspecified dementia with behavioral disturbance. This dose was ordered to be given at 9:00 am. Resident # 156 has another order for Quetiapine [MEDICATION NAME] Tablet 50 mg, Give 1 tablet by mouth one time a day related to unspecified dementia with behavioral disturbance. This dose was ordered to be given at 5:00pm. The surveyor reviewed the clinical record and could not locate and person centered target behaviors or monitoring of behaviors associated with the use of [MEDICATION NAME] for Resident # 156. On 3/22/18 at 9:50 am, the surveyor spoke with LPN (licensed practical nurse) #1 and asked about the targeted behaviors and how the nurses were monitoring the behaviors associated with the use of [MEDICATION NAME] for Resident # 156. LPN # 1 showed the surveyor a place on the MAR (medication administration record) where the staff was monitoring the side effects of the medication. The surveyor then asked LPN #1 what resident specific target behaviors did Resident # 156 exhibit. LPN # 1 stated that Resident # 156 resisted care at times. The surveyor explained to LPN # 1 that resisting care is not a reason to administer [MEDICATION NAME]. The nurse was unable to provide any documentation on the target behaviors for Resident #156 or any information on how the nurses were monitoring the effectiveness of the [MEDICATION NAME]. On 3/22/18 at 1:15 pm, the surveyor spoke with the director of nursing about the identification of target behaviors and lack of monitoring for effectiveness associated with the use of [MEDICATION NAME] for Resident #156. The director of nursing stated that she was aware of the problem in this area and stated the facility would be working to make improvements. On 3/22/18 at 2:26 pm, the administrative team was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 3/22/18.

Based on staff interview and clinical record review the facility staff failed to provide the Residents and their representative with a summary of the baseline care plan for two of 35 residents in the survey sample (Resident #363 and #44). The findings included: 1. The facility staff failed to provide the residents and their representatives with a summary of the baseline care plan for Resident #363. Resident #363 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The admission MDS was not completed at this time due to the resident being admitted on [DATE]. The surveyor performed a clinical record review of Resident #363's chart on 3/21 and 3/22/18. During this review, the surveyor noted there was no documentation in the clinical record stating that a summary of the baseline care plan had been provided to the resident or representative. On 3/22/18 at 9:53 am, the surveyor asked the director of nursing (DON) how the facility documents the implementation of the baseline care plan within 48 hours of the resident's admission to the facility and was the resident and representative given a summary of this care plan. The DON stated that she would get back to me regarding this request. At 10:20 am, Registered Nurse (RN) #1 provided the surveyor with a copy of the resident's care plan. RN #1 stated, I did the care plan within 48 hours of admission but did not review it with the resident or provide a copy to the resident or representative. At 1:45 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/22/18. 2. For Resident #44, facility staff failed to provide a written baseline care plan on admission. Resident # 44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the admission minimum data set assessment (MDS) with assessment reference date 1/5/18, the resident scored 14/15 on the brief interview for mental status and was assessed as without signs of [MEDICAL CONDITIONS], or behaviors affecting others. On 03/22/18 at 11:05 AM, Resident # 44 reported he had not been given a written plan of care upon admission to the facility. The surveyor interviewed the MDS nurse, who stated she had not been there when the resident was admitted . She reported checking with the other MDS staff who said they had not offered the resident a copy of the baseline care plan. The administrator and director of nursing were notified of the concern during a summary meeting on 3/22/18.

Based on staff interview and clinical record review, the facility staff failed to review and revise the person centered comprehensive care plan for one of 35 residents in the survey sample (Resident #63). The findings included. The facility staff failed to review and revise the person centered comprehensive care plan for Resident #63. Resident #63 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/17/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #63 was also coded as requiring limited assistance of 1 staff member for dressing and only supervision with personal care. The surveyor conducted a clinical record review of Resident #63 on 3/22/18. In the nursing documentation dated 3/7/18 read in part, .he was fitted for a Tactile Medical Flexitouch Compression pump . while the resident was at a doctor's appointment on this date. On 3/16/18 in the nursing documentation, it read in part, (MONTH) start Tactile medical flexitouch compression pump on 3/19/18 . The surveyor also reviewed the care plan of Resident #62 on 3/22/18. The surveyor noted that the person centered comprehensive care plan for this resident was not updated to include the use of the Tactile Flexitouch compression machine. On 3/22/18 at 1:45 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/22/18.

