Every finding on record at Franklin Health and Rehabilitation Center

Based on staff interviews, clinical record review, and facility document review, the facility staff failed to ensure the resident environment remained free of accident hazards as is possible for (1) one of (3) three current sampled residents, Resident #1, resulting in harm. While operating a motorized wheelchair in the facility parking lot on 4/03/26, Resident #1 struck a curb which caused the motorized wheelchair to tilt resulting in Resident #1 falling from the motorized wheelchair. Resident #1 sustained bilateral subdural hematomas, first/second cervical vertebral fractures, a scalp laceration, multiple abrasions, and a hematoma of the scalp resulting in transfer to a higher level of care and surgical intervention. The findings included: Resident #1's diagnosis list indicated diagnoses that included, but were not limited to, Parkinson's disease, unspecified hearing loss - bilateral, spinal stenosis, osteoarthritis, spondylosis, anxiety disorder, weakness, depression, nondisplaced fracture of first cervical vertebra, nondisplaced fracture of second cervical vertebra, traumatic subdural hemorrhage, and adult failure to thrive.The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 4/27/26, 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.A review of Resident #1's clinical record disclosed the following documentation:A medical provider follow-up note dated 04/03/2026 indicated Resident #1 was seen for altered mental status with increased confusion. A urinalysis was ordered on 4/02/2026 and results were pending. Resident #1 had agreed to postpone discharge for now due to the altered mental status. A fall progress note dated 04/03/2026 at 3:36 PM revealed Resident #1 was observed outside of the facility in his power wheelchair and flipped the power wheelchair on the sidewalk hitting his head causing a laceration. The resident was sent to the emergency room for evaluation, and the power-wheelchair would be sent home with the resident's family and no longer allowed back at the facility. A review of Resident #1's clinical record failed to reveal evidence of a safety skills assessment for use of a motorized power chair or education regarding safe use while residing at the facility. On 05/11/2026 at 3:28 PM, the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) were interviewed and the DON stated Resident #1 was admitted to the facility with the motorized wheelchair. When asked if the resident was evaluated for wheelchair safety upon/after admission, the RDCS stated, No, that was part of our plan of correction.On 5/11/26 at 4:38 PM, the Director of Rehab (DoR) was interviewed and stated Resident #1 admitted to the facility with a power wheelchair. The DoR stated she had worked in the facility since 2021, and this was the only power wheelchair that's been in the facility since that time. The DoR stated PT did evaluate Resident #1 upon admission to the facility and the resident was able to use the power chair at their baseline. Resident #1 used the power wheelchair daily throughout the facility and had no prior incidents/accidents with the chair and therapy worked with the resident on obstacle courses with the chair up until the day of the incident. She stated Resident #1's discharge was put on hold related to altered mental status.On 5/11/26 at 4:46 PM, the DON was interviewed again, and stated Resident #1 was on antibiotics for a urinary tract infection at the time of the incident. The DON stated the resident had been assessed to be safe to go outside in the motorized wheelchair prior to the incident and believed the resident to be cognitively appropriate to be independent in the motorized wheelchair.On 05/11/2026 at 3:50 PM the RDCS provided a facility synopsis of events file and corrective action plan for the incident that occurred on 4/3/26 with Resident #1 and stated there were no other residents in the facility with motorized wheelchairs.A review of a hospital Discharge summary dated [DATE] read in part, .status post fall from motorized scooter at.living facility.was found to have b/l SDH (bilateral subdural hematomas), C1/C2 fx (first/second cervical vertebra fractures) and taken to OR (operating room) with NSGY (neurosurgery) on 4/6 (4/6/26) for C1-5 PCDF (posterior cervical decompression and fusion involving the cervical vertebrae from C1 to C5).noted to have a scalp laceration requiring staples.This concern was discussed on 5/11/26 at 5:02 PM at the end of day meeting with the Interim Administrator, Director of Nursing, and Regional Director of Clinical Services.The Plan of Correction (POC) had a completion date of 4/10/26 and read as follows:1. What was done immediately for problem identified:Resident was assessed for injuries, EMS (emergency medical services) activated, MD (medical doctor) notified, MD order to send resident to the Emergency Department. Resident family notified of incident and imminent transport to hospital. Investigation of incident initiated, including lookback into resident EHR (electronic health record), staff interviews, etc.2. How were other residents that had potential to be affected by the problem identified:All current residents were reviewed to determine if power wheelchairs were in use.3. Education - what was done to prevent reoccurrence:admission process was initiated that all resident referrals requesting admission with their power wheelchair or scooter will be evaluated by Therapy using the Safety Skills Assessment Supplement.4. How is this going to be monitored ongoing:All admissions will be reviewed by admissions/nursing to ensure that there are orders or requests for power wheelchair/scooter.5. QA (quality assurance) Statement:The Admissions Director will alert the DON and DOR (Director of Rehab) of any admissions requesting the use of power wheelchairs/scooters. The PT (Physical Therapy) Assessment ProcessPT will conduct a pre-admission or early-admission evaluation that includes:-Review of medical records and wheelchair specifications-Cognitive/safety screening-Physical examination of motor function and control-Environmental assessment of the unit-Determination of: Approve use as-is / Approve with modifications / Restrict use pending further evaluation / Recommend manual wheelchair instead-PT will communicate findings to the admissions team and DON/Charge Nurse with an agreed-upon timeframe (48-72 hours of admission if pre-admission evaluation is not feasible).Responsible Parties: admission Director, DON, DOR 6. Completion Date4/10/2026 and ongoing.A review of the credible evidence for the POC on 4/10/26 disclosed education had been completed addressing the utilization of power wheelchairs in the facility including notification, assessment/evaluation, potential for injuries, and the PT Assessment Process.On 5/11/26 at 12:18 PM, an initial walk-through/observation of the facility was conducted. No motorized wheelchairs were observed to be in any resident rooms or within the areas of the facility that were observed.On 5/11/26 at 2:39 PM, Resident #1 was observed in room sitting in a standard wheelchair. A motorized wheelchair was not visible in the resident's room.On 5/11/26 at 4:33 PM, the Admissions Director (AD) was interviewed and asked about the process for potential admissions with requests for motorized wheelchairs. The AD stated the family and/or resident are informed the resident will be put into a regular wheelchair until PT can evaluate for a power wheelchair. PT does an evaluation/assessment and the resident can use a power chair if PT determines the resident is safe. The AD stated she has spoken with the hospital liaisons about the facility's protocol for potential admissions that may have power wheelchairs.On 5/11/26 at 4:38 PM, the Director of Rehab (DoR) was interviewed and stated the process now is to utilize the power wheelchair assessment and if a new admission would want a power wheelchair therapy has to do an evaluation. A BIMS (brief interview for mental status) has to be completed and determinations have to be made to see if the resident is safe or not safe in a power wheelchair. The DoR stated that facility staff are also to be aware of any change in condition that could arise and new assessments and/or re-evaluations would have to be completed. The DoR stated if a resident and/or family would request a power wheelchair after they are admitted , they have a contracted service that would bring a power wheelchair for demonstration and therapy would evaluate the resident in the demo chair for measurement, fit, safety, and would complete an evaluation at that time. On 5/11/26 at 4:46 PM, the DON was interviewed and a process has been put into place and prior to admission a potential resident is assessed for appropriateness for a power wheelchair and therapy completes an evaluation to determine if the resident would be safe. The DON stated nursing staff complete assessments as well for cognitive function and other factors for determination for power wheelchair use. The DON stated the same steps would be utilized for a resident that is already at the facility and concluded the facility staff attempt to deter power wheelchairs from coming into the facility, they want residents to be mobile but also want to consider all the residents safety.The other staff member who was included in the staff education, was out of the facility on leave at the time of the survey and was unavailable for interview.No further information was provided prior to exit on 5/12/26.This deficiency was cited as past non-compliance.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure that the resident environment remained as free of accident hazards as is possible as evidenced by the presence of unsecured oxygen cylinders located in 2 of 30 resident rooms in the survey sample, Resident #267 and #271. The findings included: 1. For Resident #267, the facility staff failed to secure an oxygen cylinder located beside the resident's bed. Resident #267's diagnosis list indicated diagnoses, which included, but not limited to Osteomyelitis, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3, and Schizophrenia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/07/23 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. On 9/18/23 at 8:02 PM, surveyor entered Resident #267's room and observed an unsecured oxygen cylinder located at the head of the bed on the left. Resident #267 was sitting in a wheelchair directly in front of the oxygen cylinder. Surveyor immediately notified licensed practical nurse (LPN) #6 who obtained a holder and secured the oxygen cylinder. Resident #267 did not have oxygen in use at the time of the observation. A review of Resident #267's clinical record revealed they did not have a current provider order for the use of oxygen. On 9/19/23 at 4:31 PM, the survey team met with the administrator, director of nursing, and regional nurse and discussed the concern of an unsecured oxygen cylinder located in Resident #267's room. On 9/22/23 at 9:43 AM, surveyor spoke with LPN #5 and asked if oxygen cylinders should be placed directly on the floor and LPN #5 stated no and they must be in a rack. Surveyor requested and received the facility policy titled, Respiratory/Oxygen Equipment which read in part, .Maintain proper storage, internal transportation and use of oxygen cylinders. Oxygen cylinders must be kept secure. a. Do not allow oxygen cylinder to be overturned or sustain a blow that may break off the top. b. Tanks must be in a cart or stand made for the type of tank being used or stored in a rack . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/23. 2. For Resident #271, the facility staff failed to secure an oxygen cylinder located beside the resident's bed. Resident #271's diagnosis list indicated diagnoses, which included, but not limited to dementia and ataxia. The Admission/Readmission Nursing Collection Tool V2-V10 dated 9/13/23 documented Resident #271 as being cognitively impaired and confused. On 9/18/23 at 8:49 PM, surveyor observed Resident #271 in bed with an unsecured oxygen cylinder located at the head of the bed on the left; surveyor immediately exited the room and notified registered nurse (RN) #3. RN #3 returned and stated they placed the oxygen cylinder in a holder; when asked if the oxygen cylinder should have been secured in the resident's room, the RN stated yes. Resident #271 did not have oxygen in use at the time of the observation. A review of Resident #271's clinical record revealed they did not have a current provider order for the use of oxygen. On 9/19/23 at 4:31 PM, the survey team met with the administrator, director of nursing, and regional nurse and discussed the concern of an unsecured oxygen cylinder located in Resident #271's room. On 9/22/23 at 9:43 AM, surveyor spoke with licensed practical nurse (LPN) #5 and asked if oxygen cylinders should be placed directly on the floor and LPN #5 stated no and they must be in a rack. Surveyor requested and received the facility policy titled, Respiratory/Oxygen Equipment which read in part, .Maintain proper storage, internal transportation and use of oxygen cylinders. Oxygen cylinders must be kept secure. a. Do not allow oxygen cylinder to be overturned or sustain a blow that may break off the top. b. Tanks must be in a cart or stand made for the type of tank being used or stored in a rack . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/23.

Based on observation and staff interview, facility staff failed to ensure the privacy and confidentiality of medical information in oral communication for 1 of 30 current residents in the survey sample, Resident #51. Resident #51 was admitted to the facility with diagnoses that included peripheral vascular disease and renal failure. On the Minimum Data Set assessment with Assessment Reference Date 7/12/23, the resident scored 10/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care. The resident was unaware that staff were shouting details about the resident's clinical condition in the hall. On 9/19/23 at 9:20 AM, CNA#5 yelled down the hall to LPN #1 you got any Foleys on that hall? LPN #1 replied there's no one named Foley on this hall. CNA #5 then yelled Foley catheters. LPN #1 replied [Resident #1 name] has a Foley. CNA #5 then yelled down the other hall [nurse name] you got any Foley on that hall? The nurse replied that she didn't know and would have to let her know later. F-583 guidance states that personal resident information must be communicated in a way that protects the confidentiality of the information and the dignity of residents. This includes both verbal and written communications such as the presence of lists of residents with certain conditions such as incontinence and pressure ulcers at nursing stations in view or in hearing of residents and visitors. This does not include clinical information written in a resident's record. The surveyor notified the Director of Nursing and Administrator of the concern during a brief end of day meeting on 9/19/2023. No further discussion of the incident occurred.

Based on staff interview and clinical record review, the facility staff failed to accurately code a minimum data set (MDS) assessment for 1 of 3 closed records reviewed, Resident #112. The findings were: The facility staff failed to code Resident #112's discharge status to an assisted living facility (ALF). The discharge MDS coded the resident as discharged to an acute hospital when Resident #112 was discharged to an ALF. Resident #112's admission record listed diagnoses to include but were not limited to, cerebral infarction, hemiplegia and hemiparesis affecting left non-dominant side, cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, and anxiety. Section A (Identification Information) of the most recent MDS, with an assessment reference date of 08/30/23, coded the resident's discharge status as being discharged to an acute hospital. During a review of Resident #112's clinical record, a licensed practical nurse (LPN) progress note written on 08/30/23 at 1:52 p.m. read the resident was discharged the same day via wheelchair in stable condition accompanied by the responsible party (RP) at 1:50 p.m. The discharge paperwork and discharge instructions were provided to the RP who verbalized understanding. Medications were sent with the RP for the resident to have the dose at the new facility was witnessed by the registered nurse (RN) supervisor and the director of nursing (DON). The clinical record also contained a discharge summary document with an effective date of 08/30/23 at 9:32 a.m. which listed the resident was 3. discharged to b. ALF. On 09/22/23 at 9:44 a.m., the regional director of clinical services (regional nurse) was informed of the MDS discharge status code concern. The regional nurse observed the clinical record documentation referenced above and acknowledged the progress note and discharge summary did not indicate Resident #112 was discharged to an acute hospital. On 09/22/23 at 10:16 a.m., the regional nurse reported Resident #112's MDS discharge status was modified to reflect the accurate discharge status. At an end of day meeting with the administrator and the regional nurse on 09/22/23 at 2:34 p.m., the concern about Resident #112's inaccurate MDS discharge status code was discussed. No further information was provided prior to the exit conference.