Based on observation, staff interview, and clinical record the facility staff failed to ensure a hazard free environment for two of 35 Residents in the survey sample (Resident's #45 and #107). The findings included: 1. The bed alarm for Resident #45 was observed by the surveyor to be in the off position and not in the proper operating mode. Resident #45 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The entry MDS (Minimum Data Set) dated for 3/5/18 was the only MDS available at the time of the clinical record review performed by the surveyor. On 3/21/18 10:10 am, the surveyor went into Resident #45's room and observed the bed alarm was in the off position and not in the proper operating mode. Licensed Practical Nurse (LPN) #1 went back into the resident's room with the surveyor. LPN #1 stated to the surveyor the alarm is not on. She then proceeded to turn the alarm on. The surveyor performed a clinical record review on 3/21/18 at 1030 am. The person centered comprehensive care plan had the following documentation noted by the surveyor: Under Section titled Focus it read in part, .high risk for falls/injury r/t (related to) Gait/balance problems, [MEDICAL CONDITION] .Unawareness of safety needs. Under Interventions, it read in part, The resident uses a sensor pad to his bed . The surveyor notified the administrative team of the above documented findings on 3/21/18 at 4:37 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 3/22/18. 2. Facility staff failed to follow physician orders [REDACTED].# 107. The resident's clinical record was reviewed on 3/21/18 at 11:00 AM. Resident #107 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The latest MDS (minimum data set) assessment dated [DATE], coded the resident as unimpaired cognitively. He needed staff help with hygiene, but could eat unassisted with a tray set-up. The latest CCP (comprehensive care plan) reviewed an revised on 11/17/17 documented the resident at risk for falls/injury due to deconditioning. The staff interventions included: The resident uses a sensor pad to his bed The resident uses a sensor pad to his chair . Resident #107's physician's orders [REDACTED]. 03/21/18 at 09:06 AM the surveyor was interviewing the resident. A personal alarm was observed on both the bed & chair. The resident got up off bed, transferred himself to the chair without difficulty and alarm never went off. The resident stated That's why I'm here--I fell and busted my shoulder & hip. My shoulder is still hurting. That alarm on bed never works. The surveyor observed the wire was not plugged into the alarm hanging from the bed. LPN I was asked to come to the room and determine why the alarm was not plugged up. She plugged it in and left the room. On 3/21/18 at 4:55 PM, the DON told the survey team that the MDS nurse had observed the resident cut off his chair alarm. She also said she had talked to a CNA that said , H cuts it off all the time--but I never told anyone about it. The DON said she was having inservices to ensure the staff communicated issues with the chair and bed alarms and particularly when they were found to be cutting them off. The DON said they would revisit his care plan and find another way to monitor his movements. No additional information was available prior to exit.