2. For Resident #96, the facility staff failed to ensure fall prevention and safety measures were in place per the resident's comprehensive person-centered care plan. Resident #96's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Non-traumatic Subarachnoid Hemorrhage, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Cirrhosis of the Liver. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/05/23 coded the resident as moderately impaired in cognitive skills for daily decision making with short-term memory problems. Resident #96 was coded as requiring extensive assistance with bed mobility, dressing, eating, toileting, personal hygiene and being totally dependent on staff for transfers. Resident #96's most recent Fall Risk Scoring Tool dated 9/11/23 scored the resident as being at high risk for falls. Resident #96's current comprehensive person-centered care plan documented the resident as being at risk for falls related to weakness, impaired range of motion, recent hospitalization , visual impairment, communication impairments, cognitive impairment, and incontinence. Care Plan interventions included in part a bed alarm, falls mats at bilateral bedside, and remind resident to use call light to ask for assistance with ADLs (activities of daily living). On 9/21/23 at 8:18 AM, surveyor observed Resident #96 in bed with no bed alarm or bilateral fall mats in place. The resident's call light button was tucked between the mattress and bedframe on the right side near the head of the bed out of the resident's reach. At 8:24 AM, surveyor requested the assistance of certified nursing assistant (CNA) #6 to check for the presence of a personal alarm, CNA #6 checked Resident #96's bed and stated there was no bed alarm. Surveyor asked CNA #6 if Resident #96 should have a bed alarm in place and they stated the resident used to be in room (number omitted) and they had one over there. Surveyor returned to the resident's room on 9/21/23 at 10:58 AM and Resident #96 was observed in bed with a bed alarm and bilateral fall mats in place. However, the resident's call light button remained tucked between the mattress and bedframe on the right side near the head of the bed out of the resident's reach. On 9/21/23 at 4:22 PM, the survey team met with the administrator and regional nurse and discussed the concern of Resident #96 observed in bed without a bed alarm or bilateral fall mats, and the call light being out of reach. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/23. 3. For Resident #264, the facility staff failed to provide treatment to a diabetic ulcer to the left great toe. Resident #264's diagnosis list indicated diagnoses, which included, but not limited to Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Heart Failure, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/14/23 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. Resident #264 was coded for the presence of a diabetic foot ulcer. Resident #264's current comprehensive person-centered care plan included the focus area of a diabetic ulcer to the left great toe with interventions including treatment per treatment administration record. Resident #264 was seen by the wound specialist nurse practitioner (NP) on 9/12/23, the progress note described the area to the left great toe as a diabetic ulcer measuring 0.3 cm x 0.3 cm x 0 cm with the wound base 100% epithelial. Treatment recommendations were to cleanse the area with wound cleanser, apply skin prep to base of the wound and leave open to air daily. On 9/20/23, surveyor reviewed Resident #264's current physician's orders and was unable to locate an order for treatment to the left great toe. According to the resident's September 2023 treatment administration record (TAR), Resident #264 last received treatment to the left great toe on 9/13/23. The previous treatment order was ordered on 9/06/23 to be provided from 9/07/23 through 9/13/23. On 9/21/23 at 2:55 PM, surveyor spoke with the treatment nurse, registered nurse (RN) #4, who stated they had been doing the skin prep treatment to Resident #264's left great toe daily Monday through Friday. Surveyor informed RN #4 there was no order, and the treatment was not on the TAR. Surveyor was unable to locate evidence of treatment being provided to the resident's left great toe on Saturday 9/16/23 or Sunday 9/17/23. On 9/21/23 at 4:22 PM, the survey team met with the administrator and regional nurse and discussed the concern of Resident #264's treatment to the left great toe. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/23. 4. For Resident #55, the facility staff failed to administer the oral antibiotic, Macrobid despite being available in the facility onsite medication supply on two occasions. Resident #55's diagnosis list indicated diagnoses, which included, but not limited to Urinary Tract Infection, Chronic Obstructive Pulmonary Disease, Spina Bifida, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 8/21/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #55's current comprehensive person-centered care plan included a focus area revised 9/12/23 stating the resident had developed a urinary tract infection (UTI) with an intervention for medications as ordered. Resident #55's current physician's orders included an order dated 9/11/23 for Macrobid 100 mg by mouth every morning and at bedtime for UTI. A review of Resident #55's September 2023 medication administration record revealed the Macrobid was not administered on 9/11/23 at 9:00 PM or 9/12/23 at 9:00 AM. A nursing progress note dated 9/11/23 at 10:43 PM documented the Macrobid was not available in the Omnicell and had not been delivered by the pharmacy. On 9/22/23 at 9:09 AM, surveyor spoke with licensed practical nurse (LPN) #7, writer of the 9/11/23 note who stated they did not have the Macrobid from the pharmacy and the medication was not one that was stocked in the Omnicell. A 9/12/23 9:29 AM nursing progress note documented the Macrobid was held per MD, however, surveyor was unable to locate any documentation addressing the reason for the Macrobid being held. On 9/22/23, surveyor requested to speak with the writer of the 9/12/23 progress note, however, they were unavailable for interview. Surveyor requested and received the facility Omnicell (onsite medication supply system) Inventory listing and noted Nitrofurantoin Mono 100 mg capsules were present with a par level of five (5) capsules. Nitrofurantoin is the generic form of Macrobid. On 9/20/23 at 5:46 PM, the survey team met with the administrator and regional nurses and discussed the concern of Resident #55 missing two administrations of Macrobid. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/23. 47299 Based on observation, staff interview, medical record review and facility document review, the facility staff failed to ensure and provide needed care and services that were resident centered in accordance with the resident's preferences, goals for care, and professional standards of practice for 5 of 30 residents in the survey sample (residents # 78, # 87, # 96, # 264 and # 55). The findings included: 1. For residents # 78 and # 87, the facility staff failed to ensure that medications were prepared and administered separately during a medication pass observation. On 9/19/23 at 9:00 AM this surveyor approached Registered Nurse (RN) #1 and informed them I would be observing them pour and pass medications to residents. RN # 1 stated, alright, I already have these two ready to go. RN # 1 picked up two medication cups to show this surveyor. Surveyor noted a medication cup with multiple loose pills of varying sizes, several were white in color and one was a red/brown color. The other cup had various crushed medications and was mixed with pudding. This surveyor asked RN # 1 if facility policy allowed them to pass medications to more than one resident at a time and they stated, I'm doing cluster care due to covid, both of these residents are in room # (omitted) and in isolation and this cuts back on exposure time if I do them together. RN # 1 then proceeded into the room with both medication cups and returned with no medication cups. On 9/19/23 at 9:56 AM this surveyor interviewed the Director of Nursing (DON) and asked if the facility had a different policy for medication administration for COVID and non-COVID rooms/patients. She stated, no there is just one policy. Surveyor asked if they knew of an instance it would be acceptable for a nurse to pour medications for two residents in the same room at the same time, carry them into the room at the same time, to administer them at the same time. They stated, no, absolutely not, that's not acceptable. Surveyor informed the DON of witnessing the above scenario. This surveyor requested and received the policy entitled, General Guidelines for Medication Administration with an effective date of 9-2018. The policy read in part, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer and, 4. When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.), medications are administered at the same time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. On 9/19/21 at approximately 4:30 PM the survey team met with the Administrator, Director of Nursing, and Regional Nurse Consultant and this concern was discussed at that time. On 9/20/23 at 5:50 PM the survey team met with the Administrator and Regional Nurse Consultant (Administration # 2). The Regional Nurse Consultant stated that RN # 1 had been educated and that they had stated where they came from (another state) this was a common and acceptable practice during the COVID-19 pandemic. On 9/21/23 at 11:00 AM another member of the survey team observed RN # 1 at the medication cart with 2 medication cups, each with multiple loose pills in them. The surveyor stated that each cup appeared very similar with both having white and red pills. the surveyor stood near RN # 1 and when they noticed the surveyor observing, they took one of the med cups and placed it back in the med cart. RN # 1 was wearing an isolation gown at the time. Surveyor asked RN # 1 why they had the 2 cups of loose pills on the cart, and they stated they were going to give one resident theirs first, then come back to administer the others to another resident. RN # 1 then took a cup with pills into a COVID isolation room. This surveyor met with Regional Nurse Consultant (Administration # 5) on 9/21/23 at 11:45 AM and informed them of the second observation. On 9/22/23 at 2:35 PM the survey team met with the Administrator, and both Regional Nurse Consultants and this concern was again discussed. They reported that RN # 1 had received a disciplinary action. No further information was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to ensure that a resident who needs respiratory care is provided such care consistent with the comprehensive person-centered care plan for 1 of 30 residents in the survey sample, Resident #40. The findings included: For Resident #40, the facility staff failed to turn on the oxygen cylinder to deliver oxygen support. Resident #40's diagnosis list indicated diagnoses, which included, but not limited to Multiple Sclerosis, Parkinson's Disease, Paroxysmal Atrial Fibrillation, and Bipolar Disorder. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 7/05/23 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 indicating the resident was cognitively intact. Resident #40's current comprehensive person-centered care plan included a focus area stating the resident was at risk for respiratory complications secondary to wheezing, cough, shortness of breath, and allergies with interventions including in part, to administer oxygen as ordered. On 9/19/23 at 10:19 AM, surveyor observed Resident #40 in bed with a nasal cannula in place attached to an oxygen cylinder. Resident #40 stated they were hard to wake up this morning and staff started oxygen. Surveyor observed the oxygen cylinder turned to the off position. Surveyor asked the resident if they were receiving any oxygen and the resident removed the nasal cannula, placed it to their mouth and stated, I'm not getting any. At 10:20 AM, surveyor alerted licensed practical nurse (LPN) #1 who came into Resident #40's room, checked the oxygen setting and stated, You're not wrong and turned on the oxygen cylinder. LPN #1 then checked Resident #40's oxygen saturation which was 97%. On 9/22/23 at 9:47 AM, surveyor spoke with LPN #1 who stated on the morning of 9/19/23, staff had to do a sternal rub to wake Resident #40 and their oxygen saturation was 86% at the time. LPN #1 stated a CNA (certified nursing assistant) grabbed an oxygen tank and oxygen was started at 2 liters per minute; LPN #1 stated they assumed the tank was turned on. LPN #1 stated the resident was not short of breath or in distress. A review of Resident #40's clinical record revealed a current physician's order dated 3/29/23 for oxygen therapy at 4 liters per minute via nasal cannula. On 9/19/23 at 4:31 PM, the survey team met with the administrator, director of nursing, and regional nurse and discussed the concern of staff failing to administer oxygen to Resident #40. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/23.

Based on observation, interviews, and clinical record review, the facility staff failed to ensure medications were secure and stored in locked compartments for 1 of 30 residents in the survey sample, Resident #264. The findings included: For Resident #264, the facility staff failed to ensure a bottle of Tylenol Arthritis 650 mg was secure and stored in a locked compartment. The bottle of Tylenol Arthritis was located on the resident's bedside table. Resident #264's diagnosis list indicated diagnoses, which included, but not limited to Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Heart Failure, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/14/23 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. On 9/18/23 at approximately 8:15 PM, surveyor observed a bottle of Tylenol Arthritis 650 mg located on top of Resident #264's bedside table. Surveyor spoke with licensed practical nurse (LPN) #6 and informed them of the observation. At approximately 8:20 PM, LPN #6 entered Resident #264's room and removed the bottle of Tylenol, the resident stated they have had the Tylenol since admission to the facility. According to Resident #264's clinical record, they were admitted to the facility on [DATE]. Resident #264's physician's orders included an active order for Tylenol 8 Hour Oral Extended release 650 mg by mouth every 6 hours as needed for pain. A review of the resident's September 2023 medication administration record (MAR) revealed the resident had not received the Tylenol since admission to the facility. Surveyor was unable to locate an order for the Tylenol to be kept at the bedside and self-administered. On 9/19/23 at 4:31 PM, the survey team met with the administrator, director of nursing, and the regional nurse and discussed the concern of Resident #264 having a bottle of Tylenol on their nightstand. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/23.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide laboratory services to meet the needs of the resident for 1 of 30 residents in the survey sample, Resident #267. The findings included: For Resident #267, the facility staff failed to obtain lab tests as ordered by the physician on 9/06/23. Resident #267's diagnosis list indicated diagnoses, which included, but not limited to Osteomyelitis, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease Stage 3, and Schizophrenia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/07/23 assigned the resident a brief interview for mental status (BIMS) summary score of 13 out of 15 indicating the resident was cognitively intact. A review of Resident #267's clinical record revealed a physician's order dated 9/01/23 for a CBC (complete blood count), CMP (comprehensive metabolic panel), ESR (erythrocyte sedimentation rate), and CRP (c-reactive protein) on 9/06/23 and then weekly. Surveyor was unable to locate evidence of the lab tests being obtained on 9/06/23. On 9/19/23 at 3:55 PM, surveyor met with the director of nursing and regional nurse regarding Resident #267's labs. The regional nurse stated the labs were not obtained on 9/06/23 and an error form was completed, and the provider was notified. Surveyor requested and received the facility policy titled Specimen Collection with an effective date of 11/01/19 which read in part .A licensed nurse will obtain a specimen as ordered by the physician . No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/23.

Based on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 30 residents in the survey sample, Resident #264. The findings included: For Resident #264, the facility staff failed to document treatment provided to a diabetic ulcer to the left great toe. Resident #264's diagnosis list indicated diagnoses, which included, but not limited to Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Type 2 Diabetes Mellitus, Heart Failure, and Osteoarthritis. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 9/14/23 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. Resident #264 was coded for the presence of a diabetic foot ulcer. Resident #264's current comprehensive person-centered care plan included the focus area of a diabetic ulcer to the left great toe with interventions including treatment per treatment administration record. Resident #264 was seen by the wound specialist nurse practitioner (NP) on 9/12/23, the progress note described the area to the left great toe as a diabetic ulcer measuring 0.3 cm x 0.3 cm x 0 cm with the wound base 100% epithelial. Treatment recommendations were to cleanse the area with wound cleanser, apply skin prep to base of the wound and leave open to air daily. On 9/20/23, surveyor reviewed Resident #264's current physician's orders and was unable to locate an order for treatment to the left great toe. According to the resident's September 2023 treatment administration record (TAR), Resident #264 last received treatment to the left great toe on 9/13/23. The previous treatment order was ordered on 9/06/23 to be provided from 9/07/23 through 9/13/23. On 9/21/23 at 2:55 PM, surveyor spoke with the treatment nurse, registered nurse (RN) #4, and discussed Resident #264 having no treatment order for the area to the left great toe. RN #4 stated they had been doing the skin prep treatment to Resident #264's left great toe daily Monday through Friday. Surveyor reviewed the resident's September TAR and was unable to locate documentation of RN #4 performing treatments to the left great toe diabetic ulcer. On 9/21/23 at 4:22 PM, the survey team met with the administrator and regional nurse and discussed the concern of Resident #264's treatment to the left great toe. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/23.

Based on observation, staff interviews, and facility document review, the facility staff failed to maintain an infection prevention program for preventing and controlling infection and communicable diseases during an identified outbreak of COVID-19 on 1 of 2 nursing units, Unit 2. Facility staff failed to follow facility policy and procedure and CDC (Centers for Disease Control and Prevention) guidance related to source control mask use during a COVID-19 outbreak. At the time of the survey on 9/21/23, there was a current facility total of 40 COVID-19 positive residents and 27 COVID-19 positive staff members. Unit 2 had a total of 18 COVID-19 positive residents. The findings included: On 9/20/23 at 2:05 PM, surveyor observed registered nurse (RN) #4 in Resident #22's room on Unit 2 without wearing a mask while speaking with the resident. Resident #22's room was not identified as requiring COVID-19 precautions and the resident was not identified as COVID-19 positive at the time of observation. The observation was also witnessed by the facility staff development coordinator (SDC) who remained with the surveyor until RN #4 exited the resident's room. Surveyor noted a surgical mask placed on a cart outside of Resident #22's room. When RN #4 exited the resident's room, they stated they had just taken their mask off and went into the room. RN #4 then donned the surgical mask that was on the nearby cart. On 9/20/23 at 2:55 PM, surveyor spoke with the administrator and regional nurse and requested the facility's masking guidelines. The administrator stated staff must wear a N95 mask with COVID positive residents and a minimum of a surgical mask on any unit that has a COVID positive resident. A review of the Centers for Disease Control and Prevention (CDC) guideline titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 5/08/23, read in part .Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing .Source control is recommended more broadly as described in CDC's Core IPC [Infection Prevention and Control] Practices in the following circumstances: By those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases of SARS-CoV-2 infection have been identified for 14 days) . Surveyor requested and received the facility policy titled, COVID-19 with an effective date of 5/10/23 which read in part, .4. Infection Prevention and Control measures may include, but are not limited to: a. Source control (well-fitting mask/face covering): . For those who reside or work in an area of the facility experiencing COVID-19 outbreak with uncontrolled transmission . On 9/20/23 at 5:46 PM, the survey team met with the administrator and regional nurses and discussed the concern of RN #4 being observed in a resident room without the minimum of a surgical mask in place. No further information regarding this concern was presented to the survey team prior to the exit conference on 9/22/23.