Based on staff interview and clinical record review, the facility staff failed to offer non-pharmacological interventions for pain management for 2 of 35 residents in the survey sample (Resident's #63 and #76). The findings included: 1. The facility staff failed to offer non-pharmacological interventions for pain management for Resident #63. Resident #63 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/17/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #63 was also coded as requiring limited assistance of 1 staff member for dressing and only supervision with personal care. The surveyor conducted a clinical record and Medication Administration Record (MAR) review of Resident #63 on 3/22/18. The surveyor noted that the resident had physician orders [REDACTED]. [MEDICATION NAME] (Tylenol) Tablet 325 MG (milligram) Give 2 tablet by mouth every 6 hours as needed for pain [MEDICATION NAME] HCl Tablet 50 MG Tablet Give 1 tablet by mouth every 6 hours as needed for pain. According to the MAR for the month of (MONTH) (YEAR), the resident received Tylenol for pain on 3/19/19 at 5:05 am. It was also documented that the resident received [MEDICATION NAME] for pain on 3/3/18 at 7:54 am, 3/10/18 at 9:41 pm, 3/19/18 at 8:51 am, 3/20/18 at 8:50 am and 3/21/18 at 9:15 pm. The surveyor reviewed the nurses' notes. It was noted that there were no non-pharmacological interventions documented as being offered prior to the administration of the above documented pain medications to the resident. On 3/22/18 at 11:10 am, the surveyor notified Registered Nurse (RN) #1 of the above documented findings. RN #1 reviewed the clinical record of Resident #63 and stated, I don't either. At 1:45 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/22/18. 2. The facility staff failed to offer non-pharmacological interventions for pain management for Resident #76. Resident #76 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/24/18, the resident was coded as requiring supervision of 1 staff member for dressing, personal hygiene and bathing. Resident #76 was also coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. The surveyor conducted a review of the resident's clinical record and MAR (Medication Administration Record) on 3/21/18 through 3/22/18. For the month of (MONTH) (YEAR), the resident received [MEDICATION NAME]-[MEDICATION NAME] 325 mg (milligram) 1 tablet by mouth every 6 hours as needed for pain on the following dates and times as documented on the MAR: 3/1 at 8:30 pm, 3/2 at 12:50 pm and 8:21 pm, 3/3 at 4:48 pm, 3/5 at 8:30 pm, 3/6 at 8:32 pm, 3/7 at 8:41 pm, 3/9 at 8:01 pm, 3/10 at 11:02 am, 3/12 at 9:03 pm, 3/13 at 8:06 am, 3/14 at 9:07 pm, 3/17 at 4:25 pm, 3/18 at 11:11 am, 3/19 at 8:35 pm, and 3/20 at 8:36 pm. The surveyor reviewed the nurses' notes. It was noted that there were no non-pharmacological interventions documented as being offered prior to the administration of the above documented pain medication, [MEDICATION NAME]-[MEDICATION NAME], to the resident. On 3/22/18 at 11:10 am, the surveyor notified Registered Nurse (RN) #1 of the above documented findings. RN #1 reviewed the clinical record of Resident #63 and stated, I don't either. At 1:45 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/22/18.

Based on observation and staff interview it was determined that the facility staff failed to discard expired medications on 1 of 3 Units, Unit 2 West. The facility staff failed to discard expired medications. The Unit 2 West refrigerator contained a multi-dose vial of [MEDICATION NAME] Purified Protein Derivative that expired on 3/6/18. The medication was available for use. The Findings Included: On (MONTH) 21, (YEAR) at 10:31 a.m., the surveyor observed the 2 West med room/carts. LPN (#1) accompanied the surveyor into the medication room. The surveyor observed a small medication refrigerator in the medication room. The surveyor opened the refrigerator and observed a multi-dose vial of [MEDICATION NAME] Purified Protein Derivative. The multi-dose vial had a sticker attached. The sticker read: DO NOT USE AFTER 3/6/18. The surveyor pulled the multi-dose vial out of the refrigerator and notified LPN (#1) that the medication was expired and was available for use. On (MONTH) 21, (YEAR) at 4:43 p.m. the survey team met with the Administrator (Adm), Director of Nursing (DON) and Quality Assurance and Performance Improvement (QAPI) Nurse. The surveyor notified the Administrative Team (AT) of multi-dose vial of [MEDICATION NAME] Purified Protein Derivative that was expired and still available for use on the 2 West Unit. The surveyor notified the AT that the expiration on the multi-dose vial was 3/6/18. The DON stated that she was surprised when the facility staff notified her that the surveyor had found the expired medication in the 2 West refrigerator. No additional information was provided prior to leaving the facility as to why the facility staff failed to discard expired medications. The [MEDICATION NAME] Purified Protein Derivative was still available for use in the 2 West refrigerator.