Based on observation, staff interview, clinical record review, facility document review and during a medication pass and pour observation, the facility staff failed to ensure a medication error rate of less than 5 %. There were three errors in 36 opportunities for a medication error rate of 8.3%. These errors affected Resident # 40. The findings included: For resident # 40 the facility staff failed to administer a lidocaine pain patch and lidocaine cream as ordered. Resident # 40's demographic sheet lists diagnoses including but not limited to, multiple sclerosis, generalized anxiety disorder, major depressive disorder, unspecified polyneuropathy, low back pain and spinal stenosis. Resident # 40's care plan has a problem statement for pain with an intervention reading, administer medications per order. On 9/19/23 at 9:35 AM this surveyor conducted a medication pass and pour observation on Licensed Practical Nurse (LPN) # 1. LPN # 1 administered by mouth medications and fluticasone nasal spray, one spray each nostril, to resident # 40. Surveyor did not observe LPN # 1 apply any transdermal patches, administer eye drops, or topical creams to resident # 40. This surveyor reconciled resident # 40's medications on 9/19/23 and observed the following three medication orders that were not witnessed as given, listed on the medication administration record (MAR). Order 1. Lidocaine pain relief patch 4%. Apply to left arm topically one time a day for pain. Apply at 900 and remove at 2100. Order 2. Cyclosporin ophthalmic emulsion 0.05% instill 1 drop in both eyes every morning and at bedtime. Order 3. Lidocaine HCL external cream 3% apply to right lower face/jaw topically two times daily for trigeminal neuralgia for 14 days. Surveyor also noted the order for fluticasone proplonate suspension order read, 2 sprays in each nostril in the morning for allergies. Each of these medications had been initialed as given by LPN # 1. On 9/19/23 at 12:06 PM the surveyor interviewed LPN #1. When asked about the cyclosporin eye drops, LPN stated, Oh I already had given those before you came. When asked how many sprays of the fluticasone nasal spray they gave resident # 40, they replied, one spray in each nostril. Surveyor asked if they had applied a lidocaine patch to resident # 40's left arm, they stated, I meant to mark that one as held, I didn't have any patches on the cart. When surveyor asked about the lidocaine cream to resident # 40's face/jaw they stated, I'll be honest, I haven't done that yet, but I'm going to. 9/19/23 Surveyor requested and received the policy entitled, General Guidelines for Medication Administration with an effective date of 9/2018 which read in part, 4. At a minimum, the 5 rights- right resident, right drug, right route, and right time- should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, (3) after the dose is prepared and the medication put away. This surveyor informed the Administrator, Director of Nursing and Regional Nurse Consultant of the medication errors during a brief meeting with the survey team on 9/19/23 at 4:30 PM and again during the meeting with the survey team on 9/22/23 at 2:35 PM. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure the residents receive treatment and care in accordance with the comprehensive person-centered care plan for 1 of 26 residents in the survey sample, Resident #74. The findings included: For Resident #74, the facility staff administered a Vitamin C tablet instead of the physician ordered [MEDICATION(S)] (Vitamin B12) tablet. Resident #74's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 6/22/21 assigned the resident a BIMS (brief interview for mental status) score of 7 out of 15 in section C, Cognitive Patterns. On 7/21/21 at 8:41 am, during a medication pass and pour observation, surveyor observed LPN (licensed practical nurse) #1 prepare and administer Resident #74's morning medications. LPN #1 administered a Vitamin C 1000 mg tablet to Resident #74. Surveyor reviewed Resident #74's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor did not observe LPN #1 administer a [MEDICATION(S)] 1000 mcg tablet with Resident #74's morning medications on 7/21/21. According to documentation on Resident #74's July 2021 MAR (medication administration record), LPN #1 initialed the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/21/21 at 11:10 am, surveyor spoke with LPN #1 concerning Resident #74's being administered Vitamin C instead of the physician ordered [MEDICATION(S)]. LPN #1 opened the eMAR medication administration screen for Resident #74 and showed surveyor the computer screen and stated baby (he/she) did get a Vitamin C. LPN #1 again looked at the eMAR screen and stated no the resident was given B12. Upon surveyor request, LPN #1 opened the drawer of the medication cart where the bottle of [MEDICATION(S)] was stored and surveyor observed the house stock medication bottles of Vitamin C 1000 mg and Vitamin B12 1000 mcg were located side by side in the drawer. Resident #74's current care plan included a focus area stating Nutrition Risk at admission r/t (related to) recent hospitalization , diuretic therapy, poor appetite and po (oral) intake and actual weight loss with interventions stating administer medication per MD order and provide diet and supplements as ordered. During a meeting the administrator, director of nursing, and the regional nurse consultant on 7/21/21 at 3:28 pm, surveyor discussed the concern of Resident #74 receiving Vitamin C instead of the physician ordered [MEDICATION(S)]. No further information regarding this issue was presented to the survey team prior to the exit conference on 7/22/21.

Based on staff interview and clinical record review, the facility staff failed to ensure that residents were free of significant medication errors for 1 of 26 residents in the survey sample, Resident #50. The findings included: For Resident #50, the facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #50's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 6/08/21 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, Cognitive Patterns. In section I, Active Diagnoses, Resident #50 was coded for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #50's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] < 140 scheduled on MAR (medication administration record) to be administered at 9:00 am, Novolog Solution 100 unit/ml inject 38 units subcutaneously one time a day for DM hold for blood sugar < 140 scheduled on MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] < 140 scheduled on MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #50's July 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 7/01/21 9:00 am received with BS (blood sugar) of 125 7/03/21 9:00 am received with BS of 123 7/04/21 9:00 am received with BS of 135 7/04/21 5:00 pm received with BS of 106 7/05/21 9:00 am received with BS of 99 7/06/21 9:00 am received with BS of 91 7/07/21 9:00 am received with BS of 101 7/07/21 5:00 pm received with BS of 101 7/08/21 9:00 am received with BS of 104 7/08/21 5:00 pm received with BS of 129 7/09/21 5:00 pm received with BS of 137 7/10/21 5:00 pm received with BS of 103 7/11/21 12:00 pm received with BS of 137 7/14/21 9:00 am received with BS of 118 7/15/21 9:00 am received with BS of 124 7/16/21 12:00 pm received with BS of 136 7/17/21 9:00 am received with BS of 107 7/17/21 12:00 pm received with BS of 116 7/18/21 9:00 am received with BS of 124 7/19/21 9:00 am received with BS of 125 7/20/21 9:00 am received with BS of 115 On 7/21/21 at 12:15 pm, surveyor spoke with the RNC (regional nurse consultant) and discussed the concern of Resident #50 receiving Novolog with documented blood sugars less than 140. The RNC stated they would look into this concern. At approximately 1:45 pm, the RNC returned and stated the insulin was held some of the times and documented in the progress notes but the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor reviewed Resident #50's July 2021 progress notes and was unable to locate documentation of Novolog being held on the aforementioned occasions when the BS was less than 140 and the Novolog was initialed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #50's current care plan included a focus area stating The resident has Diabetes Mellitus with an intervention stating Diabetes medication as ordered by doctor . On 7/21/21 at approximately 3:15 pm, surveyor met with the administrator, director of nursing, and the RNC and discussed of concern of Resident #50 receiving Novolog with a BS below 140 on 21 separate occasions and surveyor was unable to locate documentation in the progress notes of the Novolog being held on these occasions. No further information regarding this issue was presented to the survey team prior to the exit conference on 7/22/21.

Based on interviews, review of documents, and during the course of a complaint investigation, it was determined the facility staff failed to maintain complete and/or accurate clinical documentation for one (1) of six (6) sampled residents (Resident #5). The findings include: Facility staff members failed to identify which RP (Responsible Party) was contacted and/or attempted to be contacted for notification of Resident #5's falls (one (1) of the falls included a suspected injury). Resident #5 was admitted to the facility on [DATE]. Resident #5's [DIAGNOSES REDACTED]. Resident #5's quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 8/23/19, had the resident documented as 'sometimes understands' for 'ability to understand others'. This MDS also has the resident's Brief Interview for Mental Status (BIMS) scored as 3 out of 15. Resident #5's clinical documentation identified three (3) individuals listed as RPs (the resident himself/herself and two (2) of the resident's adult children). Resident #5's admission fall-risk assessment was reviewed with the facility's DON (Director of Nurses). The DON reported the assessment indicated the patient was at risk for falls. A note documented on 3/12/19 at 1:21 p.m. read as: fall meeting held today unit managers and don present, trigger for falls (related to) new admit, care plan reviewed and interventions appropriate at this time. dr. (name omitted) and rp (responsible party) aware. This note did not specifically identify which RP was made aware of the resident's fall care plan. A fall was documented on 8/26/19 at 7:02 p.m. Documentation indicated the RP (responsible party) was aware but documentation did not state which RP was notified. A licensed practical nurse (LPN) documented the following information in a Health Status Note dated 10/7/19 at 4:46 p.m.: 3 view right Ankle, 2 view right Femur, 3 view right foot, 2 view of right HIP, 3 view right knee, 2 vie Tibia/Fibula. R/T right hip and leg pain post FALL. Per DR. (name omitted). RP aware. This note did not identify the specific RP that the LPN contacted. This note did not document what information was reported to the RP and did not document the RP's response to the notification. A licensed practical nurse (LPN) documented the following information in a Health Status Note dated 10/7/19 at 4:46 p.m.: resident c/o hip pain, MD notified. new orders for x ray. RP not replying. vm left. (vm = voice mail) This note did not identify the specific RP that the LPN had attempted to contact. On 10/23/19 at 10:52 a.m., the facility's administrator provided a copy of a facility policy titled Admissions Policy (with an effective date of 7/27/16). The policy was provided in response to a request for a policy that guides the facility's staff related to residents' 'responsible party'. The following information was found in this policy: All applicants deemed approved for admission are required to have a responsible party, or a current power of attorney, or a legally recognized guardian. In the absence of the above, an Immediate or Conditional Power of Attorney must be executed prior to or at the time of admission. The administrator was asked about a policy/procedure to guide when a resident could be considered his/her own responsible party; the administrator reported the facility did not have a policy/procedure that addresses that specifically. The following information was found in a facility policy entitled Incident Report: . 3. A licensed nurse will immediately notify the responsible party of the occurrence. 4. Documentation and verification of the follow up to the care and treatment of [REDACTED]. The following information was found in a facility policy entitled Duties (this policy was labeled as being in the Medical Records Policies and Procedures manual with a policy effective date of 2/25/15): POLICY: The MRC is responsible for maintaining an organized record system that assures that medical records are maintained, completed, and preserved according to policy and applicable state and federal requirements. PR[NAME]EDURE: 1. An accurate and complete clinical record is to be maintained for each patient . During a meeting with the facility's Administrator, Director of Nursing, and Corporate Nurse Consultant on 10/25/19 at 11:46 p.m., Resident #5's incomplete and/or inconsistent documentation related to RP notification was discussed for a final time. The failure of facility policies to address when a resident's cognitive issues would prevent him/her from being considered his/her own RP related to notification of changes in condition was also discussed for a final time. This is a complaint deficiency.

Based on staff interview, clinical record review, and facility document review, pharmacy staff failed to submit irregularity reports to the facility director of nursing and medical director for action for 4 of 34 residents sampled (Resident #57, 72, 95, and 101). The Findings Included: 1. For resident #57, pharmacy staff failed to submit a pharmacy irregularity report recommending laboratory testing. Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the comprehensive admission minimum data set assessment with assessment reference date 8/7/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of [MEDICAL CONDITIONS], or behaviors affecting others. During medication regimen review on 9/20/18, the surveyor noted a pharmacy note dated 8/21/18 at 14:37 Pharmacy note:: Medication Review: The resident's medical record including electronic documentation was reviewed on this date. (X) See report for any noted irregularities. The surveyor asked the resident's nurse for assistance locating the report. The nurse and the unit manager were unable to locate the report. The unit manager notified the director of nursing (DON) of the request. The DON reported that there had been no reports of irregularities in (MONTH) (YEAR). The surveyor asked the DON to contact the pharmacist to confirm that there had been no reports of irregularities. The pharmacist responded by sending the (MONTH) reports and apologizing for not having sent them. The DON reported to surveyors that the reports would be printed and submitted to the physician for review and action. The surveyor requested a copy of Resident #57's report. The Consultation Report for Resident #57 dated 8/21/18 included Recommendation: Please consider monitoring a serum magnesium concentration on the next convenient lab day and annually thereafter The administrator, director of nursing , and corporate clinical consultant were aware of the concern with the pharmacy reviews. 2. The contracted pharmacy failed to provide the (MONTH) (YEAR) irregularity reports to the facility director of nursing and medical director for Resident #72. The clinical record of Resident #72 was reviewed 9/18/18 through 9/20/18. Resident #72 was admitted to the facility 7/26/18 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #72's 5-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/10/18 assessed the resident with a BIMS (brief interview for mental status) as 14 out of 15. During medication regimen review on 9/20/18, the surveyor noted a pharmacy note dated 8/21/18 at 14:31(2:31 p.m.) that read, Pharmacy note:: Medication Review: The resident's medical record including electronic documentation was reviewed on this date. (X) See report for any noted irregularities. The surveyor asked the director of nursing for the irregularities the contracted pharmacist had identified during Resident #72's (MONTH) (YEAR) medication regimen review. The DON reported that there had been no reports of irregularities in (MONTH) (YEAR). A second surveyor asked the DON to contact the pharmacist to confirm that there had been no reports of irregularities. The pharmacist responded by sending the (MONTH) (YEAR) reports and apologizing for not having sent them. The DON reported to surveyors that the reports would be printed and submitted to the physician for review and action. The surveyor requested a copy of Resident #72's (MONTH) (YEAR) Consultation Report. The report read REPEATED RECOMMENDATION from 7/27/18: Please respond promptly to assure facility compliance with federal regulation. Resident #72 receives an antipsychotic Aripiprazole, but does not have a supporting indication for use documented. The DON stated the facility does self-audits on residents and will address medication issues as they are found. The surveyor informed the administrative staff of the above concern on 9/20/18. No further information was provided prior to the exit conference on 9/20/18. 3. The contracted pharmacy failed to provide the (MONTH) (YEAR) pharmacy irregularities to the director of nursing and the medical director for Resident #95. The clinical record of Resident #95 was reviewed 9/18/18 through 9/20/18. Resident #95 was admitted to the facility 8/11/18 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #95's admission minimum data set (MDS) with an assessment reference date (ARD) of 8/31/18 assessed the resident with a BIMS (brief interview for mental status) as 13 out of 15. During medication regimen review on 9/20/18, the surveyor noted two pharmacy notes; one dated 8/16/18 at 21:07 (9:07 p.m.) and read Pharmacy note:: Medication Review: The resident's medical record including electronic documentation was reviewed on this date. (X) See report for any noted irregularities. The second pharmacy note was dated 8/31/18 at 15:58 (3:58 p.m.) and read Pharmacy note:: Medication Review: The resident's medical record including electronic documentation was reviewed on this date. (X) See report for any noted irregularities. The surveyor asked the director of nursing for the irregularities the contracted pharmacist had identified during Resident #95's (MONTH) (YEAR) medication regimen review. The DON reported that there had been no reports of irregularities in (MONTH) (YEAR). A second surveyor asked the DON to contact the pharmacist to confirm that there had been no reports of irregularities. The pharmacist responded by sending the (MONTH) (YEAR) reports and apologizing for not having sent them. The DON reported to surveyors that the reports would be printed and submitted to the physician for review and action. The surveyor requested a copy of Resident #95's (MONTH) (YEAR) consultation reports. Both reports (dated 8/16/18 and 8/31/18) read Comment: Resident #95 takes [MEDICATION NAME] a medication which is recommended to be administered with 4 to 8 ounces of water. The DON stated the facility does self-audits on residents and will address medication issues as they are found. The DON stated both of Resident #95's Consultation reports were comments which were considered to be nursing measures. The surveyor informed the administrative staff of the above concern on 9/20/18. No further information was provided prior to the exit conference on 9/20/18. 4. For Resident #101 the facility staff failed to ensure that the clinical record contained the Pharmacy Review Report. Resident #101 was a [AGE] year-old female who was admitted on was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) located in the clinical record was a Medicare Admission MDS assessment with an Assessment Reference Date (ARD) of 9/4/18. The facility staff coded that Resident #101 had a Cognitive Summary Score of 15. The facility staff also coded that Resident #101 required extensive assistance (3/3) with Activities of Daily Living (ADL's). On (MONTH) 20, (YEAR) at 2 p.m., the surveyor reviewed Resident #101's clinical record. Review of the clinical record produced a Pharmacy Note dated 8/31/18. The Pharmacy Notes read . Pharmacy Note:: Medication Review: This resident's medical record including electronic documentation was reviewed on this date. {X} See report for any noted irregularities and/or recommendations OR . (sic) Continued review of Resident #101's clinical record failed to produce the Pharmacy Recommendation. On (MONTH) 20, (YEAR) at 2:15 p.m., the surveyor walked to the Director of Nursing's (DON's) office and located the DON and the and Corporate Compliance Nurse (CCN). The surveyor notified the DON and CCN that the Pharmacy had documented a medication irregularity or a recommendation on 8/31/18. The surveyor notified the DON and ADM that review of the clinical record did not contain the Pharmacy irregularity or recommendation. The surveyor reviewed the clinical record with the DON and CCN. The DON opened up an email on her computer and printed the Pharmacy Irregularity/Recommendation. The CCN stated that the Pharmacy did not send the reports to the DON. The CCN stated that she had called the Pharmacist and asked her to send to the reports to the DON. On (MONTH) 20, (YEAR) at 3:45 p.m. the surveyor notified the Administrator (Adm), DON and CCN that the facility staff failed to ensure that the Pharmacy Report for recommendations and/or irregularities was not contained in the clinical record. No additional information was provided to the surveyor prior to the exiting the facility as to why the facility staff failed to ensure that the Pharmacy recommendation/irregularity was contained in the clinical record.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a complete and accurate clinical record was maintained for 1 of 34 residents (Resident #6). The findings included: The facility staff failed to document clinical information of Resident # 6's respiratory status and the reason for testing on 8/21/18. The facility staff also failed to document clinical information concerning a follow-up chest x-ray preformed (sic) on 9/3/18. The clinical record of Resident #6 was reviewed 9/18/18 through 9/20/18. Resident #6 was admitted to the facility 4/18/17 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #6's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 6/18/18 assessed the resident with a BIMS (brief interview for mental status) as 14 out of 15. Resident #6's current comprehensive care plan was reviewed 9/18/18 through 9/20/18. Resident #6 has a focus area that read The resident has altered respiratory status related to shortness of breath, cough. 5/10/18 New order: [MEDICATION NAME]. 8/2/18 CXR (chest x-ray) with new orders-URI (upper respiratory infection). Created on: 5/8/18 Revision on: 8/3/18. Interventions: Monitor/document changes in orientation, increased restlessness, anxiety, and air hunger. Monitor for s/sx (signs/symptoms) of respiratory distress and report to MD (medical doctor) as needed. Monitor/document/report abnormal breathing patterns to MD. O2 (oxygen) as ordered. A second focus area read The resident has altered cardiovascular status r/t (related to) [MEDICAL CONDITIONS], hypertension, [MEDICAL CONDITION], a fib, CAD [MEDICAL CONDITIONS], vitamin B-12 deficiency. Interventions: Assess lung and heart sounds as needed. The surveyor reviewed Resident #6's (MONTH) (YEAR) progress notes. The progress note dated 8/21/18 at 10:33 a.m. read New orders: 2 view CXR today, CBC (complete blood count), CMP (comprehensive metabolic panel), pBNP (brain natriuretic peptide), sed rate (sedimentation rate) today. RP (responsible party) aware. The clinical record did not include any documentation for the ordered chest x-ray and laboratory tests on 8/21/18. The surveyor asked the unit manager registered nurse #1 to review the 8/21/18 progress note. After R.N. #1 reviewed the progress note, the surveyor asked if she was able to decide why the chest x-ray and labs were ordered. The unit manager RN #1 stated that she was here on that day and the resident had respiratory issues. She was asked if the note should have a respiratory assessment or some form of documentation as to why the chest x-ray and labs were ordered. The unit manager RN #1 agreed with the surveyor that more documentation was evident. The physician order [REDACTED].#1 also. The surveyor was unable to locate either a chest x-ray ordered for 9/3/18 or that any staff member had documented about the 9/3/18 chest x-ray. A chest x-ray was not obtained on 9/3/18. The surveyor asked for the facility policy on documentation and the respiratory policy. The surveyor reviewed the facility policy titled Documentation Summary on 9/20/18. The policy read in part Document all of the facts and pertinent information related to an event, course of treatment, patient condition, response to care, and deviations from standard treatment along with the reason for the deviation. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern in the end of the day meeting on 9/20/18 at 3:45 p.m. No further information was provided prior to the exit conference on 9/20/18.

Based on observation, staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) assessment for 1 of 34 residents (Resident #9). The findings included: The facility staff failed to code the use of the wander guard on Resident #9's quarterly minimum data set (MDS) with assessment reference date (ARD) of 9/13/18. The clinical record of Resident #9 was reviewed 9/18/18 through 9/20/18. Resident #9 was admitted to the facility 3/9/18 with [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 9/13/18 assessed the resident with a BIMS (brief interview for mental status) as 9 out of 15. Resident #9's current comprehensive care plan had the focus area that the resident was a wander risk r/t (related to) history of attempts to leave facility unattended. The focus area was created and revised on 5/8/18. Interventions included: Monitor location. Notify the nurse of wandering behavior and attempted diversional interventions. In the clinical record was a physician order [REDACTED]. The surveyor observed Resident #9 numerous times during the survey from 9/18/18 through 9/20/18-in his room visiting with his family, in activities, and in the dining room. The surveyor observed the resident again after breakfast on 9/20/18 at 9:41 a.m. The resident was observed sitting in his wheelchair midway between the nurse's station and the dining room. Observed on his left ankle was a wander guard. The surveyor reviewed the quarterly MDS of 9/13/18. Section P Restraints and Alarms does not have wanderguard coded. The surveyor interviewed the minimum data set (MDS) registered nurse on 9/20/18 at 10:11 a.m. She stated she did not find documentation on the treatment administration record (TAR) where the wander guard had been charted that it was used. The MDS RN stated she only found documented the weekly function checks for the wander guard. The MDS RN stated the wander guard was not on the care plan as well. The surveyor and the MDS RN reviewed the (MONTH) (YEAR) TAR. Documented on the (MONTH) (YEAR) TAR was evidence the wander guard was in place and checked every shift for wander risk from 9/1/18 through 9/20/18. The surveyor requested copies of the quarterly MDS, care plan, face sheet, 5/8/18 physician order [REDACTED]. The surveyor informed the administrator, the director of nursing and the corporate registered nurse of the above concern on 9/20/18 at 3:45 p.m. No further information was provided prior to the exit conference on 9/20/18.

Based on observation and staff interview, the facility staff failed to provide a safe and secure environment for 10 residents on the main hallway entering into the facility from the lobby (Unit 1). The findings included: On 6/14/17 at 11 pm, two state surveyors entered into the facility using the front doors and entering Unit 1 hallway off from the lobby. There were 10 residents residing on that hallway of Unit 1. The house supervisor met the surveyors at the nurses' station on Unit 1 and stated I'll have to go back up to the front door and lock them. The surveyors continued making rounds with the certified nursing assistants and staff in the facility. At 1 am on 6/15/17, the surveyors asked the house supervisor if they could exit the building out the front doors and she stated Yes. The surveyors exited the facility using the front doors in which were used to enter the facility. The surveyors checked the door when it closed and the door remained unlocked. One surveyor stood at the door while the other surveyor entered the facility and notified the house supervisor of the front doors not locking after the surveyors exited the building. The house supervisor again attempted to lock the front doors but they would not lock. The house supervisor stated she would go and get one of the floor tech staff to come and help her make sure the doors would lock. The floor tech staff member came and stated to the house supervisor to go into maintenance and get the screwdriver that has a tag on it labeled to be used on the front doors. The floor tech staff member explained to the surveyors that if someone used the keys to lock and unlock the front door and someone used the bar to go out the door before it locked, the front doors could not be locked until you used this special tool on the bar to reset the locking mechanism on the door. The house supervisor brought back the special tool labeled to be used to lock front door and the floor tech staff member used this on the bar to reset the locking mechanism in the door. The surveyors exited the building and checked the doors behind them to make sure the doors remained locked in which they did. The house supervisor stated to the surveyors that she would let the administrator know of this problem as soon as he came into work. This surveyor met with the director of nursing, administrator and corporate consultant on 6/15/17 at 10:30 am in the administrator's office and notified the administrative team of the above documented findings concerning the locking mechanism not working when the house supervisor locked the front doors of the facility with the master key at 1 am on 6/15/17. The director of nursing stated to the surveyor, that it was the responsibility of the nurse on Unit 1 to lock the front doors every night around 10 pm. The director of nursing stated that the house supervisor stated she went and locked the doors to the facility when the 2 surveyors entered the facility at 11 pm on 6/14/17. The administrator assured the surveyor that the front doors to the facility could be locked but if you used a master key to unlock it and pushed the bar the special tool had to be used on the bar to reset the locking mechanism. The administrator stated I feel that this is certainly an educational issue that will be taken care of promptly with all of the staff members of the facility. No further information was provided to the surveyor prior to the exit conference on 6/15/17.

Based on staff interview and clinical record review, the facility staff failed to have a complete an accurate DDNR (Durable Do Not Resuscitate) for 1 of 24 residents in the survey sample (Resident #6). The findings included: Resident #6 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/27/17 coded the resident as assistance of one staff member for dressing and hygiene and required extensive assistance of one staff member for bathing. The surveyor conducted a clinical record review on 6/13 and 6/14/17 at which time, the surveyor noted that the DDNR did not contain the complete name of the resident on the top of the form. It was noted that the only information written on the line for complete name was the last name of Resident #6. On 6/14/17 at 9:30 am, the corporate consultant was shown this form by the surveyor. The corporate consultant stated What _______ (last name of Resident #6) is this for? At approximately 4:30 pm, the administrative team was notified of the above documented findings by the surveyor in the end of the day conference with the team. No further information was provided to the surveyor prior to the exit conference on 6/15/17.

Based on staff interview, facility document review, employee file review, and the Code of Virginia, the facility staff failed to follow their policy and procedure in regards to new employee hires for 2 of 25 new hires (New hire #21 and #25). The findings included. For new hire #21, the facility staff failed to complete a criminal background check within 30 days of hire. For new hire #25, the facility staff failed to verify the employees professional license and obtain a sworn statement. The surveyor and the HR (human resources) director reviewed 25 employee files on 06/14/17. Of the 25 employee files reviewed 2 were incomplete. New hire #21 was hired at the facility on 04/10/17 as a CNA (certified nursing assistant). The employee record included a request for a criminal history search that had been sent to the Virginia State Police on 04/05/17. The document revealed that the background check was being processed. The employee file did not include a final report. On 06/14/17 after reviewing the records with the surveyor the human resource director went online and printed an updated copy of the criminal background check for new hire #21. This document indicated that new hire #21 did not have any identifiable records. New hire #25 was hired at the facility on 09/06/16 as a CNA. The employee file did not include a sworn statement and there was no documentation to indicate the employees professional license had been verified. The HR director stated she was aware that the employee file did not include these documents and she had verified the employees license today. New hire #25 was no longer employed at the facility. Per the request of the team leader the facility provided the survey team with their policy titled Processing New Employees. This policy read in part-All requirements for processing newly hired employees must be completed on time .The following must be done prior to the beginning of orientation .Criminal Background Questionnaire (VA only) .Verify licenses and certifications, if applicable-Print website page for verification .The following must be completed before or during orientation: Obtain a background from Virginia State Police Central Criminal Records Exchange within thirty (30) days of employment (VA only) . The facility policy/procedure titled Criminal History Checks read in part For the safety of our patients and to comply with state laws, all employees are subject to criminal history record checks .In Virginia only, the Human Resources Manager or designee will obtain a background from the Virginia State Police Central Criminal Records Exchange within thirty (30) days of hire. The Human Resources Manager or designee will review the backgrounds . Reference: State Code of Virginia. 32.1-126.01. Employment for compensation of persons convicted of certain offenses prohibited; criminal record checks required; suspension or revocation of license. Any person desiring to work at a licensed nursing home shall provide the hiring facility with a sworn statement or affirmation disclosing any criminal convictions or any pending criminal charges .A nursing home shall, within 30 days of employment, obtain for any compensated employees an original criminal record clearance with respect to convictions for offenses specified in this section or an original criminal history record from the Central Criminal Records Exchange. The administrative staff was notified of the incomplete employee files during a meeting with the survey team on 06/14/17 at approximately 4:20 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference.